ObjectiveTo summarize our experience of emergency coronary artery bypass grafting (CABG) for the treatment of coronary accidents during percutaneous coronary intervention (PCI). MethodsFrom January 2011 to January 2013, 30 patients with coronary accidents during PCI from our hospital and other hospitals received surgical treatment in Xinhua Hospital, Medical School of Shanghai Jiaotong University. There were 21 male and 9 female patients with their age of 68±11 (54-84) years. Coronary accidents included coronary artery dissection in 12 patients, coronary artery perforation in 12 patients, acute in-stent thrombosis in 2 patients, dilation balloon rupture in 1 patient and balloon retention in 1 patient, and PCI guidewire retention in 2 patients. Among the 30 patients, 8 patients received intra-aortic balloon pump (IABP) implantation preoperatively. All the patients underwent emergency CABG, including 29 patients undergoing off-pump CABG and 1 patient undergoing CABG on pump with heart beating. The patients' medical history, PCI and surgical records were retrospectively reviewed, and surgical treatment strategies, clinical outcomes and prognosis were summarized. ResultsThe average number of grafts was 2.8±0.4. Postoperative length of ICU stay was 8.3±4.8 days, and mean hospital stay was 20.3±15.2 days. Postoperative complications included low cardiac output syndrome (LCOS) in 3 patients, tracheotomy in 2 patients, acute renal failure requiring continuous renal replacement therapy in 2 patients, and reexploration for bleeding in 1 patient. Twenty-eight were discharged, 1 patient died of multiple organ dysfunction syndrome caused by LCOS, and another patient died of refractory ventricular fibrillation. A total of 26 patients were followed up for 10.2±8.3 months and 1 patient died of stroke during the following up. ConclusionEmergency CABG can restore coronary artery blood flow quickly and provide good results for coronary accidents during PCI.
ObjectiveTo investigate the protective effect and the regulation mechanism of oxaloacetate (OAA) on myocardial ischemia reperfusion injury in rats. MethodsSixty rats, weight ranged from 200 to 250 grams, were randomly divided into 6 groups:a negative control group, a sham operation control group, a model control group, an OAA pretreatment myocardial ischemia-reperfusion model group (three subgroups:15 mg/kg, 60 mg/kg, 240 mg/kg). We established the model of myocardial ischemia reperfusion of rats and recorded the internal pressure of left ventricle (LVSP), the maximal rate of left ventricular pressure change (±dp/dtmax) and left ventricular end diastolic pressure (LVEDP). We restored reperfusion 180 minutes after ligating the left anterior descending coronary artery 30 minutes and determinated cardiac troponin Ⅰ (cTn-I), lactate dehydrogenase (LDH), superoxide dismutase (SOD), glutathione peroxidase (GSH-Px). We took out heart tissues, stained it and calculated the infarcted size. We used the Western blot to detect the expression of NF-E2 related factor 2 (Nrf2), Kelch-like ECH-associated protein-1 (Keap1) and heme oxygenase-1 (HO-1). ResultsCompared with the sham operation group, heart function indexes in the negative control group had no significant difference (P>0.05). But in the model control group there was a decrease (P<0.05) And the serum levels of LDH, cTn-I, and myocardial infarcted size were significantly increased (P<0.01). Compared with the model control group, heart function indexes in the OAA pretreatment groups improved, the serum LDH, cTn-I activity, and infarct size decreased (P<0.05), SOD and GSH-Px activity increased (P<0.05). And these results were statistically different (P<0.01) in the high dose OAA pretreatment groups. Compared with the model control group, the expression of Keap1 in the OAA pretreatment group was down-regulated (P<0.001) while total Nrf2, nucleus Nrf2 and its downstream HO-1 was up-regulated (P<0.001), which suggested that OAA enhanced antioxidant capacity by (at least in part) Keap1-Nrf2 pathway, resulting in reducing myocardial damage and protecting myocardium after acute myocardial ischemia reperfusion injury. ConclusionOxaloacetate can provide protective effects on myocardial ischemia reperfusion injury through down-regulating the expression of Keap1 and up-regulating the expression of Nrf2 and its downstream peroxiredoxins to improve antioxidant capacity.
