Preoperative evaluation is crucial for heart valvular surgery. This article discusses some issues that need to be emphasized: the impact of hypertension on the severity of aortic valve lesions, and how to improve the accuracy of clinical assessment; the identification of functional tricuspid regurgitation, in order to choose the appropriate surgical technique; the need for right ventricular function testing, and the use of risk scoring models, to better grasp surgical timing and indications and improve efficacy; and the importance of evaluating atrial mitral and/or tricuspid regurgitation complications in chronic atrial fibrillation, and making rational choices for interventional and surgical treatment.
Objective To investigate the clinical effects and the brain protection effect of different cardiopulmonary bypass in treating descending aortic aneurysms. Methods From January 2001 to December 2008, 65 patients were diagnosed to have descending aortic aneurysm with magnetic resonance imaging (MRI) in our hospital. Among them, there were 56 males and 9 females whose age was between 15 and 71 years old with an average of 48.1 years. The disease process ranged from 6 days to 4 months (19.0±6.5 d ). Preoperative diagnosis showed that there were 41 cases of DeBakey type Ⅲinterlayer, 9 cases of Marfan syndrome with postoperative complications of type Ⅲ interlayer, 7 cases of pseudoaneurysm and 8 cases of true aneurysm. We adopted artificial blood vessel repair patch to repair the damaged point of the descending aorta in 2 cases, performed vascular aneurysm resection and artificial vessel replacement on 63 patients, and carried out descending aorta replacement and intercostal artery grafting in 18 cases. Results Among the 65 cases of cardiopulmonary bypass patients, there were 13 cases of left heart bypass, 12 cases of heart bypass, 30 cases of deep hypothermic circulatory arrest (DHCA) with total body retrograde perfusion (TBRP) and 10 cases of modified separate perfusion of upper and low body. Cardiopulmonary bypass time, DHCA time, retrograde perfusion time, upper body circulatory arrest time and low body circulatory arrest time were respectively 51-212 min, 18-75min, 18-73 min, 21-31 min, and 39-67 min. No death occurred during the operation, and there were no brain complications or complications of paralysis among all the patients. Two patients died after operation because of renal failure. Conclusion Good results can be achieved by selecting different method of cardiopulmonary bypass based on the anatomical location and range of the thoracic descending aortic aneurysms. The selection criteria should be favorable to the surgical operation and organ protection.
Abstract： Objective To summarize the methods and results of supra-annular aortic valve replacement（AVR） in patients with severely damaged aortic annulus. Methods Supra-annular AVR was performed in 5 patients between March 2008 and Dec. 2010 in Changhai Hospital, Second Military Medical University. There were 4 males and 1 female with their mean age of 46.3 years (ranging from 38 to 53 years). Non-specific infectious diseases were diagnosed in 4 patients who had severe paravalvular leakage after their first AVR operations (2 patients with Behcet’s disease and 2 patients with arteritis), and one patient had severe infectious endocarditis. All the patients had severely destroyed aortic annulus and could not undergo routine AVR. The prosthetic valves were fixed to the aortic sinus wall between the annulus and coronary arterial ostia, and the sutures passed through from the outside of aortic wall into the inside and prosthetic valve ring. Coronary artery bypass grafting was performed if the coronary ostium was involved. Results All patients recovered from the operations uneventfully, and were followed up from 6 months to 3 years. All patients were in New York Heart Association（NYHA） functional class Ⅰ or Ⅱ during the follow-up period, and paravalvalar leakage, pseudoaneurysm and aortic root aneurysm were not found by the examination of 3D computed tomographic angiography and echocardiography at 6 months（4 cases）, 1 year（2 cases）, and 3 years（1 case）, respectively . Conclusions Supra-annular AVR is an alternative surgical method for patients with severely damaged aortic annulus. The procedure is simple and effective to prevent paravalvular leakage and pseudoaneurysm formation.
Objective To study effects of mitral valve replacement(MVR) on the old with mitral valve diseases(MVD). Methods The documents of 265 cases undergoing MVR were reviewed, who aged 60 years old or over between June 1991 and June 2003. Demographices, clinical preoperative conditions, indications to surgery, early postoperative course and long-term outcome were collected via hospital documents and outpatient follow-up. Many risk factors were analysed. Results Follow-up rate amounted to 93.7%(236/252). The mortality was 4.9% (13/265) within 30 days. Heart failure and renal failure were the main cause of death. Compared with younger patients(lt;60 years old), long-term survival rate was lower in the old, 5-year 87.52% vs 96.84%, 10-year 81.23% vs 94.87%. There were 15 late deaths(0.17% case/M), most of whom died of heart failure, cancers and lung infections. Risk factors for MVR in the old included New York Heart Association class Ⅳ, diabetes, and lung incompetence. Conclusions The patients with MVD over 60 years old tended to present high postoperatively mortality and morbidity.
