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Early and Mid-term Outcomes of Morphologic Tricuspid Valve Replacement with Preservation of Entire Valvular and Subvalvular Apparatus in Corrected Transposition of Great Arteries

Abstract： Objective To investigate the early and mid-term outcomes of morphologic tricuspid valve replacement by means of intravalvular implantation in corrected transposition of great arteries（cTGA）. Methods From January 2009 to January 2012，11 patients with cTGA were surgically treated in Fu Wai Hospital. There were 9 male patients and 2 female patients with their mean of age of（37.8±11.7）years and mean body weight of（73.0±11.3）kg. All the patients underwent morphologic tricuspid valve replacement with preservation of the entire valvular and subvalvular apparatus. Simultaneous surgical procedures included repair of ventricular septal defect in 2 patients，repair of atrial septal defect in 4 patients，pulmonary valvuloplasty in 1 patient，reconstruction of functional right ventricular outflow tract in 4 patients and repair of coronary-pulmonary artery fistula in 1 patient. Postoperative New York Heart Association （NYHA） classification, cardiothoracic ratio, morphological right ventricle ejection fraction, end-diastolic dimension of morphological right ventricle and left atrium were evaluated during follow-up. Results All the 11 patients were successfully surgically treated and followed up for an average duration of（13.0±10.6）months. There was no statistical difference between postoperative and preoperative average cardiothoracic ratio （0.54±0.06 vs. 0.57±0.09，t=1.581，P＞0.05），morphologic right ventricle ejection fraction （52.8%±9.0% vs. 54.9%±9.5%, t =0.712，P＞0.05），and end-diastolic dimension of . morphological right ventricle （54.3±7.5 mm vs. 56.9±9.2 mm，t =0.988，P＞0.05）. There was statistical difference between postoperative and preoperative average end-diastolic dimension of left atrium（42.1±8.9 mm vs. 53.4±11.1 mm，t =3.286，P＜0.05）and NYHA classification（Z = -2.640，P＜0.05）. Conclusion Intravalvular implantation of morphologic tricuspid prosthesis can protect the physiological structure of morphologic right ventricular and prevent furtherdamage to its function caused by morphologic tricuspid valve insufficiency. Postoperative dimension of morphologic left atrium and cardiac function are significantly improved. The early and mid-term outcomes are satisfactory．

影响冠状动脉旁路移植术加心瓣膜手术患者远期预后的危险因素分析

摘要： 目的 探讨影响行冠状动脉旁路移植术（CABG）加心瓣膜手术患者远期预后的危险因素。 方法 2003年1～10月北京阜外心血管病医院共收治冠状动脉粥样硬化性心脏病合并心瓣膜疾病患者68例，纳入研究66例(院内死亡2例)，男23例，女43例；年龄50～76岁(61.33±6.60岁)。行CABG+主动脉瓣手术19例，CABG+二尖瓣手术32例，CABG+双瓣膜手术15例；移植血管1.79±1.18支。先将各变量分别进行Cox风险模型单变量分析，再将所有有统计学意义的变量同时纳入Cox风险模型多变量分析。 结果 随访65例，随访时间50.65±17.98个月，随访期间死亡11例，其中死于胃癌2例，抗凝并发症脑出血1例，心源性猝死4例和心力衰竭4例。失访1例。Cox风险模型多变量分析结果显示：左心室射血分数（LVEF）≤40%（RR=5.960，P=0.010）、术前有糖尿病史（RR=7.170，P=0.004）是影响患者术后远期预后的独立危险因素。 结论 LVEF和术前有糖尿病史是影响CABG加心瓣膜手术患者远期预后的危险因素，术后严格控制血糖和提高心功能能改善患者的远期预后。

《瓣膜病术后抗凝个体化和低抗凝标准研究》 阶段研究进展

Validation of Four Different Risk Stratification Models in Predicting Early Death of Chinese Patients after Isolated Coronary Artery Bypass Grafting Surgery