ObjectiveTo compare clinical outcomes between biatrial ablation and right atrial ablation in the surgical treatment of atrial fibrillation (AF)for adult patients with atrial septal defect (ASD). MethodsClinical data of 47 patients with ASD and AF who underwent surgical ASD repair and radiofrequency ablation from January 2007 to December 2012 were retrospectively analyzed. There were 20 male and 27 female patients with their age of 35-76 years. AF duration ranged from 3 months to 15 years. There were 18 patients with persistent AF and 29 patients with long-standing persistent AF. There were 10 patients with mild-to-moderate or more severe mitral regurgitation (MR), and 28 patients with mild-to-moderate or more severe tricuspid regurgitation (TR). According to different surgical strategies, all the 47 patients were divided into 2 groups. In right atrial ablation group, there were 19 patients who received ASD repair and right atrial ablation. In biatrial ablation group, there were 28 patients who received ASD repair and biatrial ablation. For patients with mild-to-moderate or more severe MR or TR, concomitant mitral or tricuspid valvuloplasty was performed. All the patients received 24-hour Holter monitoring at 3, 6 and 12 months after discharge, and were intermittently followed up thereafter. ResultsCardio-pulmonary bypass time, aortic cross-clamping time and postoperative hospital stay of biatrial ablation group were significantly longer than those of right atrial ablation group. But there was no statistical difference in postoperative morbidity or recovery between the 2 groups. After heart rebeating, there were 25 patients (89.3%)with sinus rhythm (SR)and 3 patients with junc-tional rhythm (JR), and none of the patients had AF in biatrial ablation group. There were 14 patients (73.7%)with SR, 2 patients with JR and 3 patients with AF in right atrial ablation group. At discharge, 28 patients (100%)in biatrial ablation group had SR, and in right atrial ablation group there were 15 patients (78.9%)with SR and 4 patients with AF relapse (P=0.045). All the patients were followed up for 3-75 months, and there was no death or residual ASD shunt during follow-up. Two patients had mild-to-moderate or more severe MR, and 4 patients had mild-to-moderate or more severe TR. Cumulative SR maintenance rate of biatrial ablation group (87.7%±6.7%)was significantly higher than that of right atrial ablation group (47.4%±11.5%, P=0.003)at 2 years after discharge. ConclusionFor adult patients with ASD and AF, biatrial ablation can produce better clinical outcomes than right atrial ablation without increasing surgical risks.
ObjectiveTo explore surgical techniques and follow-up results of concomitant transaortic repair for moderate functional mitral regurgitation (MR)during surgical treatment for aortic root or aortic valve disease. MethodsClinical data of 25 patients who underwent concomitant transaortic repair for moderate functional MR during surgical treat-ment for aortic root or aortic valve disease between January 2006 and June 2012 in Xinhua Hospital were retrospectively analyzed. There were 18 male and 7 female patients with their age of 42-75 (57.9±9.6)years. All these patients had aortic root or aortic valve disease as well as concomitant moderate functional MR (type I Carpentier's classification). Aortic valve replacement or aortic root replacement and concomitant transaortic mitral valvuloplasty (MVP, commissure repair)were performed under general anesthesia, hypothermia and cardiopulmonary bypass. Patients were followed up at the outpatient department as well as with phone calls to evaluate the structures and function of the mitral valve and the heart. ResultsIntraoperative transesophageal echocardiography showed satisfactory MVP results as trivial residual MR in 2 patients and no MR or mitral stenosis in the other 23 patients. There was no in-hospital death in this group. Postoperative echocardiography showed that left atrial diameter and left ventricular end-diastolic dimension were significantly reduced than preoperative values (t=4.086, P=0.000;t=4.442, P=0.000), and left ventricular ejection fraction (LVEF)was significantly lower than preoperative LVEF (t=3.671, P=0.001). Postoperative mitral annulus diameter (MAD)was smaller than preoperative MAD (32.4±3.6 mm vs. 35.6±6.4 mm). Postoperative mitral valve pressure gradient (MVPG)(1.4±0.7 mm Hg vs. 1.5±0.7 mm Hg)and peak MVPG (3.7±2.2 mm Hg vs. 3.3±1.5 mm Hg)were no statistical difference than preoperative values. Twenty-three patients (92%)were followed up after discharge for 7-92 (50.4±25.3)months, and the other 2 patients were lost in follow-up. Three patients had mild MR during follow-up. Latest echocardiography examination showed MAD was 33.9±4.6 mm, MVPG was 1.3±0.6 mm Hg, and peak MVPG was 3.6±2.3 mm Hg. ConclusionConcomitant transaortic MVP during surgical treatment for aortic root or aortic valve disease is a safe, convenient and effective procedure for the treatment of moderate functional MR.
