杜娟
中国医学科学院阜外医院 心脏外科
Objective: To evaluate the long-term efficacy and safety of the implantable ventricular assist system EVAHEART I in clinical use. Methods: Fifteen consecutive patients with end-stage heart failure who received left ventricular assist device therapy in Fuwai Hospital from January 2018 to December 2021 were enrolled in this study, their clinical data were retrospectively analyzed. Cardiac function, liver and kidney function, New York Heart Association (NYHA) classification, 6-minute walk distance and quality of life were evaluated before implantation and at 1, 6, 12, 24 and 36 months after device implantation. Drive cable infection, hemolysis, cerebrovascular events, mechanical failure, abnormally high-power consumption and abnormal pump flow were recorded during follow up. Results: All 15 patients were male, mean average age was (43.0±7.5) years, including 11 cases of dilated cardiomyopathy, 2 cases of ischemic cardiomyopathy, and 2 cases of valvular heart disease. All patients were hemodynamically stable on more than one intravenous vasoactive drugs, and 3 patients were supported by preoperative intra aortic balloon pump (IABP). Compared with before device implantation, left ventricular end-diastolic dimension (LVEDD) was significantly decreased ((80.93±6.69) mm vs. (63.73±6.31) mm, P<0.05), brain natriuretic peptide (BNP), total bilirubin and creatinine were also significantly decreased ((3 544.85±1 723.77) ng/L vs. (770.80±406.39) ng/L; (21.28±10.51) μmol/L vs. (17.39±7.68) μmol/L; (95.82±34.88) μmol/L vs. (77.32±43.81) μmol/L; P<0.05) at 1 week after device implantation. All patients in this group were in NYHA class Ⅳ before implantation, and 9 patients could recover to NYHA class Ⅲ, 3 to class Ⅱ, and 3 to class Ⅰ at 1 month after operation. All patients recovered to class Ⅰ-Ⅱ at 6 months after operation. The 6-minute walk distance, total quality of life and visual analogue scale were significantly increased and improved at 1 month after implantation compared with those before operation (P<0.05). All patients were implanted with EVAHEART I at speeds between 1 700-1 950 rpm, flow rates between 3.2-4.5 L/min, power consumption of 3-9 W. The 1-year, 2-year, and 3-year survival rates were 100%, 87%, and 80%, respectively. Three patients died of multiple organ failure at 412, 610, and 872 d after surgery, respectively. During long-term device carrying, 3 patients developed drive cable infection on 170, 220, and 475 d after surgery, respectively, and were cured by dressing change. One patient underwent heart transplantation at 155 d after surgery due to bacteremia. Three patients developed transient ischemic attack and 1 patient developed hemorrhagic stroke events, all cured without sequelae. Conclusion: EVAHEART I implantable left heart assist system can effectively treat critically ill patients with end-stage heart failure, can be carried for long-term life and significantly improve the survival rate, with clear clinical efficacy.
Zhonghua xin xue guan bing za zhi 2023
Objective: To observe the changes of parameters derived from transthoracic echocardiography (TTE) before and after left ventricular assist device (LVAD) implantation, and to evaluate the clinical value of TTE in the perioperative period of LVAD implantation. Methods: This is a retrospective study. The data of patients who underwent LVAD implantation in Fuwai Hospital from January 2018 to December 2020 were analyzed retrospectively. The TTE parameters, N-terminal pro-B-type natriuretic peptide (NT-proBNP) and total bilirubin (TBil) before and 1 month after LVAD implantation were collected and analyzed. Results: A total of 12 male patients undergoing LVAD implantation were included in this study. The mean age was (43.3±8.6) years. The left atrial volume index ((41.4±12.8)ml/m2 vs. (74.9±30.7)ml/m2, P<0.001), left ventricular end-diastolic volume index ((152.1±35.3)ml/m2 vs. (205.5±35.7)ml/m2, P<0.001), left ventricular end-systolic volume index ((112.5±27.9)ml/m2 vs. (155.1±29.1)ml/m2, P<0.001), right atrial diameter index ((23.7±3.5)mm/m2 vs. (27.2±5.8)mm/m2, P=0.023), right ventricular internal diameter at end-diastole ((24.6±2.7)mm vs. (30.0±4.8)mm, P<0.001), tricuspid annular plane systolic excursion ((11.5±2.9)mm vs. (14.6±2.8)mm, P=0.007), systolic pulmonary arterial pressure ((29.2±4.8) mmHg vs. (55.1±19.3) mmHg, P<0.001, 1 mmHg=0.133 kPa) were significantly reduced at 1 month post LVAD implantation as compared to before LVAD implantation. The aortic sinus diameter ((33.8±4.7)mm vs. (31.6±5.1)mm, P=0.007), left ventricular ejection fraction ((26.3±3.0)% vs. (23.8±4.4)%, P=0.016), right ventricular fractional area change ((31.0±8.6)% vs. (23.8±5.5)%, P=0.004) at 1 month post LVAD implantation were significantly higher than before LVAD implantation. The degree of mitral and tricuspid regurgitation decreased, and the inspiratory collapse rate of inferior vena cava increased (all P<0.05). NT-proBNP ((1 418.4±812.6)ng/L vs. (5 097.5±3 940.4)ng/L, P=0.004) and TBil ((12.4±5.4)μmol/L vs. (27.5±14.0)μmol/L, P=0.001) decreased significantly at 1 month post LVAD implantation. Conclusions: TTE results show that LVAD could effectively relieve left ventricular load and improve right ventricular function. TTE can monitor the cardiac structural and functional changes during the perioperative period of LVAD implantation, and provide the imaging evidence for clinical evaluation of the therapeutic effect of LVAD.