Abstract： Objective To evaluate the early and late results of mitral valve replacement with home made C-L pugesturt tilting disc and analyse the factors which impact on the therapeutic effect，so as to elevate the operative effect. Methods A retrospective study was made on the result of clinical data and longterm followup of 259 patients who had undergone the Chinesemade C-L pugesturt tilting disc mechanical valve replacement from October 1991 to November 2006. Results The data showed that there were 12 patients died in the duration of hospital stay.The hospital mortality was 4.63% (12/259).There were no mechanical valverelated complication in the earlier postoperative period.The mortality fell to 2.59% since 1996.Among the 235 patients,12 patients were lost during the followup,the rate of followup was 95.1%(235/247).The time for followup was 9.77±3.09 years. There were 26 late deaths.During the follow-up,death associated with the deterioration of valve structure were not observed. The 5 years, 10 years and l5 years survival rates were 86.80%±2.30%, 78.20%±3.33% and 55.23%±4.34% respectively; the thromboembolic event free rates for 5 years, 10 years and l5 years were 95.95%±0.74%, 92.52%±4.11% and 80.52%±4.11% respectively; the anticoagulant related bleeding free rates for 5 years, 10 years and l5 years were 94.64%±1.75%, 89.55%±3.28% and 79.39%±4.43% respectively.There were 141 patients(67.46%) in New York Heart Association(NYHA) classⅠ, 56 patients(26.79%) in class Ⅱ, 10 patients(4.78%) in class Ⅲ and 2 patients(0.95%) in class Ⅳ. Conclusion The results of follow-up for 15 years suggest that the Chinesemade C-L pugesturt tilting disc medical mechanical valve is a reliable and safe choice for mitral valve replacement.
Abstract: Objective To evaluate the longterm results of surgical treatment of tetralogy of Fallot (TOF) in adults and discuss the perioperative treatment skills. Methods From January 2000 to March 2008, 149 patients older than 14 years with tetralogy of Fallot received surgical treatment in Changhai Hospital. Among the patients, there were 78 males and 71 females with ages ranged from 14 years to 53 years and the average age was 26.3 years. Twenty patients had previous pulmonary arterial shunts before radical treatment. A total of 129 patients underwent primary radical treatment. Thirtyeight patients received a right ventricular outflow tract patch, 107 patients had transannular patch, and 4 patients had homograft aorta with valves. Results Hospital mortality was 4.0%(6/149). Four patients died of low cardiac output syndrome (LCOS), and multiple organ failure, and 2 patients died of acute renal failure. The postoperative complications included pleural effusion in 11 patients, pulmonary edema in 10 patients, severe LCOS in 9 patients, severe cardiac arrhythmia in 7 patients, reoperation for excessive bleeding in 7 patients, reintubation in 6 patients, and residual ventricular septal defect (VSD) in 5 patients (two of them had reoperation for residual VSD repair and 2 received transcatheter closure of VSD). One hundred and thirtyfour patients were followed up for 3 to 102 months (47.2±28.6 months) with a followup rate of 93.7%(134/143). Late death occurred in 2 patients, one of whom died of secondary infective endocarditis and the other had a sudden death 29 months after operation. During the followup, one patient had residual VSD (2 mm), but had a normal life. The peak systolic right ventricletopulmonary artery pressure gradient exceeded 40 mmHg in 4 patients. Two patients had severe pulmonary regurgitation. A total of 132 patients survived and had an improved life. One hundred and twentyone patients had class Ⅰ heart function (NYHA), and 11 patients in class Ⅱ. Conclusion The pathophysiologic conditions of the patients with tetralogy of Fallot in adults are very complicated due to longterm right ventricle outlet stricture and chronic hypoxia. Preoperative evaluations and postoperative treatment of complications are necessary. The systemicpulmonary arterial shunts should be performed when hypotrophy of the pulmonary arteries or left ventricles exists. Repair of tetralogy of Fallot in adults has acceptable morbidity and mortality rates with goodlongterm outcomes.
Objective To investigate the treatment and prognosis of moderate ischemic mitral regurgitation (IMR) in coronary artery disease(CAD). Methods From January 1998 to May 2006, 28 patients of CAD with moderate IMR underwent coronary artery bypass grafting (CABG) and mitral valve plasty(MVP, 24) or mitral valve replacement (MVR,4). The Reed method were used in 9 cases, the annuloplasty ring were used in 15 cases. Mechanical valve were implanted in 1 case and biological valve in 3 cases. Results There was no operative or hospital death. Twentysix patients were followed up to a mean period of 41 months. There were two late death(one was MVP, the other was MVR). In MVP cases, nineteen patients were in New York Heart Association (NYHA) functional class Ⅰ and Ⅱ, 3 in class Ⅲ, which was better than that of preoperative one. Ultrasonic cardiography (UCG) examination showed no mitral regurgitation in 5 cases, mild in 7, light in 6, moderate in 3, severe in 1. Left atrial volume (LAV) and left ventricular enddiastolic volume (LVEDV) were 54.1±12.7ml and 60.9±14.8 ml, decreased more significantly than that preoperatively (Plt;0.05). In MVR cases, 2 cases were survival and followed. One patient was in NYHA functional class Ⅰ, 1 in class Ⅱ, which was better than that of preoperative one. Conclusion Moderate IMR with CAD should be treated carefully. MVP with annuloplasty ring have better early results. For patients with bad heart function and abnormal left ventricular wall motion, the late results need more studies.
