Recent clinical trials showed that dabigatran was superior to warfarin for stroke prevention in patients with nonvalvular atrial fibrillation, however whether it is suitable for the lifelong anticoagulation in patients after heart valve replacement, remains controversial. Many animal experiments showed that dabigatran group was better than heparin and warfarin in the prevention of thrombosis and bleeding complications after valve replacement. Randomized, phaseⅡstudy to evaluate the safety and pharmacokinetics of oral dabigatran etexilate in patients after heart valve replacement (RE-ALIGN) clinical trial showed that dabigatran wasn't as effective as warfarin in preventing thrombosis, but increases the risk of bleeding. And there are some case reports about thrombosis and bleeding complications after taking dabigatran. At present, the efficacy and safety of dabigatran applying in patients after heart valve replacement still needs further study.
Although the survival rate reported in each center is different, according to the present studies, compared to conventional cardiopulmonary resuscitation (CCPR), extracorporeal cardiopulmonary resuscitation (ECPR) can improve the survival rate of cardiac arrest patient, no matter out-of-hospital or in-hospital. The obvious advantage of ECPR is that it can reduce the nervous system complications in the cardiac arrest patients and improve survival rate to hospital discharge. However, ECPR is expensive and without the uniformed indications for implantation. The prognosis for patients with ECPR support is also variant due to the different etiology. If we want to achieve better result, the ECPR technology itself needs to be further improved.
Objective To summarize the clinical experiences of venoarterial extracorporeal membrane oxygenation (ECMO) which provides temporary cardiopulmonary assist for critical patients, and preliminary analysis of the cause of failure. Methods From February 2005 to October 2008, 58 adult patients (male 42, female 16) undergoing cardiogenic shock required temporary ECMO support. Age was 44.8±17.6 years, and support duration of ECMO was 131.9±104.7 hours. There were 24 patients (41.4%) with coronary heart disease, 11 patients (19.0%) with cardiomyopathy, 10 patients (17.2%) with cardiac valve disease,and 9 patients (15.5%) with congenital heart disease. Results 22 patients died in hospital. 11 patients (50%) died of multisystem organ failure, 5 patients (22.7%) died of refractory heart failure despite the ECMO support. Another patients died of bleeding and severe pulmonary hypertension etc. The percentage for patients need cardiac resuscitation before ECMO support and patients with acute renal failure treated by continuous renal replacement therapy (CRRT) under ECMO support were obviously higher in dead patients than those in survivor patients (45.5% vs.19.4%, 40.9% vs. 5.6%; P=0.043，0.001). All of the discharged patients were reassessed, mean followup time were 15.6 months. Three patients died of refractory heart failure， 1 patient died of neurologic complications. The other 32 survivors were in good condition with cardiac symptom of New York Heart Association class Ⅰ or Ⅱ. Conclusion ECMO offers effective cardiopulmonary support in adults. Early intervention and control of complications could improve our results with increasing experience. Combining using CRRT during the ECMO support is associated with significantly higher mortality rate. Suffered cardiac arrest prior to ECMO also influences the survival.
Objective To analyze symptoms, associated anomalies, diagnostic approach, and surgical procedures in patients with unroofed coronary sinus syndrome (UCSS), a rare congenital disorder. Methods The clinical, echocardiographic, operative, and followup data on 44 patients with unroofed coronary sinus syndrome (typeⅠin 15，typeⅡin 9，type Ⅲ in 5 and type Ⅳ in 15) between May 1998 and January 2008 were reviewed retrospectively. The initial diagnosis of unroofed coronary sinus syndrome was made by echocardiography in 12 patients, by the surgeon at repair of other congenital cardiac anomalies in 32 patients. The patients underwent cardiovascular surgery at Fu Wai hospital. Left superior vena cava(LSVC) directly drains into the left atrium (LA) were found in 15 cases, LSVC was ligated in 1 case, the intracardiac tunnel to drain LSVC to right atrium (RA) were reconstructed in 14 cases. The associated cardiac lesions were corrected concomitantly. Results There were 3 hospital deaths. One patient died of low cardiac output syndrome and 2 patients died of pulmonary infection. One case was applied diaphragm plication because of right diaphragm paralysis after the heart operation and the hospital stay was 70 days.The other 40 cases had good surgical result. The average time of extubation was 11.7±12.1 h and hospital stay was 8.1±2.8 d. In the 32 cases, who have been followed up from 4 months to 10 years, there was no death and severe complications. Conclusion Unroofed coronary sinus syndromes are often missed in the preoperative evaluation of congenitally malformed hearts. When associated with LSVC, unroofed coronary sinus syndrome should be considered as a possible additional finding.We performed different surgical approaches to deal with the different kinds of LSVC with a good result.
