Objective To investigate the effects of exosomal microRNA-1234-3p(miR-1234-3p)of lung cancer cells on the malignant behaviors of lung cancer cells,the polarization of tumor-associat-ed macrophages(TAMs),and the functions of T cells,as well as its potential molecular mecha-nisms.Methods Exosomes were extracted from lung cancer A549 cells,and their morphology was observed using transmission electron microscopy.The expression of exosomal marker proteins[tumor susceptibility gene 101(TSG101),CD63 and CD9]was detected by western blot.The relative ex-pression level of miR-1234-3p was measured using real-time fluorescence quantitative polymerase chain reaction(qRT-PCR).The expression of exosomal miR-1234-3p was inhibited by transfecting,the proliferation,migration,and invasion abilities of A549 cells were detected using the CCK-8 method,wound healing assay,and Transwell invasion assay,respectively.The exosomes were co-cultured with macrophages and T lymphocytes separately.The expression of TAM polarization markers CD206 and CD163 was detected by western blot.The secretion levels of cytokines[interleukin(IL)-6,IL-10,and transforming growth factor-β(TGF-β)]were measured using an enzyme-linked immu-nosorbent assay(ELISA).The proliferation and apoptosis abilities of T lymphocytes,as well as the expression of functional molecules[γ-interferon(IFN-γ)and programmed death receptor 1(PD-1)]were detected through cell experiments.The expression levels of proteins related to the phosphatidylinositol 3-kinase(PI3 K)/protein kinase B(AKT)signaling pathway were detected by western blot.Results The isolated exosomes were round double-layer vesicles with a diameter of 50 to 200 nm and expressed TSG101,CD63 and CD9 proteins.The expression level of miR-1234-3p in A549 cells was higher than that in human normal lung epithelial cells BEAS-2B,and the expression level of miR-1234-3p in A549 cell exosomes was higher than that in parental A549 cells,with statis-tically significant differences(P＜0.001).After inhibiting exosomal miR-1234-3p,the prolifera-tion,migration,and invasion abilities of A549 cells decreased,with statistically significantdifferenc-es(P＜0.001).After inhibiting exosomal miR-1234-3p,the levels of M2-type polarization marker proteins CD206 and CD163 in macrophages decreased,the levels of cytokines IL-10 and TGF-β de-creased,and the level of IL-6 increased,with statistically significant differences(P＜0.001),indi-cating that the polarization of macrophages toward the M2 type was inhibited.In T lymphocytes,af-ter inhibiting exosomal miR-1234-3p,cell viability increased,the apoptosis rate decreased,the ex-pression level of the functional molecule IFN-γ increased,and the expression level of PD-1 de-creased,with statistically significant differences(P＜0.01 orP＜0.001).After inhibiting exosom-al miR-1234-3p,the protein levels of phosphorylated(p)-PI3K and p-AKT in A549 cells de-creased,with statistically significant differences(P＜0.001).Conclusion Exosomal miR-1234-3p of lung cancer cells may promote the malignant behaviors of lung cancer cells,the polarization of TAMs toward the M2 type,and the dysfunction of T lymphocytes by activating the PI3K/AKT signa-ling pathway,thereby regulating the immunosuppressive microenvironment and promoting the pro-gression of lung cancer.

