ObjectiveTo investigate clinical outcomes and risk factors of patients with valvular heart disease (VHD) and giant left ventricle undergoing heart valve replacement (HVR). MethodsClinical data of 144 VHD patients with giant left ventricle who underwent HVR in Union Hospital of Tongji Medical College, Huazhong University of Science and Technology from January 2009 to December 2012 were retrospectively analyzed. There were 116 male and 28 female patients with their age of 15-69 (44.9±11.9) years and disease duration of 57.8±98.3 months (range, 1 month to 40 years). There were 92 patients with rheumatic VHD, 28 patients with degenerative VHD, 15 patients with congenital VHD, and 9 patients with infective endocarditis. A total of 137 patients who were discharged alive were followed up. Risk factors of postoperative mortality, morbidity and late death of VHD patients with giant left ventricle undergoing HVR were analyzed with t-test, chi-square test or Fisher's exact test, and logistic regression analysis. The life-table method was used to calculate long-term survival rate and draw the survival curve. ResultsMajor postoperative complications included low cardiac output syndrome (LCOS) in 19 patients (13.2%), ventricular arrhythmias in 56 patients (38.9%), prosthetic paravalvular leaks in 7 patients (4.9%), pleural effusion in 33 patients (22.9%), pericardial effusion in 8 patients (5.6%), liver failure in 23 patients (16.0%), and renal failure in 5 patients (3.5%). Seven patients (4.9%) died postoperatively. Logistic univariate analysis showed that advanced-age ( > 50 years), rheumatic VHD, higher preoperative NYHA class (Ⅲ or Ⅳ), long disease duration, poor preoperative left ventricular function[left ventricular ejection fraction (LVEF) < 40%], double valve replace-ment (DVR), other concomitant intracardiac procedures, prolonged cardiopulmonary bypass (CPB) time and aortic cross-clamping time, postoperative LCOS and ventricular arrhythmias were risk factors of early mortality of VHD patients with giant left ventricle undergoing HVR (P < 0.05). Logistic multivariate analysis showed that advanced age ( > 50 years), long disease duration, higher preoperative NYHA class (Ⅳ), poor preoperative left ventricular function (LVEF < 40%), DVR, prolonged CPB time were independent predictors of early mortality (P < 0.05). Logistic multivariate analysis showed that higher preoperative NYHA class (Ⅲ or Ⅳ), other concomitant intracardiac procedures, poor preoperative left ventricular function (LVEF < 50%) were independent predictors of postoperative LCOS (P < 0.05). Higher preoperative NYHA class (Ⅲ or Ⅳ) and preoperative non-sinus rhythm were independent predictors of postoperative ventricular arrhy-thmias (P < 0.05). Within 2 weeks after the operation, left ventricular end-diastolic dimension (LVEDD), left atrial diameter (LAD), LVEF and left ventricular fractional shortening (LVFS) were all significantly reduced compared with preoperative parameters (P < 0.05). Five patients died during follow-up. One-year, 2-year, 3-year and 4-year survival rates were 97.1%, 95.0%, 92.7% and 92.7% respectively. Preoperative LVEF, LVEDD and NYHA were significantly different between patients who died or survived during follow-up. ConclusionsHVR can produce low postoperative mortality, high long-term survival rates and satisfactory clinical outcomes for VHD patients with giant left ventricle. Advanced age ( > 50 years), long disease duration, higher preoperative NYHA class (Ⅳ), preoperative non-sinus rhythm, poor preoperative left ventricular function (LVEF < 40%), DVR and prolonged operation time may be risk factors of postoperative mortality and morbidity. Poor preoperative left ventricular function and significantly enlarged left ventricle may be risk factors of late death after HVR.