Zhonghua xin xue guan bing za zhi 2021
BACKGROUND:Few data are available on the association between postoperative serum uric acid (SUA) level and poor survival in patients undergoing coronary artery bypass grafting (CABG). We evaluated the relationship between postoperative SUA and major adverse cardiac and cerebrovascular events (MACCE) among patients undergoing CABG.METHODS:This study used data from 1614 consecutive patients undergoing CAGB at Fuwai Hospital (Beijing, China) from 2011 to 2015. Patients were stratified into statistical quartiles of postoperative SUA (between 6 and 18 hours after cardiac surgery): less than 203.7, 203.7 to 254.1, 254.1 to 316.6, and ≥316.6 µmol/L. The association of postoperative SUA with MACCE (ie, death, myocardial infarction [MI], stroke, or repeat revascularization) and the composite endpoint of mortality/MI were assessed.RESULTS:Patients had a mean age of 60.3 ± 8.4 years, and 79.3% were male. During mean follow-up of 2.5 ± 0.7 years, MACCE occurred in 201 (12.5%) patients. In separate multivariable regression models, postoperative SUA level was positively associated with in-hospital MACCE (highest vs lowest SUA quartile: odds ratio [OR]: 2.40; 95% confidence interval [CI]: 1.29, 4.48; P = .006) and in-hospital composite endpoint of mortality/MI (OR: 2.88; 95% CI: 1.45, 5.72; P = .003), respectively. And elevated postoperative SUA level was independently associated with MACCE (Hazard ratio [HR]: 1.70; 95% CI: 1.12, 2.57; P = .01) and the composite endpoint of mortality/MI (HR: 2.42; 95% CI: 1.32, 4.43; P = .004) respectively within 3 years after CABG.CONCLUSIONS:Elevated postoperative SUA level is associated with poor clinical outcomes after CABG. Patients with high postoperative SUA levels after CABG might require to be closely monitored.
Journal of cardiac surgery 2020
BACKGROUND:Complications after cardiac surgery are common and lead to substantial increases in morbidity and mortality. Meta-analyses of small randomized trials have suggested that perioperative statin therapy can prevent some of these complications.METHODS:We randomly assigned 1922 patients in sinus rhythm who were scheduled for elective cardiac surgery to receive perioperative rosuvastatin (at a dose of 20 mg daily) or placebo. The primary outcomes were postoperative atrial fibrillation within 5 days after surgery, as assessed by Holter electrocardiographic monitoring, and myocardial injury within 120 hours after surgery, as assessed by serial measurements of the cardiac troponin I concentration. Secondary outcomes included major in-hospital adverse events, duration of stay in the hospital and intensive care unit, left ventricular and renal function, and blood biomarkers.RESULTS:The concentrations of low-density lipoprotein cholesterol and C-reactive protein after surgery were lower in patients assigned to rosuvastatin than in those assigned to placebo (P<0.001). However, the rate of postoperative atrial fibrillation did not differ significantly between the rosuvastatin group and the placebo group (21.1% and 20.5%, respectively; odds ratio 1.04; 95% confidence interval [CI], 0.84 to 1.30; P=0.72), nor did the area under the troponin I-release curve (102 ng×hour per milliliter and 100 ng×hour per milliliter, respectively; between-group difference, 1%; 95% CI, -9 to 13; P=0.80). Subgroup analyses did not indicate benefit in any category of patient. Rosuvastatin therapy did not result in beneficial effects on any of the secondary outcomes but was associated with a significant absolute (±SE) excess of 5.4±1.9 percentage points in the rate of postoperative acute kidney injury (P=0.005).CONCLUSIONS:In this trial, perioperative statin therapy did not prevent postoperative atrial fibrillation or perioperative myocardial damage in patients undergoing elective cardiac surgery. Acute kidney injury was more common with rosuvastatin. (Funded by the British Heart Foundation and others; STICS ClinicalTrials.gov number, NCT01573143.).
