ObjectiveTo introduce the role of three dementional computed tomograph (3D-CT) for patients underwent transcatheter aortic valve implantation (TAVI) procedure in perioperative evaluation. MethodsFrom April 2014 to June 2015, we retrospectively analyzed clinical data of 28 patients with severe aortic stenosis underwent successful TAVI procedure using new second-generation device, who were enrolled in this study including 12 males and 16 females at mean age of 72.8±4.5 years. We used 3D-CT to get the perioperative relative evaluation, including valve morphology and calcification degree, annular diameter, aoronary ostium height, ascending aorta, aortic sinus diameter, left ventricular-aortic angle, optimal intraoperative angiogram projection angle. Based on the evaluation by 3D-CT image, the prosthesis size, balloon size, best intraoperative imaging projection angle and approach of apex were then chosen. ResultsAll patients with severe aortic stenosis underwent successful TAVI procedure with mean logistic Euro-SCORE I:26.2%±7.9%. CT image revealed that mean aortic annular diameter was 24.6±1.8 mm with mean valve prosthesis size 25.8±1.1 mm and pre-dilation balloon size 23.1±1.2 mm and 76.8% patients were of tricuspid aortic valve with severe calcification and 25% patients were of asymmetric calcification. Optimal intraoperative angiogram image was achieved in 92.9% patients with the help of preoperative CT image. There was a statistic difference in mean transvalvular gradient after valve implantation (54.1±15.3 mm Hg vs. 13.1±8.5 mm Hg, P<0.05). And there was no mortality or severe complication postoperatively. Conclusion3D-CT image palys an important role during perioperative evaluation of TAVI procedure and it can be helpful for Chinese doctors to operate TAVI successfully.
目的总结左胸骨旁小切口微创封堵分流方向偏向流出道的室间隔缺损（VSD）的初步经验。 方法2014年2～8月广州医科大学附属第一医院对15例分流方向偏向流出道的VSD患者施行左胸骨旁小切口微创封堵手术，其中男7例，女8例；年龄10个月～19岁（4.5±4.6）岁；体重5.5～54.0（14.6±14.1）kg；其中干下型6例，嵴内型6例，膜周部型3例；缺损直径2.5～6.5（4.0±1.2）mm，距主动脉瓣环距离≤1 mm 9例，≤2 mm4例，>2 mm 2例；合并主动脉瓣右冠瓣轻度脱垂5例；采用左胸骨旁第2或第3肋间1.5～2.5 cm切口，在经食管超声心动图（TEE）监视下在右心室流出道表面选择适当的穿刺点，建立VSD输送轨道并置入封堵器，观察有无残余分流、主动脉瓣反流；术后3个月复查经胸超声心动图。 结果15例均成功封堵，无中转开胸，无残余分流和心律失常，新发主动脉瓣轻微反流2例，围手术期输血1例；手术时间30～120（58±28）min，术中出血量5～200（26±50）ml；术后住院时间3～13（4.3±2.6）d，无二次开胸止血、Ⅲ°房室传导阻滞、主动脉瓣反流加重、溶血、切口感染等并发症；术后3个月返院复查经胸超声心动图13例，无新发主动脉瓣反流和封堵器脱落；2例术中新发主动脉瓣反流加重，其中1例出现残余分流。 结论左胸骨旁小切口封堵分流方向偏向流出道VSD 手术安全、切口小、操作简单，近期效果尚满意；对合并主动脉瓣轻度脱垂VSD 需慎重施行外科微创封堵手术。
Abstract:Objective To investigate clinical characteristics of patients with aortic valve disease and coronary artery disease （CAD）， and improve the pertinence of clinical management. Methods Clinical data of 78 patients who were older than 50 years and underwent isolated aortic valve replacement （AVR） in General Hospital of Shenyang Command from January to October 2010. All the patients were divided into two groups according to whether they had CAD：20 patients with CAD in the CAD group， including 19 males and 1 female with their average age of 64.6±8.3 years， and 58 patients without CAD in the control group， including 28 males and 30 females with their average age of 58.7±6.2 years. Clinical characteristics of AVR patients with CAD were analyzed by one-way analysis of variance and multiple factor analysis. Results One-way analysis showed that the incidence of old age （P=0.000）， male patients （P=0.004）， diabetes （P=0.004）， aortic regurgitation （P=0.034）， valvular lesion （P=0.028）， and postoperative mechanical ventilation time （P=0.008）of CAD group patients were significantly higher or longer than those of control group patients. Multiple factor analysis showed that independent clinical characteristics of AVR patients with CAD included male patients， old age， prolonged postoperative mechanical ventilation time， significantly decreased pulmonary arterial systolic pressure （PASP） at 6th postoperative month， and significant preoperative right ventricular diastolic dysfunction. Conclusion The screening age for possible CAD should be reasonably lowered if male patients with aortic valve disease have concomitant preoperative right ventricular diastolic dysfunction and/or tricuspid aortic valve degeneration. Patients undergoing isolated AVR need to take medications to reverse left ventricular remodeling for a long time to avoid severe arrhythmia.