Abstract: Objective To study the impact of different kinds of mechanical circulation support devices on plasma free hemoglobin(FHb). Methods From Mar. 2004 to Dec. 2005, 20 patients received mechanical circulation support in Fu Wai Hospital, who were divided into 4 groups according to the different type of supporting devices. 9 got extracorporeal membrane oxygenation (ECMO) treatment, 8 received BVS5000 left ventricular support, 2 got MEDOS left ventricular support and 1 received AB5000 left ventricular support. Random control group included 9 cardiotomy patients after CPB supporting and 9 patients with offpump coronary artery bypass grafting during the same period. Parameters such as FHb, Tbil, Dbil, Cr and BUN were monitored throughout the supporting term. The results were compared according to the different types of mechanical circulation support devices. Results The elevation of FHb caused by CPB could be decreased to normal within 1d. However, in BVS5000 group, the elevated FHb level decreased to normal till 2 days later. The others mechanical circulation support devices such as ECMO, MEDOS, AB5000 elevated the FHb throughout the whole supporting period. Compared with those in ECMO group, the patients in BVS5000 group had obviously lower level of FHb since the third day after the beginning of supporting. In patients who got ECMO treatment, there was a trend that the elevation degree of FHb was lower in those with support flow rate less than 2.5 L/min. For most patients got devices support, there was also an elevation of Tbil and BUN level during the supporting period. Conclusion Mechanical circulation support devices, such as ECMO, BVS5000, MEDOS and AB5000, can cause red cell destruction in acceptable level. BVS5000 has much smaller impact on cell destruction than others do in postoperative patients.
ObjectiveTo summarize surgical treatment experience on unruptured aneurysm of the sinus of Valsalva (SVA). MethodsClinical data of 33 patients with unruptured SVA underwent surgical repair at Fu wai Hospital between February 2007 and January 2012 were retrospectively analyzed. There were 27 males and 6 females with their mean age of 28.5±13.5 years (ranged from 4.5 to 58.0 years). The unruptured SVA originated in the right coronary sinus in 29 cases (87.8%), in non-coronary in 2 cases (6.1%) and in left coronary sinus in 2 cases (6.1%). There were 29 cases with ventricular septal defect and 20 cases with aortic valve insufficiency (AI). ResultsOnly 52.8% of unruptured SVA were correctly diagnosed by echocardiography preoperatively. All unruptured SVA received active surgical management, with no early death after operation. Thirty patients (90.9%) were followed up for 22 to 81 months (mean 42.9±18.8 months) and in NYHA classⅠorⅡ. None SVA recurrence occurred. Postoperative AI could be improved better by using the repair route only through the chamber of right ventricle for patients with unruptured SVA originated in right coronary sinus. ConclusionFor unruptured SVA patients who associated with other kinds of cardiovascular lesions, active surgical repair for unruptured SVA can achieve satisfactory results.