ObjectiveTo analyze the effect of modified B-T shunt for the treatment of complex congenital heart disease. MethodsWe retrospectively analyzed the clinical data of 150 B-T case times performed in 143 patients with complex congenital heart disease in Shanghai Xinhua Hospital between July 2006 and January 2013.There were 100 case times for male patients and 50 case times for female patients with age of 2-756 (20.17 ±80.37) months and weight of 4-63 (8.86 ±9.69) kg. ResultsThere were 5 in-hospital deaths (mortality at 3.50%). Three patients occurred abnormal bleeding (2.10%). Five patients (3.50%) performed the second B-T because of shunt occlusion. And the other patients recovered uneventfully. A total of 129 case times were followed up for 6-48 (14.38±10.05) months. Seven B-T case times (5.43%) were performed in 6 patients again because of shunt occlusion during the follow-up. Three patients died during the follow-up (mortality at 2.33%). A total of 88 patients of survival underwent corrective surgery or stage Ⅱ palliative surgery (68.22%). Main pulmonary artery have a significant increase in diameter during the follow-up(t=-15.18, P=0.00). Postoperative diameters of left pulmonary artery (t=-13.27, P=0.00), right pulmonary artery (t=-15.94, P=0.00), and right pulmonary artery (t=2.44, P=0.02) increased with statistical differences compared with preoperative values. Growth in ipsilateral pulmonary of B-T is better than that of the contralateral pulmonary (t=2.44, P=0.02). McGoon ratio increased significantly after B-T (t=10.10, P=0.00). Ejection fraction value was slightly lower than the preoperative value (t=2.77, P=0.00). Left ventricular mass index increased significantly compared with the preoperative value(t=-9.26, P=0.00). ConclusionsThe modified B-T shunt has been proved to be safe and effective in treating for complex congenital heart disease. It can significantly promote the development of pulmonary artery, especially the ipsilateral pulmonary of B-T. Small McGoon ratio and pulmonary atresia are the risk factors for limiting the further development of pulmonary. Appropriate diameter of B-T shunt choice according to preoperative pulmonary diameter and the weight of the patients is the basis to ensure successful operation and a good prognosis.
ObjectiveTo explore the midterm therapeutic effect of modified Blalock-Taussing shunts (MBTs) in the treatment of tetralogy of Fallot. MethodsWe retrospectively analyzed the clinical data of 69 children with tetralogy of Fallot undergoing MBTs in Shanghai Xinhua Hospital between July 2006 and January 2013. There were 44 males and 25 females with mean age of 17.97±24.73 months (ranged from 2 months to 10 years). The patients weighted from 4 to 24 (9.00±4.03) kg. All the MBTs between subclavian artery and pulmonary artery were performed through right or left posterior lateral incision. ResultsThe patients were followed up for 6-36 months including 57 patients with 6 months following-up, 33 patients with 6 months and 12 months following-up, 16 patients with 12 months and 24 months following-up, and 11 patients with 24 months and 36 months following-up. There was significant growth in McGoon ratio during the first 12 months follow-up (preoperative vs. 6 months:1.09 ±0.33 vs. 1.40 ±0.40, P=0.00; 6 months vs. 12 months:1.29±0.31 vs. 1.36±0.33, P=0.00). There was no obvious growth in McGoon ratio after 12 months (12 months vs. 24 month:1.22±0.31 vs. 1.19±0.32, P=0.14; 24 months vs. 36 months:1.22±0.23 vs. 1.23±0.20, P=0.45). The left ventricular end diastolic volume index (LVEDVI) increased significantly in 6 months after MBTs (preoperative vs. 6 months:29.60±10.12 ml/m2 vs. 49.18±11.57 ml/m2, P=0.00), but there was no significant growth after 6 months. There was no significant decline in left ventricular ejection fraction (LVEF) after MBTs. ConclusionThe MBTs can significantly promote the growth of McGoon ratio in 12 months of patients with tetralogy of Fallot, but there is no obvious growth of McGoon ratio after 12 months. MBTs can significantly improve left ventricular development within 6 months, and it won't lead to excessive expansion of the left ventricle when we extend follow-up time. The MBTs affects little on cardiac function of patients with tetralogy of Fallot.