Objective To develop and validate a nomogram prediction model for pulmonary infection in patients following cardiac valve replacement surgery, providing a reference for early screening of high-risk populations and implementing targeted preventive measures. Methods Clinical data of patients who underwent cardiac valve replacement surgery at the Second Affiliated Hospital of Anhui Medical University from January 2020 to October 2023 were collected. Patients were randomly assigned to a modeling group and a validation group in a 7 : 3 ratio. Based on the occurrence of pulmonary infection post-surgery, patients were divided into a pulmonary infection group and a non-pulmonary infection group. Risk factors for pulmonary infection after cardiac valve replacement were analyzed using least absolute shrinkage and selection operator (LASSO) regression and logistic regression to establish a risk prediction model, which was subsequently validated. Model evaluation was conducted using the area under the receiver operating characteristic curve (AUC), calibration curves, and decision curve analysis. Results A total of 689 patients were included, comprising 354 males and 335 females, with a median age of 58.0 (50.0, 68.0) years. The incidence of pulmonary infection was 16.0% (110/689). Independent risk factors for pulmonary infection following cardiac valve replacement included emergency admission, smoking history, chronic obstructive pulmonary disease, duration of cardiopulmonary bypass, duration of tracheal intubation, and postoperative renal injury. The AUC for the modeling group was 0.911 [95%CI (0.877, 0.946) ], with a Hosmer-Lemeshow χ2-value of 6.577 (P=0.583) in the modeling group. The AUC value was 0.891 [95%CI (0.840, 0.941) ], with a Hosmer-Lemeshow χ2-value of 5.486 (P=0.705) in the validation group. The model demonstrated good discrimination, calibration, and net benefit. Conclusion The established nomogram prediction model has significant predictive value and can be applied to risk assessment and individualized treatment for pulmonary infection in patients following cardiac valve replacement surgery.
Abstract： Objective To explore clinical outcomes of nitroglycerin perfusion via the aortic root before heart re-beating for patients undergoing heart valve replacement. Methods A total of 254 patients with valvular heart diseases underwent heart valve replacement in Beijing Anzhen Hospital from January 2008 to December 2011. According to whether or not they received nitroglycerin perfusion via the aortic root before heart re-beating during cardiopulmonary bypass （CPB）， all the 254 patients were randomly divided into two groups， the nitroglycerin group and the control group. There were 134 patients in the nitroglycerin group including 57 males and 77 females with their average age of 58.47±12.34 years. They received aortic root perfusion of 5 mg nitroglycerin diluted into 20 ml after full de-airing of the heart， and repeated aspiration was performed 8 to 10 times before heart re-beating during CPB. Aortic cross-clamp was released after the heart showed signs of automatic re-beating， and the aortic root was squeezed in high frequency by hand to make sure that the aorta was squeezed to close each time. In the control group， there were 120 patients including 64 males and 56 females with their average age of 61.85±11.97 years. Patients in the control group received routine procedures of CPB except nitroglycerin perfusion before heart re-beating. Automatic heart re-beating rate， CPB supporting time after heart re-beating， postoperative usage of inotropic drugs， mechanical ventilation time， perioperative morbidity and length of hospital stay were compared between the 2 groups， and patients were followed up and further evaluated. Results There was no in-hospital death. CPB supporting time after heart re-beating（12.32±9.76 min vs. 23.43±10.33 min， t=-1.233， P=0.000）， dopamine usage［3.45±2.33 μg/ （kg?min） vs. 5.67±3.12 μg/ （kg?min） ， t=-0.943 ， P=0.034］ and epinephrine usage ［0.026±0.013 μg/ （kg?min） vs. 0.056±0.021 μg/ （kg?min） ， t=-0.822 ， P=0.027］ of the nitroglycerin group were significantly shorter or lower than those of the control group. Automatic heart re-beating rate of the nitroglycerin group was significantly higher than that of the control group ［97.01% vs. 66.67 % ， χ 2 =-2.115 ， P=0.000］. A total of 121 patients in the nitroglycerin group were followed up for 2-36 months， and 13 patients were lost during follow-up. There was no death during follow-up. Conclusion For patients undergoing heart valve replacement， some myocardial protection strategies including nitroglycerin perfusion via the aortic root before heart re-beating， use of norepinephrine， and aortic root squeezing in high frequency by hand can significantly increase the automatic heart re-beating rate， shorten the CPB supporting time after heart re-beating， and improve postoperative clinical outcomes.