The New England journal of medicine 2016
BACKGROUND:Recent studies indicated that microRNAs (miRNAs, miRs) were important for many biological and pathological processes, and they might be potential biomarkers for cardiovascular diseases. The present study aims to determine the release patterns of miRNAs in cardiac surgery and to analyze the ability of miRs to provide early prediction of perioperative myocardial infarction (PMI) in patients undergoing coronary artery bypass graft (CABG) surgery.METHODOLOGY/PRINCIPAL FINDINGS:Thirty on-pump CABG patients were recruited in this study; and miR-499, miR-133a and miR-133b, cardiac troponin I (cTnI) were selected for measurement. Serial plasma samples were collected at seven perioperative time points (preoperatively, and 1, 3, 6, 12, 24, and 48 hours after declamping) and were tested for cTnI and miRs levels. Importantly, miR levels peaked as early as 1-3 hours, whereas cTnI levels peaked at 6 hours after declamping. Peak plasma concentrations of miRs correlated significantly with cTnI (miR-499, r = 0.583, P = 0.001; miR-133a, r = 0.514, P = 0.006; miR-133b, r = 0.437, P = 0.05), indicating the degree of myocardial damage. In addition, 30 off-pump CABG patients were recruited; miR-499 and miR-133a levels were tested, which were significantly lower in off-pump group than in on-pump group. A prospective cohort of CABG patients (n = 120) was recruited to study the predictive power of miRs for PMI. The diagnosis of PMI strictly adhered to the principles of universal definition of myocardial infarction. The data analysis revealed that miR-499 had higher sensitivity and specificity than cTnI, and indicated that miR-499 could be an independent risk factor for PMI.CONCLUSION:Our results demonstrate that circulating miR-499 is a novel, early biomarker for identifying perioperative myocardial infarction in cardiac surgery.
PloS one 2014
BACKGROUND:Severe acute kidney injury (AKI) after cardiac surgery is associated with poor clinical outcomes. This study evaluated the potential use of miR-21 as a risk marker for postoperative AKI progression and other poor outcomes.METHODOLOGY/PRINCIPAL FINDINGS:The study included 120 adult patients undergoing cardiac surgery: 40 non-AKI controls, 39 patients with progressive AKI, and 41 with non-progressive AKI. Urine and plasma levels of miR-21 were assessed by quantitative real-time PCR (RT-qPCR). Associations between miR-21 levels and AKI progression were determined by estimating areas under receiver operating characteristic curves (AUC). We demonstrated that up-regulated urine and plasma levels of miR-21 in patients with AKI were both associated with AKI progression. The AUCs for urine and plasma levels of miR-21 associated with established AKI were 0.68 (95%CI: 0.59-0.78) and 0.80 (95%CI: 0.73-0.88), respectively. Multiple logistic regression analysis, adjusting for clinical variables, indicated that the prognostic predictive power of urine and plasma miR-21 levels for AKI progression were represented by AUCs of 0.81 (95%CI: 0.72-0.91) and 0.83 (95%CI: 0.74-0.92), respectively. Urinary and plasma miR-21 levels also predicted the need for postoperative renal replacement therapy (RRT), development of Acute Kidney Injury Network (AKIN) stage 3 AKI, 30-day in-hospital mortality and prolonged stay in hospital or ICU. Urine miR-21 was a better outcome predictor than plasma miR-21, being associated with higher (1.4- to 2.6-fold) unadjusted odds ratio for progression of AKI and other poor outcomes.CONCLUSIONS:Urinary and plasma miR-21 are associated with severe AKI and other poor postoperative outcomes of cardiac surgery, indicating their potential use as prognostic markers.
