李巅远
中国医学科学院阜外医院 胸心血管外科
Cardioplegic reperfusion during a long-term ischemic period interrupts cardiac surgery and increases cellular edema due to repeated administration. The present clinical study compared the protective effects of histidine-ketoglutarate-tryptophan (HTK) solution and St. Thomas crystalloid cardioplegia. Clinical experiences of the myocardial protection induced by one single perfusion with HTK were reviewed in high-risk patients with severe pulmonary arterial hypertension associated with complex congenital heart disease. This retrospective study included 88 high-risk patients (aortic cross-clamp time, >120 min) between March 2001 and July 2012. The cohort was divided into two groups according to the technique used. Either myocardial protection was performed with one single perfusion with HTK solution (HTK group) or with conventional St. Thomas crystalloid cardioplegia (St group). The duration of cardiopulmonary bypass did not differ between the two groups. The mortality, morbidity, intensive care unit (ICU) stay, postoperative hospitalization, and transfusions of HTK group are significantly lower than those of the St group (P<0.05). Univariate and multivariate analysis demonstrated that HTK is a statistically significant independent predictor of decreased early mortality and morbidity (P<0.05). In conclusion, the present findings suggested that HTK solution decreases mortality, morbidity, ICU stay, postoperative hospitalization, and transfusions in high-risk patients with severe pulmonary arterial hypertension associated with complex congenital heart disease.
Experimental and therapeutic medicine 2017
BACKGROUND:Anomalous origin of coronary artery from the pulmonary artery (ACAPA) is a rare congenital coronary malformation with a high mortality whether in infants or adult patients. This study reviews 20years of surgical treatment in a single center and aims to establish the optimal surgical strategies for this rare pathology.METHODS AND RESULTS:From April 1994 to March 2015, 96 consecutive patients aged from 3months to 60years underwent coronary repair surgery. The surgical procedures included ligation (3 cases), ligation along with CABG (6 cases), transpulmonary baffling (Takeuchi Procedure, 14 cases) and directly implantation of the anomalous coronary artery (ACA) into the aorta (73 cases). Postoperative extracorporeal mechanical circulatory support (ECMO) was necessary in 4 cases. Mitral valve repair was performed in 40 patients with moderate or severe mitral regurgitation (MR). Mitral replacement was performed in one patient with severe MR. There were one early and two late deaths. One patient underwent a second operation because Baffle leaks. During mean 10.45±8.96year follow-up (1month-18years), both early and late improvement of left ventricular function was observed in most patients (8 patients lost of follow-up).CONCLUSIONS:The establishment of a two-coronary system is the main goal of surgical therapy today. In different procedures, the direct implantation of the ACA into the ascending aorta is the best method and has good long-term results. ECMO as a bridge to recovery that will play an integral part in moderns' surgical treatment.
International journal of cardiology 2016
Extended septal myectomy for children and adolescents with hypertrophic obstructive cardiomyopathy (HOCM) is a challenging procedure, and related data are currently limited. Our study objective was to assess the early outcomes in children and adolescents with HOCM after extended septal myectomy. From October 2007 to August 2015, 40 consecutive patients with HOCM underwent transaortic extended septal myectomy in Fuwai Hospital, Beijing, China. Patients clinical data were analyzed retrospectively. Mean age at the time of operation was 11.3 ± 4.3 (0.7-16.7) years. Mean body weight at the time of surgery was 40.8 ± 19.7 (4.3-92.0) kg. After myectomy, mean left ventricular outflow tract gradient decreased from 80.1 ± 33.8 to 14.7 ± 11.5 mmHg and mean degree of mitral regurgitation decreased from 1.9 ± 0.9 to 0.5 ± 0.5 (p < 0.001 for both). Concomitant surgical procedures were required in 13 patients (32.5 %). There was no early death. Residual systolic anterior motion and left ventricular outflow tract obstruction were reported in two and three patients, respectively. Moderate aortic regurgitation was found in one patient during a follow-up of 26.4 ± 15.1 months. Restrictive symptoms were improved in the patients with New York Heart Association functional class I or II. A 15.8-year-old patient died 16 months after operation. A permanent pacemaker was installed in one patient 3 months after operation. Extended septal myectomy is safe and effective in children and adolescents with HOCM, with excellent clinical and echocardiographic outcome at early follow-up.