Objective To explore the safety and efficacy of mobile APP in telemanagement for patients who received oral warfarin anticoagulant therapy after mechanical heart valve replacement. Methods A prospective cohort study was performed. According to the inclusion and exclusion criteria, a total of 80 patients who underwent mechanical heart valve replacement for more than half a year and received oral warfarin anticoagulant therapy in outpatient department were included in our hospital from January 1, 2017 to December 31, 2017. These patients were divided into a telemanagement group (40 paitents, telemanagement using mobile APP) and a control group (40 patients, anticoagulant management in outpatient clinics) according to patients' wishes and local hospital international normalized ratio (INR) monitoring conditions. After 12-month follow-up, clinical effect of the two groups was compared. The INR, time in therapeutic range (TTR), fraction in therapeutic range (FTTR), anticoagulation-related complications and patient satisfaction were analyzed. Results During the follow-up period of anticoagulation, there was no significant difference in INR between the two groups (P=0.732). The average interval of INR monitoring in the telemanagement group was 3-65 (21.4 ± 12.5) days, while that in the control group was 7-93 (39.6 ± 14.7) days (P=0.012). TTR was 42.7% (6 027.6 d/14 116.0 d) in the control group and 67.9% (10 168.6 d/14 972.0 d) in the telemanagement group (P=0.018). And FTTR in the two groups was 45.6% (144/316) and 67.1% (432/644), respectively (P=0.015). No serious thromboembolism or hemorrhage events occurred in the 80 patients during the 12-month follow-up period. There was no significant difference in the incidence of anticoagulation-related complications, general bleeding and embolism between the two groups (P>0.05). Conclusion For patients with stable anticoagulation after cardiac mechanical valve replacement, it is safe and effective to telemanagement by mobile APP. Telemanagement can increase the frequency of anticoagulation monitoring without increasing anticoagulation risk, meanwhile, it also could obtain more convenient and rapid consultation, save time and economic costs,and improve the quality of life and patient satisfaction.
Objective To explore clinical application and significance of coronary angiography （CAG） prior to heart valve replacement for patients with rheumatic valvular heart disease （RVHD）. Methods We retrospectively analyzed clinical data of 313 RVHD patients who underwent heart valve replacement in the First Affiliated Hospital of Chongqing Medical University from January 2002 to June 2012. All the patients received screening CAG before surgery. According to CAG results，313 patients were divided into two groups. In the coronary artery lesion （CAL） group，there were 29 patients including 17 male and 12 female patients with their age of 60.0±5.2 years. In the non-coronary artery lesion （non-CAL）group，there were 284 patients including 98 male and 186 female patients with their age of 57.0±5.4 years. Surgicaloutcomes were compared between the two groups. Univariate analysis and multivariate logistic regression were performed to analyze risk factors of CAL for RVHD patients. Results CAG showed 29 patients with CAL，and the overall prevalence of CAL was 9.27%. In CAL group，11 patients underwent concomitant coronary artery bypass grafting with 2.2 grafts for each patient on the average. Postoperatively 1 patient （3.45%） died of low cardiac output syndrome （LCOS）. In non-CAL group，5 patients （1.76%） postoperatively died mainly because of LCOS，ventricular fibrillation，sudden cardiac arrest or respiratory failure. Cardiopulmonary bypass time and aortic cross-clamp time of CAL group were significantly longer than those of non-CAL group （P＜0.05）. There was no statistical difference in postoperative mortality，incidence of LCOS，acute renal failure，respiratory failure，reexploration for bleeding，intraoperative blood loss，mechanical ventilation time or hospital stay between the two groups（P＞0.05）. There was no significant correlation between the types of valvular lesions and CAL. Age≥ 55 years （OR=5.534，P=0.005），male gender （OR=2.335，P=0.038） and diabetes mellitus （OR=4.265，P=0.006） were independent risk factors of CAL for RVHD patients undergoing heart valve replacement. Conclusion For RVHD patients with independent risk factors of CAL （age≥55 years，male gender and diabetes mellitus），CAG must beseriously considered before heart valve replacement. RVHD patients with CAL can obtain similarly satisfactory surgicaloutcomes of heart valve replacement as RVHD patients without CAL by appropriate surgical strategy and strengthened perio-perative management.
