Abstract： Objective To summarize and evaluate the clinical effect of “modified” ascending aorta and hemiarch replacement combined with stent-graft elephant trunk technique, a new surgical approach for patients with Stanford type A aortic dissection. Methods Between December 2009 and January 2011, the “modified” ascending aorta and hemiarch replacement combined with stent-graft elephant trunk technique was performed to a total of 47 patients suffering from Stanford type A aortic dissection in the First Affiliated Hospital of China Medical University. There were 35 male patients and 12 female patients. Their mean age was（57.9±16.0）years （ranging from 29 to 86 years）. Preoperative computedtomography angiography（CTA） imaging was analyzed using three-dimensional （3D） reconstruction to clarify their diagnosis.All these patients underwent their procedures under cardiopulmonary bypass（CPB）, hypothermic circulatory arrestand right axilary artery cannulation for selected cerebral perfusion. The treatment of proximal end to heart included： ascending aorta replacement in 29 patients, Bentall procedure in 11 patients, Wheat procedure in 4 patients, and David procedure in 3 patients. Five patients underwent concomitant coronary artery bypass grafting. Results Their average CPB time was （136±32） min, average aortic cross-clamp time was （97±28） min, and average selected cerebral perfusion andlower body arrest time was （27±11） min. The in-hospital mortality was （4.25% , 2/47）. Postoperatively, two patients had transient neurological disorder, 1 patient had irreversible paraplegia, and 4 patients underwent reoperations for bleeding. All the 45 surviving patients underwent 3D CTA before discharge and 6 months after operation. The stented elephanttrunk-elastic metal stent were all well exhibited in the true lumen of the descending aorta, and the true lumens distal to the stent graft were also significantly enlarged compared with their preoperative diameters（P ＜ 0.05）. All the patients were followed up from 1 to 13 months. There was no aneurysm rupture and no reoperation related to residual dissected aorta wascarried out during follow-up. Conclusions “Modified” ascending aorta and hemiarch replacement combined with stentgraftelephant trunk technique is a safe and effective approach to treat patients with Stanford type A aortic dissection without involvement of 3 vessels of the arch. The main advantage of this approach is to simplify the surgical procedure, shorten the procedure time and CPB time, and reduce morbidity with a satisfying short-term result.
Surgical Therapy for Valve Diseases Combined with Coronary Heart Diseases in Patients Over or Below 70 Years Old YU Lei, GU Tianxiang, SHI Enyi, XIU Zongyi, FANG Qin, ZHANG Yuhai. (Department of Cardiac Surgery, The No. 1 Hospital of China Medical University, Shenyang 110001, P.R. China)Corresponding author: GU Tianxiang, Email: cmugtx@sina.comAbstract： Objective To summarize the experiences of valve replacement combined with coronary artery bypass grafting (CABG) in senile patients by comparing clinical outcomes of valve diseases combined with coronary heart diseases in patients over or below 70 years old. Methods We retrospectively analyzed the clinical data of 49 patients who received valve replacement combined with CABG in our department from May 1999 to December 2007. Based on the age, the patients were divided into ≥70 years group (17 cases) with its patients at or above 70 years old and lt;70 years group (32 cases) with its patients younger than 70. The percentage of chronic obstructive pulmonary diseases (COPD) before surgery in ≥70 years group was higher than that in lt;70 years group(Plt;0.05). No significant difference was found in the other relevant factors between the two groups. The clinical index of patients in the two groups were compared and analyzed. Results There were significant differences between the two groups in such factors as the percentage of biovalve use (82.4% vs. 12.5%, χ2=23.311, P=0.000), the time of mechanic ventilation (34.5±29.3 h vs. 18.0±16.1 h, t=-2.542,P=0.014), the time of ICU stay (4.4±1.5 d vs. 3.3±0.7 d, t=-3.522, P=0.001), the time of hospital stay (21.4±7.7 d vs. 18.1±1.8 