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Bilateral Pectoralis Major Muscle Flaps for the Treatment of Sternal Dehiscence after Cardiac Surgery

Objective To investigate surgical strategies using bilateral pectoralis major muscle flaps for the treatment of sternal dehiscence after cardiac surgery. Methods From May 2005 to October 2010，21 patients with sternal dehiscence, sternal osteomyelitis and mediastinitis after cardiac surgery were admitted to Beijing An Zhen Hospital of　Capital Medical University. There were 13 male patients and 8 female patients with their age of 53-72 （64.5±7.8） years. There were 19 patients after coronary artery bypass grafting （CABG） and 2 patients after heart valve replacement. The non-viable　and necrotic bones were debrided and sternal wires partially or completely removed. The sternal origins of pectoralis major were released on both sides. The pectoralis major muscle flaps were tensionlessly sutured across medially over the sternal defect. Multiple suction drains were placed and removed in due time. The skin was intermittently closed. Results All the pectoralis major muscle flaps lived well after surgery，and all the patients were discharged in 2 weeks after surgery. Twenty patients were discharged with complete wound closure，and 1 patient had wound fistula and infection after removal of suction drains that was healed after another surgery to resect the wound fistula. During 6 month follow-up，sternal wound healed well in all the patients with normal thoracic appearance，and none of the patients had abnormal respiratory movement, infection recurrence or persistent infection. Conclusion Bilateral pectoralis major muscle flap technique is a positive and efficient surgical strategy for the treatment of refractory sternal dehiscence after cardiac surgery.

Clinical Analysis of Patients Undergoing Mitral Valvuloplasty for Anterior Mitral Leaflet Prolapse with Looped　Artificial Chordae

Objective To summarize surgical techniques，advantages and clinical outcomes of mitral valvuloplasty for anterior mitral leaflet prolapse with looped artificial chordae. Methods Clinical data of 13 patients with anteriormitral leaflet prolapse and severe mitral regurgitation （MR） who underwent mitral valvuloplasty with looped artificial chordaefrom January 2009 to December 2011 in Beijing Anzhen Hospital were retrospectively analyzed. There were 8 male and 5 female patients with their age of 21-61 （39.5±12.9） years. There were 10 patients with anterior mitral leaflet chordal rupture and 3 patients with anterior mitral leaflet elongation. Preoperative left ventricular end-diastolic diameter （LVEDD） was 52-65 （58.3±1.7） mm，and left ventricular ejection fraction （LVEF） was 53%-65% （58.8%±2.8%）. All the patients underwent mitral valvuloplasty. We measured the neighboring normal chordae with a caliper for reference and constructed the artificial chordal loops on the caliper with expended polytetrafluoroethylene（ePTFE） CV4 Gore-Tex suture lines. Three to five loops were made and fixed to the papillary muscle with a Gore-Tex suture line and the free edge of the prolapsedanterior mitral leaflet with another Gore-Tex suture line，with the intervals between the loops of 5 mm. Left ventricular watertesting was performed to evaluate MR status，annuloplasty ring implantation or “edge to edge” technique was used if nece-ssary，and left ventricular water testing was performed again to confirm satisfactory closure of the mitral valve. Patientsreceived re-warming on cardiopulmonary bypass and the heart incision was closed. The effect of mitral annuloplasty was alsoassessed by transesophageal echocardiography （TEE） after heart rebeating. Warfarin anticoagulation was routinely used for 3 months after discharge. Results There was no perioperative death in this group. Twelve patients received satisfactory outcomes after 1-stage mitral valvuloplasty with looped artificial chordae and annuloplasty ring implantation. One patient didn’t receive satisfactory outcomes in the left ventricular water testing after mitral valvuloplasty with looped artificial chordae，but satisfactory outcome was achieve after “edge to edge” technique was used，and annuloplasty ring was not used for this patient. Postoperative echocardiography showed trivial to mild MR in all the patients，their LVEDD was significantly reducedthan preoperative LVEDD （47.5±2.1 mm vs. 58.3±1.7 mm，P＜0.05），and there was no statistical difference between postoperative and preoperative LVEF（58.5%±2.6% vs. 58.8%±2.8%，P＞0.05）. All the patients were followed up for 3-36 （19.5±3.7） months. Echocardiography showed mild MR in 4 patients and none or trivial MR in 9 patients during follow-up.Conclusion Mitral valvuloplasty with looped artificial chordae is an effective surgical technique for the treatment of anterior mitral leaflet prolapse with satisfactory clinical outcomes，and this technique is also easy to perform.