Objective To explore the impact of recombinant human growth hormone （rhGH） on T lymphocyte subsets in patients with rheumatic heart disease during the perioperative period of heart valve replacement. Methods A total of 65 patients with rheumatic valvular heart disease who received heart valve replacement in Department of Cardiothoracic Surgery of Xiangyang Central Hospital from June 1， 2011 to March 31， 2012 were enrolled in this double-blind randomized controlled clinical study. All the patients were divided into 2 groups by random number produced by SAS software：the trial group and the control group. There were 35 patients in the trial group including 19 males and 16 females with their average age of 50.57 years， and 30 patients in the control group including 16 males and 14 females with their average age of 49.87 years. Apart from routine cardiac glycosides， diuretics， glucose-insulin-potassium solution， and postoperative anti-infective therapy， patients in the trial group also received subcutaneously injection of rhGH 5 U （1 ml）daily from 1 day before surgery to 3 days after surgery， and patients in the control group received subcutaneously injection of normal saline 1 ml as placebo. Peripheral venous blood samples were taken in the morning 2 days before surgery and 1 st， 3 rd， 7 th day after surgery respectively. Percentages of CD3+， CD4+， CD8+ were examined timely by flow cytometry and CD4+ /CD8+ ratio was calculated. Results In the control group， percentages of CD3+， CD4+ and CD4+ /CD8+ ratio on the 1st， 3rd， 7th postoperative day were significantly lower than preoperative levels， and percentages of CD8+ on the 1st and 3rd postoperative day were significantly lower than preoperative level （P＜0.05）. In the trial group， percentages of CD3+， CD4+， and CD8+ on the 1st and 3rd postoperative day were significantly lower than preoperative levels（P＜0.05）， while percentages of CD3+， CD4+， and CD8+ on the 7th postoperative day were not statistically different from preoperative levels （P＞0.05）; CD4+ /CD8+ ratio on the 1st postoperative day was significantly lower than preoperative level （P＜0.05）， while CD4+ /CD8+ ratios on the 3rd and 7th postoperative day were not statistically different from preoperative level （P＞0.05）. There was no statistical difference in preoperative T lymphocyte subsets between the trial group and the control group （P＞0.05）. The percentages of CD4+ and CD4+/CD8+ ratio in the trial group were significantly higher than those of the control group on the 1st postoperative day （P＜0.05）， while the percentages of CD3+ and CD4+ and CD4+ /CD8+ratio in the trial group were significantly higher than those of the control group on the 3rd and 7th postoperative day（P＜0.05）. Conclusion Use of rhGH can significantly increase T lymphocyte subsets expression， enhance body cellular immunity， and improve postoperative recovery of patients with rheumatic valvular heart disease during the perioperative period of heart valve replacement.