d, t=-2.319, P=0.025), the percentage of IABP use (29.4% vs. 6.3%, χ2=4.862, P=0.037), the percentage of pulmonary function failure (35.3% vs. 6.3%, χ2=6.859, P=0.009), the percentage of acute renal failure (23.5% vs. 3.1%, χ2=5.051, P=0.025), and the percentage of cerebrovascular accident (11.8% vs. 0.0%, χ2=3.933, P=0.048). There was no significant difference between the two groups in factors like the anastomosis of distal graft (2.5±3.1 vs. 2.4±14, t=0.301, P=0.758), the time of aortic occlusion (89.3±25.4 min vs. 88.5±31.0 min, t=0.108,P=0.913), the time of cardiopulmonary bypass (144.6±44.8 min vs. 138.3±52.9 min, t=0.164, P=0.871) and the mortality (5.9% vs. 6.3%, χ2=0.002,P=0.959). The perioperative myocardial infarction rate was zero in both groups. ≥70 years group patients were followed up for 2 months to 9 years with only 1 case missing. One patient who had undergone mechanic valve replacement died of cerebral hemorrhage 1.5 years after operation. Two died of heart failure and lung cancer 3 months and 6 years after operation respectively. For all the others, the cardiac function was at class Ⅰ to Ⅱ and their life quality was significantly improved. The follow up time of lt;70 years group was 1 month to 6 years and 5 cases were missing. Four patients who had undergone mechanic valve replacement died of complications in relation to anticoagulation treatment. One died of severe low cardiac output. Another died of traffic accident. Conclusion Surgery operation and effective perioperative treatment are key elements in improving surgery successful rate and decreasing mortality in patients with valve and coronary artery diseases. Valve replacement combined with CABG is safe for patients older than 70 years old.
Abstract: Objective To compare the therapeutic effects between offpump coronary artery bypass grafting (off-pump CABG) and onpump coronary artery bypass grafting (on-pump CABG) in the patients of multivessel coronary disease below 70 years old, in order to decide on the best surgery method. Methods From June 2007 to June 2009, 196 patients below the age of 70 underwent coronary artery bypass grafting (CABG), including 152 male patients and 44 female patients. The average age was 55.00 years old, ranging from 46 to 69 years. The patients were divided into two groups according to the methods of operation. There were 94 patients in the off-pump CABG group including 2 patients who were converted to the onpump CABG surgery because of the unstable hemodynamics. The other 102 patients were in the onpump CABG group. The type and number of the vessel grafts, the quantity of blood transfusion, intubation duration, length of stay in hospital, complications during perioperative period and mortality were compared between the two groups. Results In the offpump CABG group, 2 patients were converted to onpump CABG surgery because of the unstable hemodynamics, and 1 of them died from multiple organ failure. In the onpump CABG group, 2 patients died from severe low output syndrome and sudden heart arrest respectively. No significant difference was found in the vessel grafting materials, perioperative complications and mortality between the two groups (Pgt;0.05), while the number of anastomosis (3.22±0.65 vs. 4.52±1.11, t=9.807, P=0.000), the [CM(159mm]quantity of blood transfusion (312.57±305.26 ml vs. 744.86±279.37 ml, t=10.317, P=0.000),the intubation duration (10.71±5.32 h vs.17.12±4.67 h, t=8.683, P=0.000) and the length of stay in hospital (17.75±3.04 d vs. 21.24±6.46 d, t=4.782,P=0.000) in the off-pump CABG group were significantly lower or shorter than those in the on-pump CABG group. A total of 93 patients in the off-pump CABG group and 100 patients in the on-pump CABG group were followed up with the time periods ranging from 2 to 26 months. All patients survived without angina. Conclusion There is no significant difference in the early clinical therapeutic effects between off-pump CABG and onpump CABG in the patients of multivessel coronary disease below 70 years old, but revascularization in the on-pump CABG patients is better. So far, offpump CABG cannot replace on-pump CABG and more clinical trails are needed for evaluation of the longterm prognosis.