Pediatric cardiology 2016
BACKGROUND:Reoperation for congenital heart disease may be associated with cardiac or vascular injuries during repeat sternotomy, resulting in increased mortality and/or morbidity rates. The aim of this study was to determine the frequency of these cardiac injuries and the associated outcome.METHODS:Between January 2012 and December 2013, 4256 sternotomy procedures were performed at the Pediatric Cardiac Center in Fuwai Hospital, including 195 repeat sternotomy procedures (RS). We retrospectively studied the clinical data of 195 RS patients and 250 randomly selected primary sternotomy (PS) patients. Demographic and operative details, major injures (MI), and clinical outcomes were compared between the two groups. We also assessed the risk factors for major injury and in-hospital mortality and morbidity.RESULTS:Significant differences were observed between the RS and PS groups in terms of skin incision to cardiopulmonary bypass(CPB) time, overall CPB time, cross-clamp time and blood requirement, and ventilation time (p < 0.001). MI during RS occurred in 7 of the 195 patients (3.6 %), while operative mortality was 1.0 % (2/195). However, in the RS patients, mortality and morbidity rates were not significantly different between the MI subgroup and the non-MI subgroup (p = 1.000 and 0.556, respectively). Additionally, no significant difference was found between the RS and PS groups in terms of mortality (p = 1.000) and morbidity (p = 0.125).CONCLUSIONS:Both RS and MI are not associated with increased risk of operative mortality and morbidity. Outcomes for reoperative pediatric operations in contemporary practice are similar with those for primary operations.
Journal of cardiothoracic surgery 2015
OBJECTIVE:To evaluate the clinical experiences of one-stage repair of the interrupted aortic arch (IAA) associated with cardiac anomaly in neonates and infants.METHODS:From July 1996 to October 2008, 48 neonates or infants with IAA associated with cardiac anomaly underwent one-stage repair. There are 30 males and 18 females ranging from 0.08 to 7.00 years old (1.97 +/- 2.05) with body weight 3 - 20 (9 +/- 5) kg. 42 patients had the middle-severe pulmonary hypertension (PH), the pulmonary pressure was 61 - 106 (82 +/- 14) mm Hg and the pulmonary arterial resistance was 66 - 762 (315 +/- 259) dynxsxcm(-5). There are 40 patients with type A IAA and 8 patients with type B IAA, all patients had an associated patent ductus arteriosus, other combined malformations included ventricular septal defect (VSD) in 33 cases, atrial septal defect (ASD) in 8 cases, mitral valve insufficiency in 6 cases, tricuspid valve insufficiency in 5 cases, aortopulmonary window in 4 cases, double outlet of the right ventricule in 3 cases, mitral valve stenosis in 2 cases, and et al. the operation was performed through median sternotomy under the general anesthesia and cardiopulmonary bypass (CPB, the deep hypothermia with circulatory arrest, the deep hypothermia with low flow rate, or the deep hypothermia with low flow rate and circulatory arrest), the interrupted aortic arch repair was achieved with the arch anastomosis in 30 patients and with an interposition graft in 18 patients, the concomitant operations included VSD repair in 33 cases, ASD repair in 8 cases, mitral valve plasty in 7 cases, tricuspid valve plasty in 4c ases, aortopulmonary window repair in 4 cases, intraventricular baffle tube repair in 2 cases, arterial switch operation in 1 case, and et al.RESULTS:The time of the CPB and the aortic occlusion were 112 to 375 min (182 +/- 52) and 24 to 287 min (99 +/- 45) respectively. The endotracheal intubation time were 8 to 936 hours (179 +/- 133) and the ICU stay were 1 - 57 days (14 +/- 14). By echocardiograph examination after operation, the pressure gradient across the arch was obvious relieved and the combined cardiac malformations was satisfied corrected. 3 patients (3/48, 6.25%) died during the perioperative period. The cause of death included severe pulmonary hypertension crisis, dysfunction of the pulmonary or the serious low cardiac output syndrome. the main complications included reopen for bleeding in 2 cases, tracheostomy in 2 cases, the right diaphragma paralysis in 1 case, delayed sternal closure in 1 case, hydrothorax in 1 case, the severe pulmonary infection in 1 case. Physical activities of the survivals increased obviously and discharged from hospital uneventfully, all surviving patients had no late complications and death during the follow-up 3 months to 12 years.CONCLUSION:One-staged primary repair of IAA with other intracardiac anomalies can be the preferred surgical approach and safely applied with good results as to lead a better life.