ObjectivesTo investigate the correlation of warfarin dose genetic and polymorphism of Han-patients after heart valve replacement, to forecast the anticoagulation therapy with warfarin reasonable dosage, and to realize individualized management of anticoagulation monitoring. MethodsWe selected 103 patients between January 1, 2011 and December 31, 2012 in West China Hospital of Sichuan University who were treated by oral warfarin after heart valve replacement with monitoring anticoagulation by international normalized ratio (INR) in Anticoagulation Therapy Database of Chinese Patients after Heart Valve Replacement. There were 32 males and 71 female at age of 21-85 (48.64± 11.66) years. All the patients' CYP2C9 and VKORC1 genetic polymorphisms were detected by using polymerase chain reaction-restriction fragment length polymorphism (PCR-RELP) method and gene sequencing technology. Warfarin concentration in plasma was determined by high performance liquid chromatography (HPLC) method. The activity of coagulation factorⅡ, Ⅶ, Ⅸ, Ⅹwas determined by Sysmex CA7000 analyzer. ResultsThe multivariate linear regression analysis showed that age, body surface area, and coagulation factor activity had no significant effect on warfarin dosage. While the gene polymor-phisms of CYP2C9 and VKORC1, warfarin concentration, and age had significant contributions to the overall variability in warfarin dose with decisive coefficients at 1.2%, 26.5%, 43.4%, and 5.0% respectively. The final equation was:Y=1.963-0.986× (CYP2C9* 3) +0.893× (VKORC1-1639) +0.002× (warfarin concentration)-0.019× (age). ConclusionMultiple regression equation including gene polymorphisms of CYP2C9 and VKORC1, non-genetic factors of coagulation factor activity, warfarin concentration, age, and body surface area can predict reasonable dosage of warfarin for anticoagulation to achieve individualized management of anticoagulation monitoring and reduce the anticoagulation complications.
Abstract： Objective To construct an Anticoagulation Therapy Database of Chinese Patients after Heart Valve Replacement in accordance with blood coagulation characteristics of Chinese patients， fill the gap of Chinese clinical research in valvular heart diseases， and provide a scientific and objective basic data and information exchange platform. Methods A national multicentre，prospective and cohort clinical research method was applied to establish an anticoagulation therapy database of Chinese patients after heart valve replacement， using the Internet as a platform. A case report form （CRF）， which was in line with the actual situation of Chinese anticoagulation patients after heart valve surgery， was formulated through the discussion of experts from 36 cardiovascular surgery centers in China in the starting meeting of National Science amp; Technology Support Program during the Twelfth Five-year Plan Period.We planned to prospectively include patients receiving warfarin anticoagulation therapy and formal anticoagulation monitoring after heart valve replacement from January 1, 2011 to December 31, 2014. Database was constructed using warehousing technology， which allowed not only data monitoring， query and statistics， but also regular data backup and system updates. Results A network database entitled Anticoagulant Therapy Database of Chinese Patients after Heart Valve Replacement was constructed and linked with the homepage of Chinese Journal of Clinical Thoracic and Cardiovascular Surgery （http：//www. zgxxwkzz. com）， which constituted a national Internet information platform. From 1 January 2011 to 1 December 2012， 8 452 anticoagulation patients after heart valve replacement from 34 level-3A hospitals in China had been registered in the database. Further follow-up of these patients was being carried out in respective hospitals. Conclusion A large multi-center and open database and network information platform has been constructed. The database variables are in line with clinical characteristics of Chinese anticoagulation patients after heart valve replacement， which provide scientific and objective basic data and support for future clinical research and systemic analysis.