Objective To investigate the surgical therapy for chronic total occlusion (CTO) of coronary artery with offpump coronary artery bypass grafting (OPCAB). Methods From Aug. 1999 to Oct. 2007, 696 patients with 853 totally occluded coronary arteries (127 coronary arteries lack of opacification while the other 726 arteries with reverse flow showed by coronary angiography) underwent OPCAB. A total of 2 231 grafts were constructed including 136 placed to coronary endarterectomy (CE) targets and 28 arterialized middle cardiac veins. Blood flow was detected during operation in 26 coronary arteries with no opacification in preoperative angiography, while no blood flow was detected in 63 coronary arteries with opacification in preoperative angiography. Cardiopulmonary bypass was applied in 15 cases because of a poor hemodynamics and 6 of which were assisted with intraaortic balloon pump(IABP). Results All patients survived the operation. 6 died in hospital because of low cardiac output (2 cases), renal failure (2 cases), perioperative cardiac infarction (1 case) or cerebrovascular accident (1 case). Stress ulceration occurred in one case, mediastinal infection occurred in another case after operation. Both were treated medically and recovered. 692 patients were followed up and the rate of flup was 99.42%(685/686)， with 4 withdrawal. Freedom from cardiac angina was 99.85%(685/686) and cardiac functional grading (NYHA) was Ⅰ-Ⅱ. Conclusion OPCAB can be well performed in patients with chronic total occlusion of coronary arteries. The ralue of coronary angiography for evaluating totally occluded coronary artery is limited, and endoscope or intravascular ultrasound techniques may be helpful.
ObjectiveTo investigate the incidence of acute kidney injury (AKI) after deep hypothermic circulatory arrest (DHCA), to explore the risk factors and prognosis of postoperative AKI, and to establish a relatively accurate preoperative risk assessment strategy and prevention measures.MethodsThe clinical data of 252 patients who underwent deep hypothermic circulatory surgery in our hospital from January 2014 to October 2018 were retrospectively analyzed. There were 179 males and 73 females with an average age of 53.6±11.6 years. The patients were divided into an AKI group and a non-AKI group according to the AKI diagnostic criteria developed by kidney disease improving global outcomes (KDIGO). The data of the two groups were compared, and the risk factors related to AKI after DHCA were analyzed by single factor and multivariate logistic regression.ResultsAmong the 252 patients enrolled, the incidence of AKI was 69.0%. The postoperative hospital mortality rate was 7.9% (20/252). The univariate analysis showed that the patient's age and body mass index (BMI)≥28 kg/m2, left ventricular ejection fraction<55%, preoperative serum creatinine (Scr)≥110 μmol/L, preoperative estimated glomerular filtration rate (eGFR), Cleveland score and intraoperative cardiopulmonary bypass time, intraoperative infusion of red blood cells, intraoperative infusion of plasma, postoperative mechanical ventilation time≥40 h and other indicators were significantly different between the two groups (P<0.05); multivariate logistic regression analysis showed that there was significant difference between the two groups in age (OR=1.040, 95% CI 1.017–1.064, P=0.001), BMI≥28 kg/m2 (OR=2.335, 95%CI 1.093–4.990, P=0.029), eGFR<90 mL/(min·1.73 m2) (OR=2.044, 95%CI 1.082–3.863, P=0.028), preoperative Cleveland score (OR=1.300, 95%CI 1.054–1.604, P=0.014) and intraoperative cardiopulmonary bypass time (OR=1.009, 95%CI 1.002–1.017, P=0.014).ConclusionThe incidence of AKI is higher after DHCA. Patients with postoperative AKI have longer hospital stay and higher risk of hospitalization death. The age of patients, BMI≥28 kg/m2, eGFR<90 mL/(min·1.73) m2, Cleveland score, intraoperative extracorporeal circulation time are independent risk factors for AKI after DHCA.