Objective To evaluate clinical outcomes of mild-to-moderate or moderate functional mitral regurgitation（FMR）after aortic valve replacement （AVR） in patients with severe aortic stenosis （AS），and analyze prognostic factors of these patients with mild-to-moderate or moderate FMR （2＋to 3＋）. Methods From September 2008 to December 2011，a total of 156 patients with severe AS （peak aortic gradient （PAG）≥50 mm Hg） as well as FMR （2＋to 3＋） underwent surgical treatment in Zhongshan Hospital. There were 95 male and 61 female patients with their average age of 59.2±10.5 years. Detailed perioperative clinical data were collected，and postoperative patients were followed up. The ratio of FMRpreoperative/FMR postoperative was calculated. Patient age，gender，body weight，history of hypertension，ventricular arrhythmia，atrial fibrillation （AF），left ventricular ejection fraction （LVEF），left ventricular end-diastolic diameter （LVEDD），left atrial diameter （LAD），pulmonary artery hypertension （PAH），PAG were assessed by logistic multivariate regression analysis. Results Six patients died postoperatively，including 4 patients with low cardiac output syndrome and 2 patients with refractory ventricular arrhythmia. Perioperative mortality was 3.8%. The average follow-up time was 20.3±8.5 months and follow-up rate was 85.3% （133/156）. Eight patients died during follow-up，including 3 patients with heart failure，2 patients with ventricular arrhythmia，and 3 patients with anticoagulation-related cerebrovascular accident. Multivariate regression analysis showed that FMR preoperative/FMR postoperative ratio was not correlated with age≥55 years，male gender，body weight≥80 kg，LVEDD≥55 mm，LVEF≤50%，history of hypertension or ventricular arrhythmia. However，LAD≥50 mm，PAH≥50 mm Hg，PAG≤75 mm Hg and preoperative AF were negatively correlated with postoperative FMR improvement. Conclusions Risk factors including LAD≥50 mm，PAH≥50 mm Hg，PAG≤75 mm Hg and preoperative AF are negatively correlated with postoperative improvement of FMR （2＋to 3＋）. Patients with severe AS and above risk factors should receive concomitant surgical treatment for their FMR during AVR，since preoperative FMR（2＋to 3＋）usually does not improve or even aggravate after AVR.
Abstract： Objective To summarize surgical results of secondary subaortic stenosis （SSS） after congenital heart disease （CHD） operations，and analyze the pathogenesis of SSS. Methods We retrospectively analyzed clinical data of 19 patients who underwent surgical repair for SSS in Guangdong General Hospital from 1st June 2008 to 31st December 2012. There were 10 males and 9 females. CHD types included double outlet right ventricle，ventricular septal defect and partial atrioventricular septal defect，et al. The median age of the patients when they received their first CHD operations was 4 months （15 days to 5 year and 11 months）. The median age of the patients when they received SSS repair was 5 years and 3 months （1 year to 15 years and 3 months）. The median time interval from CHD operation to SSS repair was 4 years and 10 months （8 months to 13 years and 11 months）. Results All the patients successfully received their SSS repair. There was no surgical death in this study. Median cardiopulmonary bypass time was 79 （39 to 172） minutes，and median aortic cross-clamp time was 42 （22 to 124） minutes. Median postoperative hospital stay was 7 （5 to 9） days. Postoperatively， 1 patient required permanent pacemaker implantation. All the patients were followed up after discharge for a median durationof 1 year and 10 months （5 months to 4 years and 4 months） . During follow-up， none of the patients had any clinical symptom，their heart function was normal，and there was no late death. One patient received another subaortic stenosis repair for gradually aggravating left ventricular outflow tract stenosis. Conclusions SSS is very rare after CHD operations. The pathogenesis of SSS is perhaps related to abnormal blood flows in the left ventricular outflow tract after CHD operations. The pathogenesis time of SSS and types of CHD leading to SSS cannot be predicted. Subaortic stenosis repair is a simple and safe procedure for SSS，but postoperatively left ventricular outflow tract stenosis may appear and aggravate again.