Objective    To evaluate the data of preoperative aortic root CT angiography (CTA), compare it with two-dimensional transthoracic echocardiography and investigate the correlation of the two measurements with the actual intraoperative measurement data. Methods    Clinical data of 53 patients with aortic valve diseases who underwent aortic valve repair in our hospital from January 2018 to August 2020 were retrospectively analyzed, including 38 males and 15 females with an average age of 42.9±18.3 years ranging from 10 to 77 years. Preoperative two-dimensional transthoracic echocardiography (TTE) and aortic root CTA measurements were collected, including aortic valve annulus (AVA), aortic sinus (Sinus) and sino-tubular junction (STJ). In comparison with the intraoperative measurements during the aortic valve repair surgery, the consistency analysis was performed. Results    Both the preoperative echocardiography AVA measurements and the CT AVA measurements were positively correlated with the intraoperative AVA measurements (P<0.001). Compared with the echocardiography AVA data [correlation coefficient (ρ)=0.74, mean squared error (MSE)=12.78], the CT AVA data were more accurate and consistent with the intraoperative AVA measurements (ρ=0.95, MSE=2.72). CT AVA data had a higher correlation coefficient with the intraoperative measurements, compared to that of  the echocardiography AVA data (P<0.001). Conclusion    In comparison with two-dimensional transthoracic echocardiography, preoperative morphological evaluation of aortic root CTA is more consistent with the actual intraoperative measurements during aortic valve repair surgery.

Objective    To evaluate the midterm effect of valve-sparing aortic root replacement (VSRR) on aortic root aneurysm and moderate to severe aortic regurgitation (AR). Methods    The clinical data of patients with aortic root aneurysm and moderate to severe AR undergoing VSRR and surviving from the operation from October 2013 to May 2020 were retrospectively analyzed. There were 31 males and 9 females, with an average age of 47.1±13.4 years. There were 30 patients with true aneurysm of aortic root and 10 patients with dissecting aneurysm of aortic root. There were 3 patients with bicuspid aortic valve, and 12 patients with Marfan syndrome. The AR measured by the echocardiogram was moderate in 18 patients and severe in 22 patients. The average diameter of aortic annulus was 27.0±3.9 mm, and the mean largest diameter of aortic sinus was 52.3±6.1 mm. Results    A total of 32 patients underwent David technique and 8 patients underwent Yacoub technique, and 10 patients underwent aortic cusp repair simultaneously. All 40 patients  completed the follow-up, and the follow-up period was 12-86 (45.7±18.9) months. During the period, 1 patient died of heart failure, 2 had reoperation due to new-onset Stanford B aortic dissection, and no patients had reoperation related to aortic valve. The postoperative New York Heart Association cardiac function classification (1.6±0.5 vs. 2.8±0.8), left ventricular end-diastolic dimension (52.2±7.8 mm vs. 61.4±10.6 mm) and left ventricular end-diastolic volume (136.0±58.8 mL vs. 193.3±83.9 mL) of the patients were significantly improved compared with preoperative ones (P<0.05). By echocardiography, 19 patients had no AR, 18 patients had mild AR, 3 patients had mild-moderate AR, and no patients had moderate or higher AR. Conclusion    In patients with aortic root aneurysm and moderate to severe AR, VSRR technique avoids prosthetic valves and anticoagulation-related complications, has lower rate of AR recurrence and reoperation, and improves the quality of life in the midterm period.

Objective    To evaluate the short and mid-term outcomes of valve repair in patients with insufficient bicuspid aortic valves (BAV). Methods    The clinical data of 27 consecutive patients with insufficient BAV undergoing valve repair in Shanghai Chest Hospital from September 2016 to January 2020 were retrospectively reviewed. There were 24 males and 3 females with a mean age of 38.5±14.6 years (range: 20-68 years). BAV of all patients was type 1 in Seviers' classification. There were 23 patients with left-right fusion and 4 patients with right-noncoronary fusion. There was aortic regurgitation in the patients measured by the echocardiogram, including moderate regurgitation in 3 patients, moderate-severe in 18 patients, and severe in 6 patients. The diameter of aortic annular base was 27.9±3.4 mm, and the largest diameter of aortic sinus was 39.9±7.6 mm. Left ventricular end diastolic diameter was 62.7±6.5 mm, and the volume was 197.9±53.6 mL. Results    All 27 patients completed the follow-up, and the mean time was 24.2±12.5 months (range: 12-51 months). No patient died or required aortic valve-related reoperation during the follow-up. The cardiac function of the patients significantly improved postoperatively (P<0.05). By echocardiography, 11 patients had no aortic regurgitation, 13 had mild aortic regurgitation, and 3 had moderate aortic regurgitation, and no patient had severe aortic regurgitation. Postoperative left ventricular end diastolic diameter and volume decreased, compared to preoperative ones (P<0.05). Conclusion    In patients with insufficient BAV, valve repair is safe and effective, and has excellent short and mid-term outcomes.

