Surgical aortic valve replacement is the primary choice for the treatment of aortic valve stenosis. It can significantly improve the quality of life and life expectancy of patients, but some patients have risks such as advanced age and poor general conditions and can not receive open chest surgery. In 2002, a French doctor, Cribier, successfully performed transcatheter aortic valve implantation (TAVI) surgery on a patient with aortic stenosis. At present, the safety and effectiveness of TAVI surgery have been confirmed by many studies. However, its complications are also relatively common. This article summarizes the related reports at home and abroad.
Pulmonary hypertension due to left heart disease (PH-LHD) is the most common in various types of pulmonary hypertension. Although there are many treatments for pulmonary hypertension, it may be harmful when we adopt treatment without detrimental diagnosis and classification of pulmonary hypertension. Therefore, it is very crucial to have accurate diagnosis and classification of pulmonary hypertension before making treatment decisions. However, there are still some difficulties in the classification of pulmonary hypertension in clinical work. It is a great challenge with limited treatment to solve the PH-LHD which often has complicated pathophysiological mechanisms of precapillary and postcapillary pulmonary hypertension. Here, we review the research status of PH-LHD.
Objective To modify the method for aortic end strengthening in acute type A aortic dissection operation, and investigate its clinical efficacy. Methods We modified the method for aortic end strengthening in acute aortic dissection operation based on ‘Sandwich method’ in the department of thoracic and cardiovascular surgery of West China Hospital. From January 2006 to December 2008, twentyeight patients with acute type A aortic dissection underwent modified aortic end strengthening operation. We made adventitia turn over and enfold to strengthen the aortic end in 10 cases, and placed stripshaped felt or pericardium belts between dissection (between adventitia and intima)and inner intima and strengthened the aortic end by suture in 18 cases. The hemorrhage of anastomotic stoma and the postoperative early prognosis were observed. Results No bleeding complication was found in all the cases. Two cases died, one died of severe low cardiac output syndrome and another died of multiple organ failure. No nervous system complication was found except that 2 cases had delayed revival. No sternum and surgical incision related complication was found. The rest 26 cases were cured and discharged. Conclusion The modified method for aortic end strengthening can not only strengthen the aortic end but also make people be able to find the petechia of anastomotic stoma clearly, then stitch hemostasia could be done effectively. The method is easy to implement and effective, it should be extend in clinic.
【摘要】 目的 了解心脏瓣膜置换术后认知功能障碍（POCD）的危险因素，明确围手术期脑糖代谢异常是否为术后POCD的可能发病机制之一。 方法 选取2004年3月-2009年7月心脏瓣膜置换术患者70例，根据术后第7天患者认知功能测定结果分为POCD组（n =31）和非POCD组（n =39），比较两组患者年龄、性别、体外循环（CPB）时间、主动脉阻断时间、主动脉阻断后平均动脉压和平均灌注流量，并且分别于麻醉后手术前（T1）、CPB稳定的低温期（T2）、复温至33℃（T3）、CPB结束后30 min（T4）4个时点采动脉及颈内静脉血，测定血气、血糖浓度，计算出脑摄氧率（CEO2）、脑糖摄取Glu（a-v）。 结果 发生POCD的患者年龄较非POCD组大，并且CPB时间和主动脉阻断时间也更长，两组之间比较有统计学差异（Plt;0.05），但是两组在性别、主动脉阻断后平均动脉压和平均灌注流量比较无统计学差异。两组的CEO2变化趋势一致，各时点的值无明显变化，两组间比较无差异；非POCD组的Glu（a-v）各时点间比较无统计学差异，POCD组的Glu（a-v）T1、T2时点也无明显变化，但POCD组的Glu（a-v）在T3、T4明显降低，并且与非POCD组比较有统计学意义（Plt;0.05）。 结论 年龄、CPB时间和主动脉阻断时间是POCD发生的危险因素。脑糖代谢异常是POCD发生的可能机制之一。【Abstract】 Objective To understand the risk factor of postoperative cognitive dysfunction (POCD), and identify whether perioperative brain glucose metabolism disorder was or not pathogenesis of POCD after heart valve replacement operation. Methods From March 2004 to July 2009, 70 patients with heart valve replacement were divided into POCD group (n=31) and non-POCD group (n=39) according to cognitive function status tested on the seventh day after operation. The age, sex, cardiopulmonary bypass (CPB) duration, aortic crossclamp duration, mean arterial blood pressure and mean priming volume after aortic crossclamp of two groups were compared. Blood samples were drawn from the radial artery and jugular bulb catheters for determination of blood gas and glucose after induction of anaesthesia (baseline), at the time of the lowest CPB temperature, rewarming to 33℃, and 30 minutes after termination of CPB, CEO2 and Glu (a-v) were calculated: CEO2= (CaO2－CvO2) /CaO2. Results In POCD group, the average age was larger and CPB duration and aortic crossclamp duration was longer than in non-POCD group (Plt;0.05) , but there were no statistical differences in sex, mean arterial blood pressure and mean priming volume after aortic crossclamp. The change tendency of CEO2 of two groups were similar and without significant difference. Glu (a-v) of non-POCD group had no difference in every point, and Glu (a-v) of POCD group had no difference in T1 and T2 points, but value of Glu (a-v) of POCD group decreased obviously and had distinct difference with that of non-POCD group in T3 and T4 points (Plt;0.05). Conclusion Age, CPB duration, and aortic crossclamp duration were risk factors of POCD. Brain glucose metabolism disorder was possibly one of pathogenesis of POCD.