Clinical Outcomes of Preservation of Posterior Leaflet and Subvalvular Structures in Mitral Valve Replacement

Abstract： Objective To summarize our experience and clinical outcomes of preservation of posterior leaflet and subvalvular structures in mitral valve replacement（MVR）. Methods We retrospectively analyzed the clinical data of 1 035 patients who underwent MVR in Beijing An Zhen Hospital from January 2006 to March 2011. There were 562 male patients and 473 female patients with their age of 37-78（53.84±13.13）years old. There were 712 patients with rheumatic valvular heart disease and 323 patients with degenerative valve disease, 389 patients with mitral stenosis and 646 patients with mitral regurgitation. No patient had coronary artery disease in this group. For 457 patients in non-preservation group, bothleaflets and corresponding chordal excision was performed, while for 578 patients in preservation group, posterior leafletand subvalvular structures were preserved. There was no statistical difference in demographic and preoperative clinical characteristics between the two groups. Postoperative mortality and morbidity, and left ventricular size and function were compared between the two groups. Results There was no statistical difference in postoperative mortality（2.63% vs. 1.21%, P =0.091）and morbidity （8.53% vs. 7.44%, P=0.519）between the non-preservation group and preservation group, except that the rate of left ventricular rupture of non-preservation group was significantly higher than that of preservation group（1.09% vs. 0.00%, P=0.012）. The average left ventricular end-diastolic dimension （LVEDD）measured by echocardiography 6 months after surgery decreased in both groups, but there was no statistical difference between the two groups. The average left ventricular ejection fraction (LVEF) 6 months after surgery was significantly improved compared with preoperative average LVEF in both groups. The average LVEF 6 months after surgery in patients with mitral regurgitation in the preservation group was significantly higher than that in non-preservation group （56.00%±3.47% vs. 53.00%±3.13%，P =0.000）, and there was no statistical difference in the average LVEF 6 months after surgery in patients with mitral stenosis between the two groups（57.00%±5.58% vs. 56.00%±4.79%，P =0.066）. Conclusion Preservation of posterior leaflet and subvalvular structures in MVR is a safe and effective surgical technique to reduce the risk of left ventricle rupture and improve postoperative left ventricular function．

先天性双冠状动脉-肺动脉瘘缝扎术后再通一例

Comparison Analysis Between Chordal Transposition and Chordal Shortening in Repairing Anterior Leaflet Prolapse

Objective To compare chordal transposition and chordal shortening in repairing anterior leaflet prolapse (ALP)， and explore the surgical indications as well as merits and demerits of these two techniques. 〖WTHZ〗Methods We retrospectively reviewed the data of 90 ALP patients recruited into Anzhen Hospital between March 1986 and March 2008, and classified them into chordal shortening group (n=23) and chordal transposition group (n=67). KaplanMeier survival curve and freedom from reoperation curve were established to compare the two groups. Univariate analysis and multivariate logistic analysis regression were used to identify independent risk factors for early death and late cardiac events. 〖WTHZ〗Results There were three perioperative deaths in chordal shortening group（13.0%）, and three deaths in chordal transposition group (4.4%), and the difference was not significant (χ2=2.019，P=0.155). The follow-up time ranged from 1 month to 18 yrs（7.70±5.41 yrs）. There were 5 late deaths, of which 3 were in chordal shortening group and 2 in chordal transposition group. The KaplanMeier survival curve showed that 5-year survival rate of chordal shortening group was significantly lower than chordal transposition group (70.00%±18.24% vs.98.00%±1.98%,χ2=12.50, P=0.000); And the KaplanMeier freedom from reoperation curve showed [CM(159mm]that 5-year reoperation rate of chordal shortening group was also significantly lower than chordal transposition group (83.30%±15.20% vs.96.10%±2.71%,χ2=10.27，P≤0.001). By the univariate analysis, we found that age＞55 yrs old, concomitant CABG procedure, New York Heart Association (NYHA) function class Ⅲ-Ⅳ, preoperative heart failure history, aortic clamping time＞90 min, and preoperative lefe ventricular ejection fraction (LVEF)＜45% were the risk factors for perioperative death and risk factors for late cardiac events included postoperative mitral regurgitation＞2+, chordal shortening technique, preoperative heart failure history, and aortic clamping time＞90 min. The multivariate logistic analysis regression showed that aortic clamping time＞90 min, concomitant CABG procedure, preoperative LVEF＜45% were the independent predictors for perioperative death, and NYHA class ⅢⅣ, chordalshortening technique and residual mitral regurgitation＞2+ were the independent predictors for the late cardiac events. Conclusion （1） There is no statistically difference between chordal transposition and chordal shortening in the perioperative survival rate. (2) Chordal transposition has a relative superiority to chordal shortening in terms of 5-year survival rate. (3) Chordal transposition has a higher mid and longterm rate of freedom from reoperation than chordal shortening. （4） Although chordal transposition has a lower incidence of reoperation and ahigher mid and longterm survival rate, the indication for it is restricted to less extensive ALP and patients with transferrable chord in the posterior leaflet. Chordal shortening is an independent risk factor for late events.

