Objective To assess different anticoagulant regimens in pregnant women with mechanical heart valves: taking oral warfarin throughout the pregnancy, or heparin in the 1st trimester and oral warfarin for the other trimesters. The main outcome measures were major maternal complications and perinatal outcomes. Methods The MEDLINE, EMbase, CBM and CNKI were searched. The quality of the included studies was evaluated and data were extracted by two reviewers independently. Meta-analyses were performed on the results of homogeneous studies. Result Seven studies involving 629 pregnancies in 469 patients met the inclusion criteria for this review, all of which were retrospective surveys. The comparison between the administration of heparin in the 1st trimester plus oral warfarin for the other trimesters and warfarin throughout the pregnancy showed that, there are not significant different in the incidence of major maternal complications and the incidence of adverse perinatal outcomes. Conclusion Compared with the administration of warfarin throughout the pregnancy, the administration of heparin in the 1st trimester and oral warfarin for the other trimesters might increase the incidence of major maternal complications, but with a similar incidence of adverse perinatal outcomes.
Clinical application history of prosthetic heart valves has been over five decades, and mechanical heart valves have satisfactory clinical outcomes for surgical treatment of valvular heart disease. The development history of mechanical heart valves experienced from the first generation of ball valves and caged disc valves to the second generation of single tilting disc valve, and to the third generation of bileaflet valves. In 1960， ball valve was first used for heart valve replacement in abroad. In 1963， China-made ball valve was also produced and used in clinical practice. In 1969， the second generation of single tilting disc valve was developed in abroad. In 1978， China-made single tilting disc valve was produced and widely used in clinical practice with satisfactory clinical outcomes. Since 1980 when it was first produced， bileaflet valve has taken the place of above 2 types of valves for its excellent performance, and become the mainstream product all over the world. Currently, the development of China-made bileaflet valves has lagged behind， and domestic mechanical heart valve market has almost been monopolized by foreign bileaflet valve products. Therefore, the development of ideal China-made mechanical heart valve deserves further research.
Objective To evaluate postoperative quality of life （QOL） of patients aged over 65 after mitral valvereplacement （MVR）. Methods Ninety patients aged over 65 undergoing MVR by the same surgical group in Departmentof Cardiovascular Surgery of Anzhen Hospital were prospectively enrolled in this study. There were 62 male and 28 femalepatients with their age of 65-76 （68.6±6.8） years. There were 55 patients with hypertension，38 patients with type 2 diabetes，and all the patients had persistent atrial fibrillation. Nottingham Healthy Profile （NHP，Part I） and Duke Activity StatuIndex （DASI） were used to evaluate preoperative and postoperative QOL. According to the choice of prosthetic heart valves they received，all the patients were divided into two groups with 45 patients in each group: biological valve group and mechanical valve group. All the patients received MVR via the interatrial groove approach under general anesthesia and cardiopulmonary bypass. Mechanical valve replacement was performed using continuous suture without preserving the posterior leaflet of the mitral valve. Biological valve replacement was performed using interrupted suture and some of the posteriorleaflet of the mitral valve was routinely preserved. Patients in both groups underwent intraoperative bilateral pulmonary vein isolation and left atrial appendage ablation using a bipolar radiofrequency ablation device. The left atrial appendage was not excised or ligated. Results Postoperative QOL of all the patients was significantly better than preoperative QOL. There was no statistical difference in NHP and DASI at the 6th month after discharge between the 2 groups. But from the 1st year after discharge，QOL of the biological valve group was significantly better than that of the mechanical valve group. At the 3rd year after discharge，NHP and DASI of the mechanical valve group was not statistically different from those at the 1st year after discharge，but NHP and DASI of the biological valve group was significantly better than those at the 1st year after discharge. Conclusions QOL of elderly patients are significantly improved after MVR. Patients who receive biologicalvalve replacement may acquire better long-term QOL than patients who receive mechanical valve replacement.
