Objective To compare surgical outcomes of Stanford type A acute aortic dissection between operations at midnight and daytime. Methods From January 2004 to March 2013，195 patients with Stanford type A acute aortic dissection received surgical treatment in Nanjing Hospital Affiliated to Nanjing Medical University （Nanjing Cardiovascular Disease Hospital）. Patients with identical or similar propensity scores were matched from 127 patients who underwent emergency operation at daytime and 68 patients who underwent emergency operation at midnight. A total of 58 pairs of matched patients which had the same or similar propensity score were selected in daytime surgery group （n=58，43 males and 15 females，47.7±14.6 years） and midnight surgery group （n=58，45 males and 13 females，48.3±14.6 years）. Operation time，postoperative chest drainage，mechanical ventilation time，postoperative incidence of dialysis and tracheostomy，length of ICU stay and in-hospital mortality were compared between the daytime group and midnight group. Results A total of 58 pair of patients were matched in this study. There was no statistical difference in postoperative incidence of tracheostomy ［19.0% （11/58） vs. 6.9% （4/58），P=0.053］ or in-hospital mortality ［8.6% （5/58） vs. 6.9%（4/58），P=0.729］ between the midnight group and daytime group. Operation time （485.7±93.5 minutes vs. 428.5±123.3 minutes，P=0.048），postoperative chest drainage （979.5±235.7 ml vs. 756.6±185.9 ml，P=0.031），mechanical ventilation time （67.9±13.8 hours vs. 55.7±11.9 hours，P=0.025），postoperative incidence of dialysis ［17.2% （10/58） vs. 5.2%（3/58），P=0.039］ and length of ICU stay （89.4±16.2 hours vs. 74.8±12.5 hours，P=0.023） of the midnight group weresignificantly longer or higher than those of the daytime group. A total of 107 patients were followed up for 4-6 months after discharge. During follow-up，there was no late death. Among the 13 patients who required postoperative dialysis，12 patientsno longer needed regular dialysis. Conclusion Emergency operation at midnight does not increase in-hospital mortalitybut increase some postoperative morbidity in patients with Stanford type A acute aortic dissection. Whether at midnight or daytime，better preoperative preparation and surgeons’ vigor are needed for timely surgical treatment for patients with Stanford type A acute aortic dissection.
ObjectiveTo investigate the impact of deep hypothermic circulatory arrest (DHCA) with antegrade cerebral perfusion (ACP) on cognitive function of patients undergoing surgical therapy for acute Stanford type A aortic dissection (AD). MethodsBetween January 2009 and March 2012, 48 patients with acute Stanford type A AD underwent Sun's procedure (aortic arch replacement combined with stented elephant trunk implantation) under DHCA with ACP in Nanjing Hospital affiliated to Nanjing Medical University. There were 40 males and 8 females with their age of 51.3±13.6 years. Circulatory arrest time and time for postoperative consciousness recovery were recorded. Preoperative and postoperative cognitive functions of each patient were evaluated by mini-mental status examination (MMSE). ResultsMean cardiopulmonary bypass time of the 48 patients was 237.3±58.5 minutes, and mean circulatory arrest time was 37.3 ±6.9 minutes. Four patients died postoperatively with the causes of death including lung infection, multiple organ dysfunction syndrome, myocardial infarction and acute respiratory distress syndrome. Forty-one patients recovered their consciousness within 24 hours postoperatively, and the mean time for postoperative consciousness recovery was 15.3±6.5 hours. Preoperative MMSE score was 28.6±1.1 points, and MMSE score at 1 week postoperatively was 23.6±4.5 points. Thirty-one patients were followed up for 6 months with the follow-up rate of 70.45%. The average MMSE score of the 31 patients at 6 months after surgery was 27.6±2.1 points which was significantly higher than postoperative average MMSE score (P < 0.05), but not statistically different from preoperative average MMSE score (P > 0.05). ConclusionsDHCA with ACP can provide satisfactory cerebral protection for patients undergoing surgical therapy for acute Stanford type A AD, but patients' cognitive function may be adversely affected in the short term. As long as cerebral infarction or hemorrhage is excluded in CT scan of the brain, such adverse impact may generally disappear automatically within 6 months after surgery.