Abstract: Objectives To evaluate the accuracy of four existing risk stratification models including the Society of Thoracic Surgeons(STS) 2008 Cardiac Surgery Risk Models for Coronary Artery Bypass Grafting (CABG), the European System for Cardiac Operative Risk Evaluation (EuroSCORE), the American College of Cardiology/American Heart Association (ACC/AHA) model, and the initial Parsonnet’s score in predicting early deaths of Chinese patients after CABG procedure. Methods We collected clinical records of 1 559 consecutive patients who had undergone isolated CABG in the Fu WaiHospital from November 2006 to December 2007. There were 264 females (16.93%) and 1 295 males (83.06%) with an average age of 60.87±9.06 years. Early death was defined as death inhospital or within 30 days after CABG. Calibration was assessed by the Hosmer-Lemeshow (H-L) test, and discrimination was assessed by the receiveroperatingcharacteristic (ROC) curve. The endpoint was early death. Results Sixteen patients(1.03%) died early after the operation. STS and ACC/AHA models had a good calibration in predicting the number of early deaths for the whole group(STS: 12.06 deaths, 95% confidence interval(CI) 5.28 to 18.85; ACC/[CM(159mm]AHA:20.67deaths, 95%CI 11.82 to 29.52 ), While EuroSCORE and Parsonnet models overestimated the number of early deaths for the whole group(EuroSCORE：36.44 deaths，95%CI 24.75 to 48.14；Parsonnet：43.87 deaths，95%CI 31.07 to 56.67). For the divided groups, STS model had a good calibration of prediction(χ2=11.46, Pgt;0.1)，while the other 3 models showed poor calibration（EuroSCORE：χ2=22.07，Plt;0.005；ACC/AHA：χ2=28.85，Plt;0.005；Parsonnet：χ2=26.74，Plt;0.005）.All the four models showed poor discrimination with area under the ROC curve lower than 0.8. Conclusion The STS model may be a potential appropriate choice for Chinese patients undergoing isolated CABG procedure.

Ventricular Septal Myotomymyectomy on Hypertrophic Obstructive Cardiomyopathy and the Treatment Strategies during Perioperative Period

Objective To summary the clinical experiences of ventricular septal myotomymyectomy on hypertrophic obstructive cardiomyopathy(HOCM) and investigate the treatment strategies during perioperative period for better clinical results. Methods From October 1996 to June 2009, 62 patients with HOCM underwent surgical treatment. There were 41 male and 21 female, aged 668 years with mean 34.05 years. The ventricular septal myotomymyectomy operation (Morrow operation or modified Morrow operation) was performed through the aortic incision under general anesthesia and hypothermic cardiopulmonary bypass (CPB). The concomitant operations included coronary artery bypass grafting (5 cases), mitral valve replacement (12 cases), mitral valve plasty(9 cases), aortic valve replacement (4 cases), tricuspid valve plasty(2 cases) and ductus arteriosus closure (2 cases). During the perioperative period, the patients were examined by echocardiography or transesophageal echocardiograph(TEE), electrocardiogram or dynamic echocardiogram and chest radiography. Left atrial diameter，left ventricular enddiastolic [CM(159mm]diameter，left ventricular outflow tract (LVOT) pressuregradient，interventricular septal thickness, ejection fraction[CM)](EF), the changes of mitral valve construction and function were evaluated. Results The time of CPB and aortic occlusion were 104.23±47.14 min and 66.76±36.32 min, respectively. The endotracheal intubation time was 13.23±11.76 h and the postoperative intensive care unit(ICU) stay was 42.53±37.41 h. Four patients died and the mortality was 6.45％(4/62). The main causes of death included septic shock complicated with acute renal failure(1 case), refractory arrhythmia, ventricular fibrillation, atrial flutter complicated with severe low cardiac output syndrome (1 case), severe acute renal failure(1 case) and Ⅲ°atrioventricular(AV) block complicated with low cardiac output syndrome(1 case). Postoperative left atrial diameter (34.56±6.45 mm vs.43.46±7.21 mm，t=6.948,P=0.000), left ventricular enddiastolic diameter (37.14±6.31 mm vs.42.03±6.23 mm，t=3.145,P=0.020), LVOT pressure gradient (23.54±17.78 mm Hg vs. 103.84±44.04 mm Hg,t=13.618,P=0.000) and interventricular septal thickness (17.12±5.67 mm vs.26.93±5.23 mm, t=10.694,P=0.000) decreased significantly compared with those before operation. There was no mitral valve regurgitation, or only mild mitral valve regurgitation. No systolic anterior motion(SAM) was found. The main postoperative arrhythmias included complete left bundle branch block, intraventricular block, complete atrioventricular block and atrial fibrillation. All the 58 cases were cured and discharged. Fiftythree cases were followed up for 3 months12 years, and 5 cases were lost. No death, complication and reoperation were found. Symptoms relieved significantly. The cardiac function was in New York Heart Association grade Ⅰ-Ⅱ. The quality of life improved significantly. Conclusion Most patients with HOCM can achieve satisfactory relief of LVOT obstruction and SAM via ventricular septal myotomymyectomy. The main arrhythmias after operation are bundle branch block and atrial fibrillation. Satisfactory effects can be achieved by accurate surgical technique and effective drug treatments.