Objective To analyze the causes of cardiac myxoma recurrence and discuss its clinical classification. Methods We reviewed the data of two female patients, aged thirty three and forty two, with recurrent cardiac myxoma, who were admitted into our hospital separately in December 2004 and October 2005. We searched articles with “cardiac myxoma” as the key words at www.cqvip.com, and reviewed literature of big case groups having undergone surgical operations, case reports of recurrence and literature with a followup time longer than 4 years between January 1994 and December 2008. Results We reviewed a total of 1 969 cases of cardiac myxoma, in which there were 60 recurrent cases with a recurrence rate of 3.0%, and there were 15 recurrence case reports. Data analysis showed that single pedicle recurrence rate was 3.0% (3/99) and multiple pedicle recurrence rate was 35.7% (5/14); In two reports on cardiac myxoma distributed in multiple chambers, the recurrence rate was 41.7% (5/12) and 33.3% (3/9) respectively;Average interval of recurrence was 4.1 years; Repeated recurrence happened to 9 cases (12.0%) with the most repetition times of 4 in one case; Malignancy on recurrence was found in one case; Reoperation rate was 64.0% (32/50); Six cases (8.0%) were familial myxoma. Accordingly, we advocate a clinical classification of “typical” and “atypical” cardiac myxoma. The typical myxoma refers to the tumors located at left atrium with single pedicle, rooted at or around fossa ovalis, and without abnormal DNA, while the atypical myxoma are familial tumors and tumors stemming from multiple points or multiple chambers, rooted in abnormal position of the left atrium, arising from clear gene mutation, or with malignant tendency. Conclusion Myxomas with multiple pedicles, distributed in more than one chamber, and rooted in abnormal position of the left atrium have a much higher recurrence rate. Close follow-up is needed for abovementioned patients to achieve an optimal treatment results.
Objective To summarize the experiences of surgical treatment for periprosthetic leakage(PPL). Methods A total of 63 patients with PPL (mitral PPL in 34, aortic PPL in 29), age 41±12 years, underwent reoperation with prosthetic valve replacement from Dec. 1980 to Dec. 2005 in this department. Patient characteristics, operative profiles and follow-up data were described and analyzed in detail. Results The perioperative complications occurred in 11 patients (17.5%), five of whom died (the overall hospital mortality: 7.9%). Fifty-five patients were in close follow-up and three of them lost in that period, five patients died in late. Fifty patients long-term survivals were in New York Heart Association class Ⅰ-Ⅱ and follow-up evaluation by echocardiography showed no evidence of recurrence or residual PPL and PPL-related complications. Conclusion More attention should be paid to the study on etiology, pathophysiology, diagnostic methods, and clinical classification of PPL. For patients with PPL, reoperation with prosthetic valve replacement is considerably effective and can obtain an acceptable longterm results.
Abstract: Objective To explore whether clinically mild functional tricuspid regurgitation should be addressed at the time of mitral valve repair (MVP) for moderate or severe mitral regurgitation due to myxomatous degeneration. Methods We retrospectively analyzed the outcomes of 135 patients with moderate or severemitral regurgitation due to myxomatous degeneration with mild functional tricuspid regurgitation. All patients were treated between January 1993 and March 2008 in the Department of Cardiothoracic Surgery of Changhai Hospital, the Second Military Medical University. We divided the patients into a MVP group (n=76) and a MVP+tricuspid valvuloplasty (TVP) group(n=59) according to whether they underwent combined TVP, and observed the perioperative mortality rate, degree of tricuspid regurgitation, and compared survival rate, and freedom from longterm moderate or severe tricuspid regurgitation after operation. Cox regression was used to analyzethe risk factors for longterm moderate or severe tricuspid regurgitation after operations. Results (1) There were no deaths during the perioperative period, and postoperative transthoracic echocardiography of all patients indicated that tricuspid regurgitation was mild or less. (2) Survival rate at 5 years, 10 years after operations in MVP group was 98.4%, 95.0%, respectively, and survival rate at 5 years, 10 years after operations in MVP+TVP group was 100.0%, 93.7%, respectively, and there was no significant difference in the survival rate after operations between the two groups(P=0.311), butthere was a significant difference in the freedom from longterm moderate or severe tricuspid regurgitation after operations between the two groups (P=0.040). Multivariate Cox regression showed that preoperative pulmonary artery pressure gt;30 mm Hg (95%CI 1.127 to 137.487, P=0.040 )and atrial fibrillation (95%CI 1.177 to 23.378, P=0.030) wereindependent risk factors for longterm moderate or severe tricuspid regurgitation afteroperations.Conclusion TVP is necessary for most patients undergoing MVP for moderate or severe mitral regurgitation due to myxomatous degeneration who have coexistent mild functional tricuspid regurgitation, especially those patients with preoperative pulmonary artery pressure gt;30 mm Hg or atrial fibrillation.