升主动脉隔离装置在升主动脉近端钙化患者非体外循环冠状动脉旁路移植术中的应用

摘要： 目的 评价升主动脉近端隔离装置（Heartstring和Enclose近端吻合装置）在非体外循环冠状动脉旁路移植术（OPCAB）中的应用效果。 方法 2006年1月至2008年2月收治了150例合并升主动脉近端钙化的冠心病患者，其中男102例，女48例；年龄55～78岁，平均年龄69岁。所有患者在冠状动脉旁路移植术中应用升主动脉近端隔离装置，大隐静脉与升主动脉近端共完成251个吻合口，升主动脉近端吻合口1～3个/例，大隐静脉桥血管完成后应用流量仪进行流量测定。术后观察神经系统并发症的发生情况。 结果 术后死于低心排血量综合征1例（067%）；二次开胸止血2例，其中1例为乳内动脉床渗血，1例为胸骨后出血；其余患者术后24 ｈ胸腔引流量为100～200 ml。所有患者均于术后24～48 ｈ内顺利拔除气管内插管；术后均未出现明确的昏迷、肢体偏瘫、语言障碍及运动不协调等神经系统并发症；大隐静脉桥血流量为28.5～70.1 L/min（53.7± 23.9 L/min）。术后随访145例，随访率97.32%，随访时间3个月～1年；4例失访。随访期间患者未发生迟发性脑出血或脑梗死等神经系统并发症。结论 在OPCAB术中应用Heartstring和Enclose升主动脉近端隔离装置，安全、有效，能有效地降低脑卒中的发生率。

Comparative Study of Surgical Treatments between Proximal and Distal Types of Chronic Thromboembolic Pulmonary Hypertension

Abstract: Objective To retrospectively compare the difference of the effects of pulmonary thromboendarterectomy (PTE) between distal and proximal types of chronic thromboembolic pulmonary hypertension (CTEPH). Methods The data of 70 patients (including 44 male patients and 26 female patients, the average age was 46.2 years old, ranging from 17 to 72) with CTEPH having undergone PTE from March 2002 to March 2009 in Anzhen Hospital were retrospectively reviewed. We classified them into two different groups which were the proximal CTEPH group (n=51) and the distal CTEPH group (n=19) according to the pathological classification of the CTEPH. Clinical data, hemodynamics blood gas analysis and so on of both groups were compared. Results There was no perioperative deaths in both groups. Compared with the proximal group, cardiopulmonary bypass time [CM(159mm](189.5±41.5 min vs.155.5±39.5 min,P=0.003), aorta cross clamp time (91.3±27.8 min vs.67.2±27.8 min,P=0.002) and DHCA time (41.7±14.6 min vs.25.7±11.6 min,P=0.000) were significantly longer in the distal group. The incidence of residual pulmonary hypertension in the distal group was significantly higher than that in the proximal group (42.1% vs.13.7%,P=0.013), while the incidence of pulmonary reperfusion injury postoperatively in the proximal group was significantly higher than that in the distal group (41.2% vs.10.5%, P=0.021). SwanGanz catheterization and blood gas index were obviously improved in both groups. However, the pulmonary artery systolic pressure (PASP, 67.8±21.3 mm Hg vs.45.5±17.4 mm Hg,P=0.000) and the pulmonary vascular resistance ［PVR, 52.8±32.1 kPa/(L·s) vs.37.9±20.7 kPa/(L·s),P=0.024］ 　in the distal group were significantly higher than those in the proximal group and the partial pressure of oxygen in arterial blood of the distal group was significantly lower than that of the proximal group (76.7±8.7 mm Hg vs.88.8±9.3 mm Hg,P=0.000). After operation, 70 patients were followed up with no deaths during the followup period. The time of the followup ranged from 2 to 81 months (32.7±19.6 months) with a cumulative followup of 191.8 patientyears. Three months after operation, 47 patients were examined by pulmonary artery computer tomography angiogram (PACTA) and isotope perfusion/ventilation scan, which showed that the residual occlusive pulmonary artery segment in the proximal group was significantly fewer than that in the distal group (isotope perfusion/ventilation scan: 2.2±11 segments vs. 4.7±2.1 segments, P=0.000; PACTA: 3.5±1.4 segments vs. 4.9±2.0 segments,P=0.009). The New York Heart Association (NYHA) functional class and 6 minute walk distance (6MWD) in the proximal group were significantly better than those in the distal group (1.7±0.5 class vs 2.3±0.4 class; 479.2±51.2 m vs. 438.6±39.5 m, P=0.003). Venous thrombosis in double lower limbs reoccurred in two patients. According to KaplanMeier actuarial curve, the freedom from reembolism at 3 years was 96.7%±2.8%. Bleeding complications occurred in three patients. The linear Bleeding rate related to anticoagulation was 2.47% patientyears. Conclusion Although the early and midlong term survival rate of PTE procedure to treat both proximal and distal types of CTEPH is agreeable, the recovery of the PASP, PVR and 6MWD, and blood gases in patients with proximal type of CTEPH are significantly better than those in patients with distal type of CTEPH. On one hand, anticoagulation can singularly provide enough protection to patients with proximal type of CTEPH, but on the other hand, diuretics and pulmonary hypertension alleviation drug should be added to the treatment regimen for patients with distal type of CTEPH after the procedure of PTE.