Objective To evaluate the preliminary effect of tricuspid annuloplasty for patients with dilated tricuspidannulus and left-sided heart valve surgery by employing combined bicuspidization and modified Kay annuloplasty. Methods?Combined bicuspidization and modified Kay annuloplasty were performed in 158 patients with dilated tricuspidannulus （tricuspid annulus diameter/body surface area≥21 mm/m2） and left-sided heart valve surgery in West China Hospitalbetween January 2010 and May 2011. There were 27 male and 131 female patients whose age ranged from 17 to 74 （45.9±10.4） years. A total of 92 patients had atrial fibrillation and 66 patients were in sinus rhythm. The severity of tricuspid regurgitation（TR）was graded 0 through 5 as determined by echocardiography.?Results?All the patients recovered from surgery and were discharged from hospital. The average cardiopulmonary bypass time was 100.8±30.5 （range, 54 to 273） min, and the average aortic cross clamping time was 64.5±22.0（range, 25 to 162）min. The average lowest esophageal temperature during aortic cross clamping was 28.5±1.1（range, 26.3 to 34.1）?℃. The average postoperative follow-up was 11.0±5.0 （range, 3 to 19） months. The postoperative TR severity was significantly lower than preoperative TR severity （2.2±1.3 versus 0.4±0.8， P＜0.05）. The postoperative right atrium diameter, right ventricle diameter and left atrium diameter were significantly lower than preoperative measurements （56.5±11.1 mm versus 47.5±8.9 mm， P＜0.05；22.4±4.4 mm versus 20.1±3.3 mm， P＜0.05；62.8±20.1 mm versus 51.9±14.1 mm， P＜0.05）. During follow-up, 5 patients had moderate or severe TR （3.2%， 5/158, moderate in 4 patients, moderate to severe in 1 patient）. There was no significant difference between preoperative and postoperative left ventricle ejection fraction （60.4%±7.9% vervsus 59.6%±8.2%， P＞0.05）.?Conclusion?It is reasonable to perform tricuspid annuloplasty for patients with dilated tricuspid annulus and left-sided heart valve surgery according to their index of tricuspid annulus diameter/body surface area （≥21 mm/m2）. To prevent postoperative residue or progression of TR in patients with dilated tricuspid annulus,it is effective to employ combined bicuspidization and modified Kay annuloplasty.
Abstract: Objective To investigate the anticoagulation effect of warfarin on pregnant women with prosthetic mechanical heart valves during the whole course of pregnancy and their fetuses. Methods Followup survey was carried out on 103 pregnant women with prosthetic mechanical heart valves treated in the Second Xiangya Hospital of Central South University from April 1998 to June 2010. Their age ranged from 19 and 38 years (26.4±3.8 years). All the 103 pregnant women were given oral administration of warfarin during the whole course of pregnancy. The average dose of domestic warfarin was 3.30±0.43 mg/d (87 cases), while the average dose of imported warfarin was 2.90±1.05 mg/d (16 cases). Results None of the patients suffered from serious embolic events. One patient suffered from spontaneous peritoneal hemorrhage. There were 4 cases of intrauterine deaths, and 5 cases of fetal malformation including 1 case of Down’s syndrome and 4 cases of hydrocephalus. Six cases of low birth weight infants and 1 case of ABO hemolytic disease were also found. All the other neonates were healthy with normal weight. No pregnant women suffered from postpartum hemorrhage. Conclusion Oral administration of low dose warfarin (lt;5 mg/d) during the whole course of pregnancy is a relative safe and effective anticoagulation protocol.
Objective To develop a tissue engineering scaffold by using 4arm branched polyethylene glycol-VS (PEG-VS) crosslinked with decellularized valved conduits (DVC), and to research on its mechanical and biological functions. Methods The valved aortic conduits of rabbits were taken and decellularized by trypsin method and then were crosslinked with 4arm branched PEG-VS to construct the composite scaffolds (CS). The functions of decellularized valved conduits and the composite scaffolds were tested by mechanics test system. Thirty New Zealand white rabbits were equally and randomly assigned to one of the three groups: the control group, the DVC group, and the CS group. Valved aortic conduits, decellularized valved conduits and composite scaffoldswere transplanted into the common carotid artery of the abovementioned three groups of rabbits respectively. Twentyeight days after the operation, patency of the transplants was tested by Color Doppler ultrasound; micromorphology and inflammatory infiltration were observed by hematoxylin eosin（HE） staining andscanning electron microscope (SEM)，and endothelialization of composite scaffolds was detected by immunofluorescent staining. Results A series of biomechanical analyses revealed that the composite scaffolds had highly similar mechanical properties as fresh tissue, and had superior elastic modulus (P=3.1×10-9) and tensile strength (P=1.1×10-6) compared with decellularized valved conduits. Color Doppler ultrasound revealed that the graft patency for the CS group was better than the control group (P=0.054) and the DVC group (P=0.019), and the intraaortic thrombosis rate and distortion rate decreased significantly. HE staining and SEM showed that the endothelialization of composite scaffolds in the CS group was significantly higher than the other two groups with the endothelial cells evenly distributed on the scaffolds. The [CM(159mm]immunofluorescent staining indicated that the positive rate of the endothelial cell marker CD34 was higher than the other two groups. Conclusion The composite scaffolds using 4arm branched PEGVS crosslinked with DVC have great mechanical and biological properties.