目的总结采用分期全主动脉置换治疗急性A型主动脉夹层合并胸腹主动脉瘤的手术方式和早期治疗效果。 方法自2013年2月至2014年2月，2例急性A型主动脉夹层合并Crawford Ⅱ型胸腹主动脉瘤的马方综合征患者进行了分期全主动脉置换手术。患者均为男性，年龄分别为41岁和26岁。一期在部分深低温停循环下行主动脉根部、全弓置换及支架象鼻植入术，二期在常温非体外循环下应用四分叉人工血管行全胸腹主动脉置换术。 结果手术结果满意，2例患者均康复出院，无任何并发症。 结论分期全主动脉置换术治疗急性A型主动脉夹层合并全胸腹主动脉瘤是一种安全、有效的方法。
ObjectiveTo compare early outcomes of the minimally invasive mitral valve surgery (MIMVS) through right anterolateral mini-thoracotomy (ALMT) with conventional mitral valve surgery (MVS), and evaluate feasibility and safety of MIMVS. MethodsFrom January 2011 to December 2013, 120 patients undergoing elective MVS in Nanjing First Hospital were prospectively enrolled in this study. There were 72 male and 48 female patients with their age of 22-71 (42.4±11.0) years. Using a random number table, all the patients were randomly divided into a portaccess MIMVS group (MIMVS group, n=60) and a conventional MVS group (conventional group, n=60). MIMVS group patients received port-access cardiopulmonary bypass (CPB) establishment via femoral artery, femoral vein and right internal jugular vein cannulation through right ALMT 5-6 cm in length. Special MIMVS operative instruments were used for mitral valve repair or replacement. Conventional group patients received mitral valve repair or replacement under conventional CPB through median sternotomy. Perioperative clinical data, morbidity and mortality were compared between the 2 groups. ResultsThere was no death in-hospital or shortly after discharge in this study. CPB time (98.0±26.0 minutes vs. 63.0±21.0 minutes) and aortic cross-clamping time (68.0±9.0 minutes vs.37.0±6.0 minutes) of MIMVS group were significantly longer than those of conventional group (P<0.05). Postoperative mechanical ventilation time (6.0±3.9 hours vs. 11.2±5.6 hours), length of ICU stay (18.5±3.0 hours vs. 28.6±9.5 hours) and postoperative hospital stay (8.0±2.0 days vs. 13.5±2.5 days) of MIMVS group were significantly shorter than those of conventional group (P<0.05). Chest drainage volume within postoperative 12 hours (110.0±30.0 ml vs. 385.0±95.0 ml) and the percentage of patients receiving blood transfusion (25.0% vs. 58.3%) of MIMVS group were significantly lower than those of conventional group (P<0.05). Patients were followed up for 1-24 months, and the follow-up rate was 94.2%. There was no statistical difference in postoperative morbidity or mortality between the 2 groups (P>0.05). ConclusionMIMVS through right ALMT is a safe and feasible procedure for surgical treatment of mitral valve diseases. MIMVS can achieve similar clinical outcomes as conventional MVS, but can significantly shorten postoperative ICU stay and hospital stay, reduce blood transfusion, and is a good alternative to conventional MVS.
ObjectiveTo summarize the clinical experience in the treatment of Carpentier's type Ⅲb ischemic mitral regurgitation through the mitral valve repair versus mitral valve replacement, and to evaluate the early and midlong term effects. MethodsWe retrospectively analyzed the clinical data of 308 consecutive patients with type Ⅲb ischemic mitral regurgitation undergoing coronary artery bypass grafting (CABG) with mitral valve repair (a repair group, n=172) or with mitral valve replacement (a replacement group, n=136) in our hospital between January 2000 and March 2014. Among the 308 patients, 215 were males and 93 were females with mean age of 62.7±11.5 years(ranged 30-78 years). In the repair group, 170 patients underwent restrictive mitral annuloplasty (128 patients with total ring, 42 patients with C ring), and 2 patients underwent commissural constriction. In the replacement group, 11 patients underwent mechanical valve prosthesis and 125 patients underwent biological valve prosthesis. ResultsThe time of total aortic cross-clamp was 81.9±21.5 min. The time of total extracorporeal circulation was 122.0±31.3 min. Six patients died during the perioperative period. No significant differences were observed between the two groups in general information (P>0.05). There were no significant differences between the two groups in aortic cross-clamp time, total extracorporeal circulation time, numbers of bypass grafts and the usage rate of left internal mammary artery. The early result after the surgery showed that the incidence rates of low cardiac output and ventricular arrhythmia were significantly higher in the replacement group compared with those in the repair group. The patients were followed up for 1-85 months. No significant difference was revealed in the mid-long term survival rate between the two groups. The severity of mitral regurgitation and the rate of redo mitral valve replacement were significantly lower in the replacement group compared with those in the repair group (P<0.05). ConclusionThe early-term curative effect of valve repair is better than valve replacement for the treatment of Carpentier's type Ⅲb ischemic mitral regurgitation. In mid-long term, Chordal-sparing mitral valve replacement remains a low incidence of valve-related complications compared with mitral valve repair.
Objective To explore the therapeutic effect of mild hypothermia on the inflammatory response, organ function and outcome in perioperative patients with acute Stanford type A aortic dissection (AAAD). Methods From February 2017 to February 2018, 56 patients with AAAD admitted in our department were enrolled and randomly allocated into two groups including a control group and an experimental group. After deep hypothermia circulatory arrest during operation, in the control group (n=28), the patients were rewarmed to normal body temperatures (36 to 37 centigrade degree), and which would be maintained for 24 hours after operation. While in the experimental group (n=28), the patients were rewarmed to mild hypothermia (34 to 35 centigrade degree), and the rest steps were the same to the control group. The thoracic drainage volume and the incidence of shivering at the first 24 hours after operation, inflammatory indicators and organ function during perioperation, and outcomes were compared between the two groups. There were 20 males and 8 females at age of 51.5±8.7 years in the control group, 24 males and 4 females at age of 53.3±11.2 years in the experimental group.Results There was no obvious difference in the basic information and operation information in patients between the two groups. Compared to the control group, at the 24th hour after operation, the level of peripheral blood matrix metalloproteinases (MMPs) was lower than that in the experimental group (P=0.008). In the experimental group, after operation, the awakening time was much shorter (P=0.008), the incidence of bloodstream infection was much lower (P=0.019). While the incidence of delirium, acute kidney injury (AKI), hepatic insufficiency, mechanical ventilation duration, intensive care unit (ICU) stays, or hospital mortality rate showed no statistical difference. And at the first 24 hours after operation, there was no difference in the thoracic drainage volume between the two groups, and no patient suffered from shivering. Conclusion The mild hypothermia therapy is able to shorten the awakening time and reduce the incidence of bloodstream infection after operation in the patients with AAAD, and does not cause the increase of thoracic drainage volume or shivering.