Surgical Treatment of Myocardial Bridge

Objective To investigate the clinical characteristics, operative indications, operative methods and operative effect of myocardial bridge(MB). Methods From Oct.1996 to Feb.2007, 34 cases with MB underwent MB operation in Fu Wai Hospital. There were 10 cases with isolated myocardial bridge, 4 complicated with coronary artery heart disease, 15 complicated with heart valve diseases, 3 complicated with hypertrophic obstructive cardiomyopathy, 1 complicated with Marfan’s syndrome and 1 complicated with atrial septal defect. All the 34 cases were diagnosed definitely by coronary angiography. According to cardiac function classification（NYHA）, there were 30 cases in gradeⅡ and 4 cases in gradeⅢ. Thirtytwo cases involved left anterior descending(LAD), 1 involved posterior descending branch(PDB) and 1 involved circumflex(CX), with a length of 1-6 cm respectively. Fifteen cases underwent myotomy on myocardial bridge and 19 cases underwent coronary artery bypass grafting(CAGB). Results Among cases who underwent myotomy on myocardial bridge, there was 1 intraoperative right ventricle perforation which was cured after repair. Among cases who underwent myotomy on myocardial bridge with mitral valve replacement concomitantly, there was 1 death caused by left ventricular rupture. There was no other operative complication. Thirty cases were followed up for 15-124 months. Two cases with isolated MB had angina pectoris after myotomy on myocardial bridge and were controlled by drugs. Among 30 cases with MB, 25 in NYHA gradeⅠ, 2 in gradeⅡ and 3 in gradeⅢ. Conclusion The surgical treatments of myocardial bridge include myotomy on myocardial bridge and CABG, and can be properly chosen according to the length, position of myocardial bridge, and having or not having mural coronary artery proximal atherosclerosis. Both the two treatments can obtain satisfactory clinical outcome.

Surgical Treatment of Pulmonary Atresia with Ventricular Septal Defect in Elder Children and Adults

Objective To investigate the surgical treatment methods and effects for pulmonary atresia with ventricular septal defect (PAVSD) in elder children and adults in order to promote the treatment effects. Methods From October 1996 to October 2008, we performed stage1 or staged biventricular repair on 39 PAVSD patients including 21 males and 18 females, ranging from 8 to 27 years old with an average age of 13.43 years. There were 14 cases of type A, 11 cases of type B, and 14 cases of type C. Among them, 23 patients underwent stage1 radical repair in which either human blood vessel with valves or bovine jugular vein with valves were used to connect the pulmonary artery and the right ventricular outflow tract. In these 23 patients, 3 patients complicated with major aortopulmonary collaterals(MAPCAs) underwent unifocalization (UF) operation. The other 16 patients received staged repair, including 9 cases of systemic to pulmonary artery shunt and 7 of staged radical cure. Results There were 6 perioperative deaths with a total mortality of 15.38%(6/39), including 4 (17.39%) stage1 radical repair cases and 2 (12.50%) staged radical repair cases. The former 4 were all type C patients, dying from low cardiac output due to increased pulmonary arterial pressure. In the latter 2 deaths, 1 was a type B secondary shunt patient, and the other was a type C staged radical repair case, both of whom died of bleeding caused by aortic injury in the succeeding operations. Followup was done on 28 cases with a followup rate of 84.85%. The followup time ranged from 14.0 months to 9.2 years with 5 cases missing. No patient died during the followup, and 9 patients maintained their cardiac function at class Ⅰ, 13 at class Ⅱ, 5 at class Ⅲ and 1 at class Ⅳ. Three patients had aortic valve regurgitation of small to medium volume, the treatment of which included an administration of oral potassium diuretic medication and regular follow-up. Conclusion Pulmonary vessels of elder children and adults with PAVSD are usually injured severely and oftentimes it is complicated with MAPCAs. Standard for stage1 radical repair should be defined more strictly based on the present one.

European System for Cardiac Operative Risk Evaluation Predicts Postoperative Complications and Prognosis of Chinese Patients Operated for Acquired Heart Valve Diseases