Abstract: Objective Using Amplex red fluorometric assay to detect the lysyl oxidase (LOX) enzyme activity in tissue engineered heart valve (TEHV). Methods Porcine aortic valves were decellularized with trypsin+ethylene diaminetetraacetic acid(EDTA), TritonX-100, and RNaseⅠ＋DNaseⅠ, then they were seeded by myo-fibroblasts that harvested from rats. Then they were fed with Dulbecco’s modified Eagle medium (DMEM) which contained high glucose for 27 days, they were fed with phenol red-free and serumfree DMEM for 24 hours, and the medium was harvested and used for LOX enzyme activity assays with the Amplex red fluorometric assay. And reverse transcription-polymerase chain reaction (RT-PCR) technique was used to analyze the expression of LOXmRNA in TEHV. Results All the samples produced measurable amounts of active LOX enzyme. The fluorescence units were 45.60±1.66, and the corresponding concentration of LOX enzyme were 0.123±0.003μg/ml. At the same time, all the samples expressed LOXmRNA. The expression of LOXmRNA was corresponding to the results of the Amplex red fluorometric assay. Conclusion It is feasible to detect the LOX enzyme activity in TEHV with the Amplex red fluorometric assay. And this assay gives a way to reflect that LOX plays an important role in collagen cross-linking of extracellar matrix in TEHV.
Objective To observe whether Cyclo-RGDfK (Arg-Gly-Asp-D-Phe-Lys) could enhance the adhesion of myofibroblast to decellularized scaffolds and upregulate the expression of Integrin αVβ3 gene. Methods Myofibroblast from the rat thoracic aorta was acquired by primary cell culture. The expression of Vimentin and α-smooth muscle actin(α-SMA) has been detected by immunoflurescent labeling. Decellularized valves have been randomly divided into three groups (each n=7). Group A (blank control): valves do not receive any pretreatment; Group B: valves reacted with linking agent NEthylN(3dimethylaminopropyl)carbodiimide hydrochloride (EDC) for 36 hours before being seeded; Experimental group: Cyclo-RGD peptide has been covalently immobilized onto the surface of scaffolds by linking agent EDC. The fifth generation of myofibroblast has been planted on the scaffolds of each group. The adhesion of myofibroblast to the scaffolds was evaluated by HE staining and electron scanning microscope. The expression of Integrin αVβ3 was quantified by halfquantitative reverse transcriptionpolymerase china reaction (RT-PCR). Results We can see that myofibroblast has exhibited b positive staining for Vimentin and α-SMA. Besides, it has been shown that the expression of Integrin αVβ3 was much higher in the experimental group than that of the group A and group B(Plt;0.05). There was no statistically difference in group A and group B (P=0.900). Conclusion RGD pretreatment does enhance the adhesive efficiency of seeding cells to the scaffolds and this effect may be related to the upregulation of Integrin αVβ3.
Objective To introduce a new type of bileaflet mechanical prosthetic heart valve （GK bileaflet valve）and evaluate clinically the early hemodynamic effect and short term follow-up after its replacement. Methods Sixty-one patients with heart valve diseases were operated upon. The mitral valve replacement was performed in 34 patients, aortic valve replacement in 16 patients and double valve replacement in 11 patients. A total of 72 GK bileaflet mechanical valves were implanted, 45 in mitral position, and 27 in aortic position. Blood consistency and hemodynamics were monitored. Follow-up was carried out routinely to check whether there were some valve-related complications. Results There was no early mortality （〈30 d）. Only one patient died of trauma 2 months after the operation. Follow-up was 100% and extended 1 to 2. 5 years. Without valve-related complications all patients had lived for more than 1 to 2.5 years. In 98% （60/61） of survivors heart functional performance had improved to New York Heart Association class Ⅰ or Ⅱ . Conclusion Early clinical results and short term follow up demonstrate that GK bileaflet prosthetic heart valve exhibits excellent hemodynamic properties, satisfied blood consistency and a low incidence of valve-related complications. Midterm and long-term results should be observed further.
Objective To explore the role of thrombus precursor protein(TPP) in the monitoring of anticoagulation in the patients with atrial fibrillation (Af) after mechanical heart valve replacement, and suggest the reasonable anticoagulant range. Methods Ninety patients were divided into Af group (n=45), sinus rhythm group (SR group, n=45), and control group (20 patients with non-valvular heart diseases), according to whether Af exist after mitral valve replacement. TPP concentrations and International Normalized Ratio(INR) in the anticoagulant patients were analyzed. Results In patients after mechanical mitral valve replacement, plasma TPP concentrations in both SR group and Af group were lower than that in control group (Plt;0.05,0.01), their INR value were higher than that in control group (Plt;0.01), and Af group had higher plasma TPP concentrations than that in SR group((Plt;)0.05). It was found that there existed contradictions between INR and plasma TPP concentrations in Af group. There were 28 patients with plasma TPP concentrations below 6 μg/ml and without spontaneous bleeding complications in the group with Af, who might be at the optimal anticoagulant status. Their 95% confidence of INR value was 1.90-2.30 and their plasma TPP concentration was 4.29±0.75μg/ml. Conclusion Patients with Af after mechanical heart valve replacement might have higher risk of thromboembolism, INR between 1.90 - 2.30 and plasma TPP concentration between 2.84-6.00 μg/ml might be the optimal anticoagulant therapeutic range.