Abstract： Objective To summarize the methods and results of supra-annular aortic valve replacement（AVR） in patients with severely damaged aortic annulus. Methods Supra-annular AVR was performed in 5 patients between March 2008 and Dec. 2010 in Changhai Hospital, Second Military Medical University. There were 4 males and 1 female with their mean age of 46.3 years (ranging from 38 to 53 years). Non-specific infectious diseases were diagnosed in 4 patients who had severe paravalvular leakage after their first AVR operations (2 patients with Behcet’s disease and 2 patients with arteritis), and one patient had severe infectious endocarditis. All the patients had severely destroyed aortic annulus and could not undergo routine AVR. The prosthetic valves were fixed to the aortic sinus wall between the annulus and coronary arterial ostia, and the sutures passed through from the outside of aortic wall into the inside and prosthetic valve ring. Coronary artery bypass grafting was performed if the coronary ostium was involved. Results All patients recovered from the operations uneventfully, and were followed up from 6 months to 3 years. All patients were in New York Heart Association（NYHA） functional class Ⅰ or Ⅱ during the follow-up period, and paravalvalar leakage, pseudoaneurysm and aortic root aneurysm were not found by the examination of 3D computed tomographic angiography and echocardiography at 6 months（4 cases）, 1 year（2 cases）, and 3 years（1 case）, respectively . Conclusions Supra-annular AVR is an alternative surgical method for patients with severely damaged aortic annulus. The procedure is simple and effective to prevent paravalvular leakage and pseudoaneurysm formation.
Abstract： Objective To estimate the effectiveness and safety of intra-aortic balloon pump （IABP）in the patients with mild or mild to moderate aortic regurgitation. Methods A total of 15 patients with mild or mild to moderate aortic regurgitation and low left ventricular ejection fraction (LVEF＜ 40.00%) including 11 males and 4 females, who underwent IABP application after cardiac surgery between September 2006 and January 2011, were included in this study. Their age ranged from 50 to 74 years with an average age of 63.60 years. There were 9 patients with mild aortic regurgitation and 6 patients with mild to moderate aortic regurgitation, all with LVEF ＜ 40.00%. IABP catheters were inserted before operation and IABP worked after heart the recovery of heart beat. Mean aortic pressure (MAP), cardiac index (CI), systemic vascular resistance index (SVRI), pulmonary vascular resistance index (PVRI), LVEF , and aortic regurgitation volume before the use of IABP and after stopping use of it were compared. Results The total mortality was zero. The patients’ CI significantly improved from 1.99±0.23 L/(min.m2) to 3.30±0.29 L/(min.m2) after IABP （t =48.30，P=0.00）. Their LVEFs were significantly improved after use of IABP (37.20%±1.37% versus 42.60%±2.87%， t =11.34，P=0.00）. Their SVRI improved significantly (2 347.00±190.00 dyn·s/(cm5·m2) versus 2 128.00±204.00 dyn·s/(cm5 · m2)，t=20.60, P=0.00）after use of IABP. However, their aortic regurgitation volume were not significantly increased（χ2=0.60, P=0.44）. Conclusion Application of IABP in patients with mild or mild to moderate aortic regurgitation and low LVEF can obtain good circulation support after operation without increasing their aortic regurgitation.