PloS one 2013
OBJECTIVE:To observe the relationship between preoperative pulmonary artery pressure and postoperative right ventricular function in heart transplant patients.METHOD:A total of 54 heart transplant patients were divided to two groups: group I (n = 34): preoperative pulmonary arterial systolic pressure (sPAP) > or = 45 mm Hg (1 mm Hg = 0.133 kPa) [(60 +/- 12) mm Hg]; group II (n = 20): sPAP < 45 mm Hg [(25 +/- 9) mm Hg]. Cardiac index (CI), pulmonary circulation resistance (PVR) and CVP were measured preoperatively and up to 60 hours post operation by Swan-Ganz catheter. The extent of tricuspid regurgitation at preoperation and 3, 7, 14, 21, 30 days post operation was evaluated by bedside echocardiography. Postoperative pulmonary hypertension was treated by diuresis, nitrates, Ilomedin 20 and hemofiltration (CRRT).RESULT:All patients survived the operation. Preoperative PVR was significantly higher in group I patients than that of group II patients [(358 +/- 150) dyn x s(-1) x cm(-5) vs. (140 +/- 68) dyn x s(-1) x cm(-5), P < 0.01]. Right heart insufficiency early post operation was more often in group I patients than that in group II patients (70.6% vs. 35.0%, P < 0.05). The PVR was higher and tricuspid regurgitation extent severer in group II than group I early post operation and were similar 30 days post operation.CONCLUSION:Post operative right heart insufficiency was associated to preoperative pulmonary hypertension in heart transplant patients.
Zhonghua xin xue guan bing za zhi 2007
OBJECTIVE:To determine the influence of normal pulmonary artery pressure, and mild to moderate and severe pulmonary hypertension on the early hemodynamics, morbidity, and mortality after orthotopic heart transplantations.METHODS:Sixty-seven heart disease patients, 54 males and 13 females, aged (46.4 +/- 14.6), including ischemic heart diseases (n = 16), myocardiopathy (n = 43), and other heart diseases (n = 8), underwent orthotopic heart transplantation. Before and after transplantation routine right heart catheterization was conducted. According to the preoperative pulmonary arterial pressure the patients were divided into 3 groups: Group I (n = 15) without pulmonary hypertension (PH) with the pulmonary vascular resistance (PVR) < or = 2.5 Wood's units; Group II (n = 42) with mild to moderate PH with the PVR between 2.5 and 5.0 Wood's units; and Group III (n = 10) with severe PH with the PVR > or = 5.0 Wood's units. Heart rate (HR), mean artery pressure (MAP), central venous pressure (CVP), mean pulmonary artery pressure (MPAP), pulmonary artery wedge pressure (PAWP), PVR, cardiac output index (CI), and mixed venous oxygen saturation (S(V)O(2)) were measured preoperatively, immediately and 12, 24, and 48 hours postoperatively. 1, 3, and 7 days, and 1 and 3 months post-operatively echocardiography was conducted to measure the left ventricular end-diastolic diameter (LVEDD), left ventricular ejection fraction (EF), mitral valvular regurgitation (MVR), and tricuspid valvular regurgitation (TVR). Postoperative complications and mortality were recorded.RESULTS:The 30-day mortality was zero in all 3 groups. The cardiovascular support used for weaning CPB and postoperative period included dopamine, ephedrine and isoproterenol. In addition, nitroglycerin, NO and iloprost were administered for pulmonary artery vasodilation if the pulmonary artery pressure was higher than 45 mm Hg. The EF value of Group III was significantly lower compared with group (P < 0.05). Before the heart transplantation, 52 patients (86%) had mild to severe PH, of which 10 patients (27%) had severe PH. The patients of Group III had longer CPB time and tracheal intubation time in comparison with the patients of Group I (P < 0.05). Postoperatively 6 patients, 1 in Group I, 2 in Group II, and 3 in Group III, had acute right ventricular failure and 3 patients, 1 in Group II and 2 in Group III, had renal failure. Basiliximab, cyclosporine A, mycophenolate mofetil, and methylprednisolone were administered for immunosuppressive treatment perioperatively.CONCLUSION:The patients with severe PH pre-operatively have significantly lower pulmonary resistance and pressure, and have more complications, such as acute right heart failure, post-operatively. Active treatment with cardiac stimulant and diuretics is helpful. Smooth anesthetic induction and maintenance, peri-operative stable hemodynamic managements, especially the protection of right ventricle function for the first 2 weeks after the transplantation, myocardial protection of donor heart, and immunosuppressive regimen all play important roles for successive heart transplantation.
Zhonghua yi xue za zhi 2007