Application of Posterior Leaflet Chordal Transfer in the Treatment of Anterior Mitral Leaflet Prolapse

Objective To summarize the clinical experiences of the application of posterior leaflet chordal transfer in the treatment of anterior mitral leaflet prolapse, and to investigate the best time for mitral valve repair. Methods From October 2004 to October 2008, 16 patients with anterior mitral leaflet prolapse underwent mitral valve repair. The echocardiography diagnosis revealed that 10 patients had chordal rupture, 4 had chordal elongation, 2 had both rupture and elongation. And there were 3 with A1 segment prolapse, 6 with A2 segment prolapse, 3 with A3 segment prolapse, 2 with both A1 and A2 segment prolapse, 2 with both A2 and A3 segment prolapse. All the patients underwent posterior leaflet chordal transfer, and one of them with coronary artery disease underwent coronary artery bypass grafting. Results There was no operative death. The echocardiography examination revealed that there were 2 patients with mild regurgitation, 6 with trivial regurgitation and 8 with no regurgitation before discharge. The patients received nticoagulation treatment of warfarin for 3 months after discharge. All the patients were followed up for 1-46 months(22.0±3.5 months). The echocardiography examination showed that there were 3 patients with mild regurgitation, 7 with trivial regurgitation and 6 with no regurgitation. There were 12 patients with New York Heart Association(NYHA) classⅠ, and 4 with class Ⅱ. The left ventricular ejection fraction(LVEF) was lower than that before operation(53.0%±3.4％ vs.65.0%±4.2％,P=0.013),and there was no statistical significance compared with that before operation(61.0%±2.1％vs.65.0%±4.2％, P=0.110). The left ventricular end diastolic diameter decreased significantly compared with that before operation(50.0±3.2 mm, 47.0%±2.8 mm vs.580±6.5 mm，P=0.031，0020). The postoperative cardiac function improved significantly (P=0.002). Conclusion Posterior leaflet chordal transfer is an effective method for anterior mitral leaflet prolapse. The best time for mitral valve repair is when LVEF＞60%, left ventricle enlarges a little, and NYHA class＞Ⅲ before operation.