Objective    To evaluate the feasibility and safety of modified Yacoub technique with aortic annuloplasty in the patients with aortic root aneurysm and dilatation of aortic annular base. Methods    We performed a retrospective review of 6 patients with aortic root aneurysm undergoing modified Yacoub technique with aortic annuloplasty from November 2017 to January 2019. There were 5 males and 1 female, with a mean age of 54.1±12.3 years. The preoperative cardiac function of 3 patients was in New York Heart Association (NYHA) classⅡand the other 3 patients were in class Ⅲ. There were two patients with bicuspid aortic valve, and no Marfan syndrome. There was aortic regurgitation in the patients measured by the echocardiogram, 1 in mild aortic regurgitation, 1 in moderate aortic regurgitation, and 4 in severe aortic regurgitation. The diameter of aortic annular base was 27.8±1.9 mm, and the largest diameter of aortic root was 49.8±3.7 mm. Six patients underwent modified Yacoub technique with aortic annuloplasty, including 5 patients who underwent aortic cusp repair at the same time. Results    All 6 identified patients survived. There was no severe complication (bleeding, stroke, or acute renal failure). The cardiopulmonary bypass time was 204.6±13.5 min, aortic cross-clamping time 168.0±17.1 min, mechanical ventilation time 21.3±19.5 h, ICU stay time 67.8±62.2 h. The follow-up time ranged from 4 to 18 months with an average time of 12.8±4.7 months. Patients' cardiac function improved postoperatively with four patients in NYHA classⅠand two patients with classⅡ. Two patients had no aortic valve regurgitation, four patients had mild regurgitation. Left ventricular end diastolic volume decreased significantly (118.6±20.4 mL vs. 169.1±58.4 mL, P<0.05). Conclusion    The modified Yacoub technique with aortic annuloplasty is effective and safe for the patients with aortic root aneurysm and dilatation of aortic annular base, and the early- and mid-term outcomes are satisfactory.

Objective To investigate the safe and effective method for laryngeal microsurgery in difficult la‐ryngeal exposure cases .Methods We selected 62 patients’ clinical data who had received laryngeal microsurgery with difficult laryngeal exposure and could not exposure by normal self -retaining laryngoscope between July 2012 and June 2015 .There were 42 cases of vocal cord polyp ,9 cases of the vocal cyst ,5 cases of the vocal amyloidosis , 4 cases of severe atypical hyperplasia of vocal cords and 2 cases of vocal cord high differentiated squamous carcino‐ma .We completed all kinds of laryngeal microsurgery to expose the glottis by adjusting the postures of patients ,in‐creasing the anesthesia depth ,using self -retaining laryngoscope with endoscopy which can be adjusted and pressing the throat .Results In 62 patients ,58 patients were successfully operated with adjustable self -retaining laryngo‐scope with endoscopy ,the success rate was 93 .55% .And 25 cases was exposed the glottis completely by increasing the anesthesia depth ,however ,when we increased the anesthesia depth ,there were 10 cases needed to combined with pressing the throat to expose .Five patients had retropharyngeal injure with different levels .One case with small jaw deformity of the vocal cord polyp surgery was not successful ,the success of electronic endoscopic under surface anesthesia surgery .The other one case with teeth unkempt and porcelain teeth and two cases of intraoperative frozen tip vocal cord cancer completed the operation of the open throat under the non trachea incision .Conclusion Most of difficult exposed laryngeal can be safely and effectively exposed through using the adjustable self -retaining laryngo‐scope with endoscopy while normal self -retaining laryngoscope can not .When necessary ,we can put 30°endoscope into the side channel of self -retaining laryngoscope to complete all kinds of laryngeal microsurgery .