Abstract: Objective To evaluate the prediction validation of European system for cardiac operative risk evaluation （EuroSCORE） in prolonged intensive care unit (ICU) stay, mortality, and major postoperative complications for Chinese patients operated for acquired heart valve disease. Methods Between January 2004 and January 2006, 2 218 consecutive patients treated for acquired heart valve diseases were enrolled in Fu Wai Hospital. All these patients accepted valvular surgery. Both logistic model and additive model were applied to EuroSCORE to evaluate its ability in predicting mortality, prolonged ICU stay and major postoperative complications of patients who had undergone heart valve surgery. An receiver operating characteristic curve（ ROC) area was used to test the discrimination of the models. Calibration was assessed by HosmerLemeshow goodnessoffit statistic. Results Discriminating abilities of logistic and additive EuroSCORE algorithm were 0.710 and 0.690 respectively for mortality, 0.670 and 0.660 for prolonged ICU stay, 0.650 and 0.640 for heart failure, 0.720 and 0.710 for respiratory failure, 0.700 and 0.740 for renal failure, and 0.540 and 0.550 for reexploration for bleeding. There was significant difference between logistic and additive algorithm in predicting renal failure and heart failure (Plt;0.05). Calibration of logistic and additive algorithm in predicting mortality, prolonged ICU stay and major postoperative complications were not satisfactory. However, logistic algorithm could be used to predict postoperative respiratory failure (P=0.120). Conclusion EuroSCORE is not an accurate predictor in predicting mortality, prolonged ICU stay and major postoperative complications, but the logistic model can be used to predict postoperative respiratory failure in Chinese patients operated for acquired heart valve diseases.

Surgical Treatment to Ventricular Septal Rupture after Acute Myocardial Infarction

Objective To summarize the surgical experiences of ventricular septal rupture (VSR) after acute myocardial infarction (AMI) and investigate the time and methods of surgery. Methods From January 1999 to December 2008, 22 patients with VSR after AMI underwent surgical procedures. There were 17 male and 5 female with a age of 3978 years (mean age of 61.77 years). There were 18 cases with anterior VSR and 4 cases with posterior VSR, all of them combined with left ventricular aneurysm. Twentytwo cases underwent ventricular septal repair and aneurysm resection, 16 cases underwent coronary artery bypass grafting concomitantly with a graft of 2.11±1.57. Results There were 2 perioperative deaths (9.09%), 1 died of severe low cardiac output syndrome and 1 died of massive cerebral embolism. The other 20 cases were all cured and discharged. According to cardiac function classification from New York Heart Association（NYHA）, there were 4 cases in grade Ⅲ, 12 cases in grade Ⅱ and 4 cases in grade Ⅰ. Echocardiography showed that there were no VSR shunt and 2 cases with mild mitral valve regurgitation. Postoperative left ventricular enddiastolic diameter (LVEDD) reduced significantly compared with that before operation (50.27±5.33 mm vs. 57.94±6.79 mm, t=4.437, P=0.000). Sixteen cases were followed up, and the follow-up time was 3.24 months (13.9±6.5 months). Four cases were lost. There was no late death and cardiovascular event during following up. There were 11 cases in cardiac function classification (NYHA) grade Ⅱ and 5 in grade Ⅰ. Echocardiography showed that LVEDD reduced significantly (49.50±4.66 mm vs. 57.94±6.79 mm, t=5.041, P=0.000) and left ventricular ejection fraction (LVEF) increased significantly (55.08%±6.72% vs. 45.57%±11.31%, t=2.719, P=0.013)compared with those before operation. Conclusion VSR after AMI is one of the serious complications of AMI. Proper operation timing, perfect preoperative preparation, appropriate perioperative treatment, right surgical method and the avoidance of complications can effectively reduce the mortality and improve the prognosis.

Diagnosis and Surgical Treatment of Primary Pulmonary Artery Tumor

Abstract: Objective To investigate the clinical features, differential diagnosis, surgical treatment and outcome of primary pulmonary artery sarcoma. Methods Between January 1994 and December 2004, 5 patients with primary pulmonary artery sarcoma were identified at operation and treated by surgical resection. Pulmonary valve stenosis were initially diagnosed in 3 patients, and chronic pulmonary embolism were initially diagnosed in 2 patients. Tumor resection from the vascular bed was performed in 1 patient and tumor resection and homograft reconstruction of pulmonary arteries were performed in 4 patients. Results One patient died of postoperative refractory pulmonary hypertension, 2 patients died 4 months after operation because of brain metastases, 1 patient was alive for 9 months after operation with recurrent pulmonary tumor, and 1 patient was alive for 2 years after operation without clinical or radiological signs of tumor recurrence or metastasis. Histological examinations showed 4 malignant mesenchymomas and 1 fibrosarcoma. Conclusions Primary pulmonary artery sarcomas are rare and usually fatal tumors of the cardiovascular system. The diagnosis is difficult and this disease is frequently misdiagnosed as chronic pulmonary hromboembolism and pulmonary valve stenosis. Early diagnosis can be improved by computerized tomography scanning and magnetic resonance imaging. Radical surgical resection was the most effective modality for shortterm palliation. The prognosis of pulmonary artery sarcoma is poor. The survival time after resection varies from several months to several years depending on the presence of recurrence or metastasis.