Objective To observe the influence of edaravone perfusion via the pulmonary artery on postoperative lung tissue and lung function during pulmonary ischemia in deep hypothermic circulatory arrest （DHCA）， and explore its possible mechanism. Methods A total of 24 healthy New Zealand white big-ear rabbits were randomly divided into three groups： （1） control group： DHCA model under cardiopulmonary bypass （CPB） was established； （2）low potassium dextran （LPD）group： LPD solution perfusion via the pulmonary artery after the establishment of DHCA； （3）edaravone group：LPD solution containing edaravone （5 mg/kg） perfusion via the pulmonary artery after the establishment of DHCA. Oxygenation index and lung compliance were observed at the time of baseline condition， recovery of ventilation， 1 hour and 2 hours after recovery of ventilation， and postoperative lung function of the three groups were compared. Malondialdehyde （MDA） and superoxide dismutase （SOD） in pulmonary venous blood were measured. All the rabbits were sacrificed after the operation. HE staining and immunohistochemistry were performed on the lung tissues to investigate lung structure changes and inflammatory reaction. Transmission electron microscopy was used to compare ultrastructural changes of lung.Results There were no statistical difference in oxygenation index， lung compliance， MDA and SOD among the 3 groups under the baseline condition （P＞0.05）. After recovery of ventilation， oxygenation index and lung compliance deteriorated to varying degrees in all 3 groups. Oxygenation index and lung compliance of the control group and LPD group at the time of recovery of ventilation， 1 hour and 2 hours after recovery of ventilation were significantly lower than those of edaravone group （oxygenation index：recovery of ventilation and in control group and edaravone group: 198.25±11.02 mm Hg vs. 244.87±13.05 mm Hg；lung compliance：one hour after recovery ventilation in control group and edaravone group：45.88±1.64 ml/cm H2O vs. 59.75±2.38 ml/cm H2O；P＜0.05）. After CPB removal， MDA levels were increased to varying degrees in all 3 groups. MDA levels of the control group and LPD group at the time of CPB removal， 1 hour and 2 hours after CPB removal were significantly higher than those of edaravone group （P＜0.05）. After CPB removal， SOD levels were decreased to varying degrees in all 3 groups. SOD levels of the control group and LPD group at the time of CPB removal， 1 hour and 2 hours after CPB removal were significantly lower than those of edaravone group （P＜0.05）. HE staining showed clear lung structure， less red blood cell leakage， less inflammatory cell infiltration， and less alveolar fluid accumulation in the edaravone group. Immunohistochemistry showed that integral light density of interleukin 6 （IL-6）in edaravone group was significantly lower than those of the LPD group and control group （14.44±1.75 vs. 20.18±2.22， P＜0.05）. Transmission electron microscopy showed integral basement membrane structure， clear blood gas barrier structure， significantly larger number of type II epithelial cells， abundant but not swollen mitochondria and lamellar bodies in the cytoplasm in the edaravone group， which were destroyed in varying degrees in the LPD group and control group. Conclusion Pulmonary artery perfusion of protective solution in low temperature can significantly reduce lung injury induced by DHCA and CPB. Protective solution containing edaravone in low temperature can better decrease lung injury and protect oxygenation.
Objective To compare the clinical outcomes and safety of minimally invasive and routine mitral valve repair or replacement for patients with single mitral valve disease. Methods We retrospectively analyzed the clinical data of 67 patients with single mitral valve disease （without aortic valve and tricuspid valve lesion or other heart diseases including atrial septal defect） who underwent mitral valve repair or replacement in the First Affiliated Hospital of China Medical University between January and July 2011. The patients were divided into two groups according to different surgical approaches：the minimally invasive surgery group （n=29，8 males and 21 females，age 51.4±9.4 years） underwent minimally invasive mitral valve repair or replacement via right mini-thoractomy；and the routine surgery group （n=38，11 males and 27 females，age 53.6±11.9 years） underwent mitral valve repair or replacement via middle sternotomy. In the minimally invasive surgery group，9 patients underwent mitral valve repair while the other 20 patients underwent mitral valve replacement. And no patient underwent transition to routine operation. In the routine surgery group，15 patients underwent mitral valve repair and 23 patients underwent mitral valve replacement. Clinical