Antegrade cerebral perfusion (ACP) and retrograde cerebral perfusion (RCP) are the two major types of brain protection during aortic arch surgery. Which one is better has still been debated. By summarizing and analyzing the research progress of the comparative research of antegrade cerebral perfusion and retrograde cerebral perfusion in aortic arch surgery, we have found that there was no significant difference between ACP and RCP in terms of temporary nerve dysfunction (TND), permanent nerve dysfunction (PND), stroke, early mortality, morbidity, long-time survival, and a composite outcome of hospital death, bleeding, prolonged ventilation, need for dialysis, infection and stroke. But RCP resulted in a high incidence of prolonged mean ICU-stay and hospital-stay, longer mean extubation time as well as higher cost. And the surgeon is given more time to reconstruct the vessels of the arch since mean operative time is longer in the ACP. So we think that antegrade cerebral perfusion might be preferred as the brain protection method for complicated aortic arch procedures. If a surgeon confirms that the surgery is not very sophisticated and can be completed in a short time, it is better to choose RCP because of no catheter or cannula in the surgical field to impede the surgeon. The article aims at providing a reference to cardiac surgeries when choosing cerebral protection strategy in aortic arch surgery.
Transcatheter aortic valve replacement (TAVR) has been confirmed to be safety and efficacy for high-risk elderly aortic stenosis, and the clinical effect of TAVR for medium and low-risk aortic stenosis is not worse than that of surgery. The development of surgical techniques and instruments has made cardiologists attempt to broaden the surgical indications. Many elderly and high-risk patients with pure native aortic regurgitation have been treated “off label” with similar techniques, completing artificial valve replacement, restoring valve function and improving the prognosis. However, due to the high requirements of surgical techniques and surgical complications, there is a lack of randomized controlled studies to confirm its safety and effectiveness. Unlike aortic stenosis, native aortic regurgitation presents unique challenges for transcatheter valves. In this article, the authors review current advances in the treatment of aortic valve regurgitation with TAVR.
ObjectiveTo evaluate the early and mid-term outcomes of total thoracoscopic Box Lesion radiofrequency ablation in patients with atrial fibrillation.MethodsThe clinical data of 31 patients with atrial fibrillation who underwent total thoracoscopic Box Lesion radiofrequency ablation between November 2011 and March 2018 at the Department of Cardiac Surgery in our hospital were retrospectively analyzed, including 23 males and 8 females at an average age of 66.17±8.32 years. All patients did not have concomitant severe organic heart disease which required surgical intervention.ResultsThere were 20 patients with paroxysmal atrial fibrillation, 8 with persistent atrial fibrillation, and 3 with long-standing persistent atrial fibrillation. Twenty-nine patients got the 3-year follow-up, and 2 patients were lost to the follow-up 6 months after the surgery. The procedure was successfully performed in all patients, with an average operation time of 113.00±26.00 min. There was no perioperative death or related complication. All patients were restored to sinus rhythm immediately after surgery. Five patients got atrial fibrillation during postoperative hospitalization, which reverted to sinus rhythm after electrical cardioversion. The rate of sinus rhythm maintenance was 62.9%, 55.9% and 52.4% in postoperative 1, 2 and 3 years, respectively. No patient died during the period, and no procedure-related complication was observed.ConclusionTotal thoracoscopic Box Lesion radiofrequency ablation effectively shortens operation time, and reduces surgical trauma and procedure-related complications, meanwhile, ensures the surgical outcomes.
Transcatheter aortic valve replacement (TAVR) for severe aortic stenosis is growing rapidly. The use of new heart valves prosthesis has improved surgical safety and efficacy. This report described a 72-year-old male patient with severe aortic stenosis combined with severe aortic regurgitation, who was evaluated at moderate-high risk of surgery and received a transapical TAVR using the Ken-Valve heart valve. The transcatheter operation time was 8 min, and the blood loss was 50 mL. The tracheal intubation was removed immediately after the surgery. Transesophageal echocardiography on the 4th postoperative day showed that the aortic valve leaflets worked well, and there was no valve orifice and paravalvular leakage. The patient was discharged on the 5th day after the surgery without complications. Transapical TAVR using Ken-Valve was an easy surgical procedure for aortic valve disease, and had short operation time.
Transcatheter aortic valve replacement (TAVR) techniques have been rapidly developed in recent years. Current guidelines and studies mainly focus on aortic stenosis patients treated by transfemoral approach, but they are not completely appropriate to patients with isolated aortic regurgitation or other patients who need transapical TAVR (TA-TAVR), which affects the standardized treatment of those patients. Therefore, our team pronounced the operational standards for TA-TAVR, based on fully reviewing the literatures worldwide, combined with the opinions of experts from 15 heart centers with rich experience in carrying out TA-TAVR in China. This standard aims to provide clinicians with standardized diagnosis and treatment principles of TA-TAVR and improve the quality of TA-TAVR in China.
The technique of transcatheter aortic valve implantation has become increasingly mature. Although the transapical approach has a certain degree of minimally invasive trauma, it still has the characteristics such as heart beating without cardiopulmonary bypass, and the low technical requirements of catheter guide wire. In particular, the valve path is short and coaxial, which is easy to manipulate, and pure regurgitation and stenosis can be easily operated and are not subject to the limit of peripheral artery stenosis. It is still one of China's main approaches for transcatheter aortic valve replacement. Its perioperative management still has specific features and differs from the femoral artery approach. In addition, there is little relevant literature abroad. Therefore, domestic experts in this field were organized to discuss the development of perioperative management specifications to provide reference and techniques support for developing this field in China and further improve the quality of clinical operation and perioperative management. It will provide more safe and more effective medical services to these patients.