ObjectiveTo analyze the clinical effects of staged repair for severe tetralogy of Fallot (TOF), and to investigate a better individual treatment of TOF. MethodsWe retrospectively analyzed the clinical data of 110 children with TOF in our hospital from January 2009 through December 2014. The patients were divided into a severe TOF group (Group A, n=23) and a mild TOF group (Group B, n=87). In the group A, all 23 patients underwent staged surgery (modified Blalock-Taussig and radical operation of TOF). In the Group B, all 87 patients only received a radical operation of TOF. The patients' preoperative and postoperative arterial oxygen saturation, McGoon ratio, left ventricular end-diastolic volume index (LVEDVI), the results of perioperation and follow-up were compared. ResultsIn the group A, there was no death after modified Blalock-Taussig (MBT). The median interval time between MBTs and radical operation was 9 months (ranged from 6.3 to 25.3 months). Compared with that before MBTs, the McGoon ratio and LVEDVI were significantly increased at the time of radical operation. And the pulmonary artery development and left ventricle volume reached the standard of radical operation of TOF (P < 0.01). After the radical operation, one patient died for pneumonia in the early postoperation period. In the group B, three patients died for low cardiac output syndrome during perioperation. There was no significant difference between the group A and the group B in in-hospital mortality, length of hospital stay, intensive care unit (ICU) stay, ventilation time, cardiopulmonary bypass time, aortic cross-clamp time, rate of using trans-annular repair path, or drainage of pleural fluid. ConclusionStaged repair of severe TOF is safe and effective for children, who are not suitable for one-stage radical operation. Severe TOF received staged repair can achieve the similar outcomes with that of mild TOF underwent one-stage radical operation.
ObjectiveTo compare the safety and clinical outcomes of isolated aortic valve replacement (AVR)through right anterior minithoracotomy (RAMT)and conventional median sternotomy. MethodsFrom March 2006 to March 2013, 169 patients underwent isolated AVR in Department of Cardiothoracic Surgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine. Among them, 42 patients received AVR via RAMT (RAMT group)including 30 males and 12 females with their age of 59.31±8.30 years. And 127 patients received AVR via conventional median sternotomy (conventional surgery group)including 89 males and 38 females with their age of 60.02±5.93 years. There were 75 patients with aortic valve stenosis (AS), 42 patients with aortic regurgitation (AR)and 52 patients with AS+AR. Postoperative outcomes were compared between the 2 groups. ResultsThere was no statistical difference in preoperative clinical characteristics between the 2 groups. All the patients successfully received isolated AVR. 153 patients received mechanical prosthesis and 16 patients received bioprosthetic valves. Fifty-two patients received 21 mm valves, and 117 patients received 23 mm valves. Cardiopulmonary bypass time and aortic cross-clamping time of RAMT group were significantly longer than those of conventional surgery group (P < 0.001). But mechanical ventilation time, length of postoperative ICU stay and hospital stay of RAMT group were significantly shorter than those of conventional surgery group (P < 0.001). Postoperative thoracic drainage, intraoperative and postoperative blood transfusion of RAMT group were significantly less than those of conventional surgery group (P < 0.001). In conventional surgery group, 2 patients underwent reexploration for bleeding and 2 patients had wound infection postoperatively. Two patients died postoperatively, both in conventional surgery group, including 1 patient with low cardiac output syndrome and multiple organ dysfunction syndrome, and another patient with prosthetic valve endocarditis secondary to sternal wound infection. ConclusionCompared with conventional median sternotomy, RAMT is safe and efficacious for patients undergoing isolated AVR with minimal surgical injury, better postoperative recovery and cosmetic outcomes.