Objective To introduce a modified Sakakibara classification system for a ruptured sinus of Valsalva aneurysm （RSVA），and suggest different surgical approaches for corresponding types of RSVA. Methods Clinical data of 159 patients undergoing surgical repair for RSVA in Fu Wai Hospital between February 2006 and January 2012 were retrospectively analyzed. There were 105 male and 54 female patients with their age of 2-71 （33.4±10.7） years. All these patients were divided into 5 types as a modified Sakakibara classification system. Type I: rupture into the right ventricle just beneath the pulmonary valve （n=66），including 84.8% patients with ventricular septal defect （VSD） and 53.8% patients with aortic valve insufficiency （AI）. TypeⅡ：rupture into or just beneath the crista supraventricularis of the right ventricle （n=17），including 88.2% patients with VSD and 23.5% patients with AI. Type Ⅲ：rupture into the right atrium （typeⅢ a，n=21） or the right ventricle （typeⅢv，n=6） near or at the tricuspid annulus，including 18.5% patients with VSD and 25.9% patients with AI. TypeⅣ：rupture into the right atrium （n=46），including 23.9% patients with AI but no patient with VSD. TypeⅤ：other rare conditions，such as rupture into the left atrium，left ventricle or pulmonary artery （n=3），including 100% patients with AI and 33.3% patients with VSD. Most RSVA originated in the right coronary sinus （n=122），and others originated in the noncoronary sinus （n=35） or left coronary sinus （n=2）. Results All the type V patients （100%） and 50% patients with typeⅢv received RSVA repair through aortotomy. In most patients of typeⅠ，II andⅣ，repair was achieved through the cardiac chamber of the fistula exit （71.2%，64.7% and 69.6% respectively）. Both routes of repair were used in 76.2% patients with typeⅢ a. The cardiopulmonary bypass time （92.4±37.8 minutes） and aortic cross-clamp time （61.2±30.7 minutes） was the shortest to repair typeⅣRSVA. There was no in-hospital death in this group. Two patients （type I andⅡrespectively） underwent reoperation during the early postoperative period because of restenosis of the right ventricular outflow tract. Most patients received reinforcement patch for RSVA repair （n=149），and only 10 patients received simple suture repair （including 5 patients with typeⅣ，4 patients with typeⅢ a and 1 patient with typeⅡ）. Aortic valve replacement was performed for 33 patients （66.7% of those with typeⅠ）. A total of 147 patients （92.5%） were followed up after discharge. Two patients （type I andⅢ a respectively） developed atrial fibrillation and received radiofrequency ablation treatment，1 patient （typeⅣ） underwent reoperation for residual shunt，and there was no late death during follow-up. Conclusion Modified Sakakibara classification system for RVSA provides a guidance to choose an appropriate surgical approach，and satisfactory clinical outcomes can be achieved for all types of RSVA.
Objective To summarize our clinical experience of pulmonary artery banding （PAB） for the treatment of complex congenital heart diseases as a palliative procedure.?Methods?From January 1997 to November 2010, 138 patients with complex congenital heart diseases underwent PAB in Fu Wai Hospital. There were 87 male patients and 51 female patients with their age of 22.2±26.5 months and average body weight of 7.5±4.6 kg. All the 138 patients were divided into 3 groups according to the purpose of PAB：left ventricular retraining （group 1, n=55）, initial procedure for functional single ventricle with unobstructed pulmonary blood flow （group 2, n=32） and initial palliative procedure followed by later biventricular repair （group 3, n=51）. The intraoperative and postoperative clinical parameters of all participants were observed, and follow-up was made for these 3 groups of patients.?Results?The in-hospital mortality of PAB was 5.1% （7/138）. Three patients underwent re-banding procedure to adjust the size of banding. In group 1, there was 1 postoperative death. Among the 55 patients, 36 patients with dextro-transposition of great arteries received PAB at an average age of 19.6±29.5 months, 29 patients of whom underwent concomitant modified Blalock-Taussig shunt. After an average training interval for 42 days, 83.3% of them（30/36）successfully received arterial switch operation. The other 19 patients in group 1 with isolated corrected transposition of great arteries received PAB at an average age of 45.3±27.2 months. Afteran average training interval for 9 months, 42.1% of them （8/19） successfully received double-switch operation. In group 2, there was 2 postoperative death. Thirty-two patients with functional single ventricle and unobstructed pulmonary blood flow received PAB at an average age of 14.1±14.9 months. Their postoperative mean pulmonary artery pressure decreased significantly from 34.00±10.00 mm Hg to 23.00±7.40 mm Hg, and their oxygen saturation of blood （SpO2） significantly decreased from 92.60%±5.90% to 83.30%±6.30%. After a median interval of 2 years, 18.8% of them （6/32） underwent right heart bypass operation. In group 3, there was 4 postoperative death. Fifty-one patients received PAB at an average age of 20.60±25.60 months. After PAB procedure, the ratio of systolic pulmonary artery pressure and systolic blood pressure significantly decreased from 0.81±0.14 to 0.46±0.15, and their SpO2 significantly decreased from 93.10%±7.60% to 85.00%±10.00%. After a median interval of 6 months, 23.5% of them （12/51） received biventricular repair.?ConclusionAlthough PAB is a palliative procedure with comparatively high risks, it still plays an indispensable role in terms of protecting pulmonary vascular beds, retraining ventricular function and two-stage surgical correction for the treatment of complex congenital heart diseases.