Risk Factors of Atrial Fibrillation after Coronary Artery Bypass Grafting

Objective To analyze the preoperative risk factors of atrial fibrillation (AF) in patients with coronary artery disease after coronary artery bypass grafting (CABG). Methods From September 2007 to April 2008, the clinical information of 226 patients who underwent onpump coronary artery bypass grafting(CABG)or offpump coronary artery bypass grafting(OPCAB) was collected. The patients were divided into nonAF group and AF group according to whether AF lasted more than 5 mins in 3 days after operation. Ultrasonic cardiography (UCG) and clinical information of preoperation in two groups were analyzed. Results Twentyfour（10.6%） patients had AF after operation. There were more patients whose left atrial diameter gt;35 mm in AF group than that in nonAF group ［41.7%（10）vs. 22.3% (45),χ2=4.380, P=0.036）］, more patients had mitral regurgitation in AF group than that in nonAF group ［37.5%（9） vs. 17.3% (35),χ2=5.568, P=0.018）］, more patients had left main coronary artery involvement in AF group than that in nonAF group ［33.3% (8) vs.12.4% (25),χ2=7.560,P=0.006］, and patients in AF group were older than those in nonAF group ［65.7±9.5 years vs. 60.1±10.1 years,t=-2.724,P=0.010］. In univariate analysis, in terms of preoperative clinical indexs such as the aged, mitral regurgitation, left atrial diameter, left mainm coronary artery involvement, and postoperative clinical indexs such as ventilatory time （χ2=4.190，P=0.040）, electrocardiogram (ECG) monitoring time（χ2=5.948，P=0.015）, hospitalization expense（χ2=4.110，P=0.043）, there were significant differences between 2 groups. Conclusion Risk factors such as the aged, mitral regurgitation, left atrial diameter and left main coronary artery involvement are related to AF after CABG. Clinical index, ECG and echocardiography are helpful to predict AF, and can provide better prevention and treatment, and reduce the rate of AF.

The Early and Middle- long Term Clinical Outcome of Surgical Treatment of Pulmonary Embolism

Abstract: 　Objective　To invest igate the early and m iddle2long term clinical outcome of surgical t reatment for pulmonary th romboembo lism (PTE). 　Methods　The data of 57 cases of surgical t reatment fo r pulmonary embolism from O ctober 1994 to O ctober 2007 in A nzhen Ho sp italw ere analyzed ret ro spect ively, of w h ich 47 casesw ere ch ronic PTE done w ith pulmonary th romboendarterectomy, and 10 w ere acute PTE done w ith pulmonary embo lectomy. 　Results　There w ere 6 (12. 8%) perioperat ive death s in ch ronic PTE and 4 (40. 0%) death s in acute PTE (P =0.030). F ifteen cases suffered w ith residual pulmonary hypertension and 25 casesw ith severe pulmonary reperfusion injury. The pulmonary artery systo lic p ressure (PA SP) and the pulmonary vascular resistance (PVR ) of 41 cases with ch ronic PTE at 72 hours after surgery w ere low ered significant ly than tho se befo re surgery (52. 9±26. 1 mmHg vs. 91. 2±37. 4 mmHg; 410. 3±345. 6 dyn?s/ cm5 vs. 921. 3±497. 8 dyn?s/ cm5). The arterial oxygen saturat ion (SaO 2) and the arterial part ial p ressure of oxygen (PaO 2 ) at 72 hours after surgery w ere h igher significant ly than tho se befo re surgery (94.8% ±2.7% vs. 86.7% ±4.3%; 84. 4±5. 4 mmHg vs. 51. 8±6. 4 mmHg, P lt; 0. 05). With the fo llow -up of 44. 6±39. 3 month s (cumulat ive fo llow -up w as 160. 1 pat ient-years) of the 47 perioperative survivo rs, there w ere 5 late death s, of w h ich 4 ch ronic PTE and 1 acute PTE. A cco rding to Kap lan-Meier survival curve, the 5 years survival rate w as 89. 43%±5. 80% fo r ch ronic PTE and 83. 33%±15. 21% fo r acute PTE (Log rank test= 1.57, P = 0. 2103). The lineal bleeding rate related to ant icoagulat ion w as 1. 25% pat ient-years, and the lineal th romboembo lic rate related to ant icoagulat ion w as 0. 62% pat ient-years. A nd of the 42 mid-long term survivo r, the heart funct ion in 29 cases w as N ew Yo rk Heart A ssociat ion (NYHA ) class I , 10 cases NYHA class II , 3 cases N YHA class III. A cco rding to logist ic regression, the risk facto rs fo r the early death w ere acute PTE (OR = 3.28, peripheral type of PTE (OR = 2. 45) , unadop t ive of deep hypertherm ia and circulato ry arrest (OR = 2.86) ; and the risk facto rs fo r late death w ere peripheral type of PTE (OR = 2. 69) , lower limb edema p rep rocedure (OR = 2.79). 　Conclus ion　The operat ive mo rtality in acute PTE is significant ly h igher than that in ch ronic PTE, and the mid-long term survival rate is agreeable in bo th acute and ch ronic PTE, and the comp licat ions rate related to ant icoagulat ion is relat ively accep table.