ObjectiveTo compare the outcomes of repeated tricuspid valve surgery for patients with late severe tricuspid regurgitation (TR) after cardiac surgery through right anterior minithoracotomy and conventional median sternotomy approaches. MethodsBetween June 2002 and June 2013, 89 patients with late severe tricuspid regurgitation after cardiac surgery underwent repeated tricuspid valve surgery through right anterior minithoracotomy in our hospital. The patients were divided into two groups. Fifty one patients were in a minimally invasive group with 28 males and 23 females at age of 46.59±11.53 years. Thirty eight patients were in a conventional median sternotomy (conventional group) with 15 males and 23 females at age of 50.42±9.30 years. The outcomes of the two groups were compared. ResultsThere was no statisitcal difference in preoperative clinical data between two groups. All patients successfully underwent repeated tricuspid valve surgery. Tricuspid valve replacement (TVR) was performed in 68 patients (38 patients vs. 30 patients), and tricuspid valvuloplasty (TVP) was performed in 21 patients (13 patients vs. 8 patients). Compared with the conventional group, operation time, time of establishing cardiopulmonary bypass and postoperative in-hospital time were significantly shorter in the minimally invasive group (P<0.001). The postoperative drainage was significantly reduced in the minimally invasive group compared with the value of the conventional group (P<0.001). Three patients died in the early postoperative period (1 patient vs. 2 patients). In the conventional group, one patient needed re-exploration for bleeding and 2 patients had wound infection. At discharge, transthoracic echocardiography showed that all patients had no or mild TR and no paravalvular leakage occurred. During the follow-up (12-144 months), 4 patients died (2 patients vs. 2 patients). In the minimally invasive group, one patient underwent repeated TVR due to severe TR associated with infective endocarditis, and another patient had moderate TR. In the conventional group, one patient underwent repeated TVR due to mechanical valve thrombosis. ConclusionRight anterior minithoracotomy is safe, effective and reliable for patients with late severe TR after cardiac surgery. It has the similar effect of the correction of valvular lesions with conventional median sternotomy, but right anterior minithoracotomy has more benefits, including more, minimally invasive, less blood loss, shorter operation time and faster recover.
ObjectiveTo explore the mid-term outcomes achieved by using the left internal mammary artery to saphenous vein composite grafts in off-pump coronary artery bypass surgery (OPCAB) for elderly patients. MethodsA total of 59 elderly patients (≥70 years old) underwent OPCAB by using left internal mammary artery (LIMA) to radial artery (RA) or saphenous vein (SV) composite grafts in Xinhua Hospital between March 2006 and October 2012. There was 37 males and 22 females at age of 72.71±1.95 years. Twenty one patients used LIMA-SV composite grafts (LIMA-SV group), and 38 patients used LIMA-RA composite grafts (LIMA-RA group). ResultsAll patients successfully underwent OPCAB with LIMA-SV or LIMA-RA composite grafts. There was one early death in the LIMA-RA group. No statistical differences in early postoperative outcomes were found between the two groups (P > 0.05). During a follow-up of 12 to 91 months, no patient occurred revascularization. There were no statistical differences in overall survival or graft patency rate, and 1 year, 3 years or 5 years survival rates between the two groups (P > 0.05). The patency rate of LIMA in each group was 100% respectively. There was also no statistical difference in overall patency rate of SV and RA between the two groups at the end of 1 year, 3 years or 5 years (P > 0.05). ConclusionAlthough artery grafts are the best choice for OPCAB, LIMA-SV composite grafts can be used as an alternative graft for elderly patients whose RA or right internal mammary artery is not possible or advisable.