Objective To discuss the application value in increasing the frequency of monitoring and ensuring the safety of anticoagulation therapy in patient self-monitoring (PST) and self-management (PSM) of portable coagulometer. Method This non-randomized prospective controlled study was conducted in 100 patients receiving oral warfarin anticoagulation therapy after heart valve replacement and met the inclusion criteria in our hospital between March 2013 and April 2014 year. All the patients were divided into three groups including an outpatient follow-up group(outpatient group), a self-monitoring group and a self-management group. Meanwhile, the patients in the outpatient group visited professional institutions, performed international normalized ratio (INR) testing with central lab and adjusted the dosage of orally administered warfarin by the doctors. And the other two groups performed INR testing with CoaguChek XS portable coagulometer by themselves, and the patients in the self-management group performed management by themselves. The follow-up time was 6 months. The dates of time in therapeutic range (TTR), fraction of time in therapeutic range (FTTR) and anticoagulation complications in the three groups were analyzed and compared. Results There was no significant difference in the INR results obtained from the follow-up time among the three groups (P=0.845) . TTR value of INR of the outpatient group, the self-monitoring group, and the self-management group was 45.9% (4368.0 days/9517.0 days), 61.2% (6057.0 days/9897.0 days), and 65.4% (2833.8 days/4333.0 days), respectively with a statistical difference among the three groups (P<0.001) . FTTR value of INR obtained from the outpatient group, the self-monitoring group, and the self-management group was 48.3% (99 times/205 times), 60.7% (164 times/270 times), and 64.9% (100 times/154 times) respectively. There was a statistical difference in the FTTR between the outpatient group and the self-monitoring group (P=0.007) , and also between the outpatient group and the self-monitoring group (P=0.002) . But there was no statistical difference between the self-monitoring group and the self-management group (P=0.392) . There were not any major bleeding and thrombosis complications in all study. And there was no statistical difference in the total complications, thrombosis, and bleeding complications rates between the outpatient group and the self-monitoring group, and also between the outpatient group and the self-management group (P>0.05) . Conclusions The patients receiving oral anticoagulation after heart valve replacement or their care providers were able to perform PST and PSM. The use of portable coagulometer for self-monitoring and self-management can increase the frequency of anticoagulation monitoring and achieve better INR target value control. PST and PSM could achieve higher quality of anticoagulation management and life and without increasing the risk of oral anticoagulation than the traditional monitoring method. The monitoring frequency of once a month is reasonable for the patients receiving oral anticoagulation more than half a year after heart valve replacement.
Abstract： Objective To use tissue Doppler strain rate imaging to evaluate the impact of low dose dopamine and milrinone on systolic and diastolic function of the left ventricle of patients undergoing heart valve replacement. Methods Forty patients undergoing selective heart valve replacement in West China Hospital of Sichuan University between March and May 2011 were included in this study. All the patients were randomized into 2 groups with 20 patients in each group： milrione group and dopamine group. After anesthesia induction and before cardiopulmonary bypass setup， left ventricular ejection fraction （LVEF） was measured by echocardiography. Tissue Doppler strain rate imaging was used to measure the left ventricular lateral wall and midventricular segment from the four-chamber view， which was compared with Doppler parameters. Results LVEF， ratio of early-diastolic to end-diastolic velocity （E/A） of transmitral flow， ratio of mitral inflow velocity to early diastolic velocity in the annulus （E/Et） of both 2 groups were significantly different between before and after dopamine and milrinone administration （P＜0. 05）. In the milrinone group， 4 segments systolic peak velocity （Vs）， 1 segment early diastolic peak velocity （Ve）， 4 segments late diastolic peak velocity （Va）， 3 segments Ve/Va ratio， 2 segments systolic peak strain rate （SRs）， 2 segments late diastolic peak strain rate （SRa）， and 3 segments early diastolic peak strain rate SRe/SRa ratio after dopamine and milrinone administration were significantly higher than those before dopamine and milrinone administration （P＜0. 05）. In the dopamine group， 4 segments systolic peak velocity （Vs）， 1 segment Ve， 4 segments Va， 1 segment Ve/Va ratio， 2 segments SRs， 1 segment SRe， 1 segment SRa， and 1 segment SRe/SRa ratio after dopamine and milrinone administration were significantly higher than those before dopamine and milrinone administration （P＜0.05）. To compare the milrione group and dopamine group after medication administration， 2 segments Vs， 4 segments Va， 1 segment SRe， 1 segment SRa， 2 segments Ve/Va ratio， and 2 segments SRe/SRa ratio of the milrione group were significantly higher than those of the dopamine group （P＜0.05）， and 1 segment Vs， two segments SRs of the milrione group were significantly lower than those of the dopamine group （P＜0.05）. Conclusion Both milrinone and dopamine can improve left ventricular systolic function of perioperative patients undergoing heart valve replacement assessed by tissue Doppler strain rate imaging， while milrinone can improve the diastolic function of the left ventricle on the long axis more significantly.