outcomes and safety of the operations were compared between the two groups. Results There was no statistical difference in operation time between the two groups （207.9±18.1 min versus 198.4±27.5 min，P=0.076）. The amount of postoperative drainage （126.7±34.5 ml versus 435.6±87.2 ml，P=0.000） and blood transfusion （red blood cell 1.4±0.8 U versus 2.3±1.1 U，P=0.000；blood plasma 164.3±50.4 ml versus 405.6±68.9 ml，P=0.000） of the minimally invasive surgery group were significantly lower than those of the routine surgery group. The cardiopulmonary bypass time （81.7±23.9 min versus 58.7±13.6 min，P=0.000） and aortic-clamping time （51.6±12.7 min versus 38.4±11.7 min，P=0.000） of the minimally invasive surgery group were significantly longer than those of the routine surgery group. The length of ICU stay （22.5±3.6 h versus 31.7±8.5 h，P=0.000），mechanical ventilation （7.4±3.2 h versus 11.2±5.1 h，P=0.000） and postoperative hospitalization （7.1±1.6 d versus 13.5±2.4 d，P=0.000） of the minimally invasive surgery group were significantly shorter than those of the routine surgery group. There was no statistical difference in postoperative complications between the two groups. Minimally invasive surgery group patients were followed up for 5.3±2.4 months with a follow-up rate of 72.4%（21/29）. Routine surgery group patients were followed up for 5.5±3.8 months with a follow-up rate of 71.0%（27/38）. There was no significant complication during follow-up in both two groups. Conclusion Minimally invasive mitral valve operation via right mini-thoracotomy is effective and safe with a good cosmetic result. Compared with routine operation，patients undergoing minimally invasive operation recover better and faster.
Objective To study the technical characteristics, clinical outcomes and short- and long-term results of minimally invasive multi-vessel coronary artery bypass grafting and to evaluate the feasibility and efficacy. Methods From April 2012 to December 2014, minimally invasive cardiac surgery for coronary artery bypass grafting (MICS CABG) in 11 patients was performed in the First Hospital of China Medical University. All patients were males and the average age was 62.7 (47.0-73.0) years. Eight patients with 3-vessel lesions and 3 patients with 2-vessel lesions. General anesthesia was performed with double lumen endotracheal intubation and single lung ventilation. The patient was positioned 15 degrees to 30 degrees in right lateral position. The left anterior and lateral incision was made at the fourth/fifth intercostal space with the length of 5-7 cm and 2/3 part of the incision located in the medial side of anterior axillary line. Left internal thoracic artery (LIMA) was harvested from the third intercostal space up to the subclavian vein and down to more than fifth intercostal space through the surgical window. Through the xiphoid and sixth intercostal space incision with the length of 1 cm, the Starfish and Octopus system were placed to fix apex and ascending aorta and target vessels were exposed. The proximal and distal anastomosis was done under the direct vision. The sequence of distal anastomosis was from posterior descending branch to obtuse/diagonal branch and left anterior descending branch. The chest and pericardial draining tubes were placed through the xiphoid and sixth intercostal space incision. Results The mean operation time was 4.1 (3.2–5.8) h. Five patients underwent the operation with the assist of cardiopulmonary bypass and the mean assisting time was 21.0 (17.0-38.0 ) min. The mean number of distal anastomosis was 2.8 (2.0-3.0) and LIMA was harvested and grafted in all 11 patients. The mean drainage was 425.0 (180.0-750.0) ml, mean ventilation time 7.8 (4.3-11.2) h, ICU stay 15.9 (11.0-38.0) h, and hospital time 7.7 (5.0-14.0) d. There was no operative death and re-exploration for bleeding. One patient was complicated by paroxysmal atrial fibrillation and one patient myocardial infarction. The average follow-up was 19.4 (12.0-36.0) months, and no chest pain, re-admission or re-intervention happened. Coronary artery CT angiographies demonstrated that all LIMAs were patent and 4 vein grafts were occluded and venous graft patency rate was 80.0% one year after surgery. Conclusion MICS CABG has the advantage of quick recovery, good cosmetic effect and low incision infection rate compared to the conventional CABG. Compared with robotic surgery, the cost of MICS CABG is low and the same as that of the conventional CABG. It is a new kind of CABG and could be performed following the learning curve under strict training of doctors and careful patient selection. With the good short- and middle-term results, MICS CABG needs to be evaluated for long-term graft patency rate, re-revascularization rate, and clinical evidence.