Zhonghua yi xue za zhi 2010
OBJECTIVES:This study reviews 9 patients with aortico-left ventricular tunnel (ALVT) and aims to establish the optimal surgical strategies for this exceptional and rare pathology.METHODS:54,882 patients underwent open-heart surgery at the Fuwai Hospital between July 1996 and May 2008. Nine of these patients were diagnosed with ALVT. One patient died of acute heart failure before operation. The remaining 8 patients underwent operation. The mean age of these 8 patients was 22.5 years. Clinical, echocardiographic and surgical details were reviewed.RESULTS:At operation the diagnosis was confirmed, and then repaired by direct suture closure (n = 1), single patch closure of the aortic end of the ALVT (n = 4), or aortic valve replacement (n = 3). In 5 patients, the aortic opening of the tunnel was above the right coronary sinus of Valsalva while in the other 3 it was above the left coronary sinus. All patients recovered safely. There was 1 late death (from perivalvular leak). The remaining patients remain asymptomatic at a mean follow up of 30.1 months.CONCLUSIONS:ALVT is a rare cardiac entity that should be treated soon after the diagnosis is made. The specific surgical operation should be individualized based on unique cardiac anomaly of each patient.
Cardiology 2009
OBJECTIVE:To discuss the clinical features and surgical treatments of giant coronary artery aneurysm (CAA).METHODS:From July 1996 to October 2004, 6 giant CAA patients were underwent surgery at Fuwai hospital. Three cases were underwent CAA resection, 2 concomitant coronary bypass, 3 reconstruction. The giant CAA was often combined with other cardiac diseases. Four cases underwent additional procedures of fistula closure, 3 aortic valve replacements, 2 aortoplasty and 1 thrombus cleaning at the same time.RESULTS:All patients recovered uneventfully. The mean of cardiopulmonary bypass time was (144 +/- 26) min (range 67 to 207 min). Aortic cross clamping time was (104 +/- 21) min (range 56 to 172 min). Patients follow-up time occurred from 8 to 87 months (mean of 48 months). All patients were free of symptoms during follow-up. None of the patients died during the follow-up period and none of the CAA recurred.CONCLUSIONS:The giant CAA is a serious cardiovascular disease, early diagnosis and surgical treatment are mandatory.
Zhonghua wai ke za zhi [Chinese journal of surgery] 2006
OBJECTIVE:To review the results of the valve-sparing operation (David procedure) in patients with aortic root disease.METHODS:Twenty-nine patients with aortic root disease, 20 males and 9 females, aged 39 +/- 17 (10-64), 10 being of heart functional class I, 15 of class II, and 4 of class III, and 15 with gentle, 9 with moderate, and 5 with severe aortic insufficiency underwent David procedure, one undergoing the aortic valve-sparing reimplantation (David I), 25 undergoing aortic valve-sparing remodeling (David II), and 3 undergoing a new modified aortic valve-sparing operation. After the operation the patients were followed up for 29 +/- 15 months (5-74 months).RESULTS:No intra-operative death was found. The mean extracorporeal circulation time was 126 min +/- 25 min, and the aortic crossclamp time was 87 min +/- 22 min. All patients recovered to heart functional class I. Post-operatively 11 patients showed no normal, eight gently and two moderate aortic regurgitation.CONCLUSION:The valve-sparing operation is an ideal operation to the aortic root aneurysm with more or less normal aortic leaflets and valvular ring normal.
Zhonghua yi xue za zhi 2005
OBJECTIVE:Giant coronary artery aneurysm is an extremely uncommon disease. Most previous reports have involved only single cases. This report describes 6 patients with giant coronary artery aneurysm, examines its causes, and aims to establish the optimal surgical strategies for this exceptional and rare pathology.METHODS:From July 1996 to October 2004, a total of 30,268 patients underwent heart surgery at Fuwai Hospital in Beijing. Among these, 6 patients had giant coronary artery aneurysm diagnosed and underwent operation. Various surgical strategies were used for the operations of these 6 patients, such as coronary artery aneurysm resection, coronary artery reconstruction, and concomitant coronary bypass. Additional procedures, such as fistula closure, aortic valve replacement, aortoplasty, and embolectomy, were done at same time for the patients with complications of coronary fistula, aortic valve insufficiency, or thrombus. Patients were followed up from 8 to 87 months, with a mean of 48 months. Doppler echocardiography, ultrafast computed tomography, and 3-dimensional aerial image studies were performed during follow-up.RESULTS:Five of these six cases were found combined with coronary artery fistula, and the cause for these giant coronary artery aneurysms was congenital. The remaining case was caused by atherosclerosis. After surgery, all patients recovered uneventfully, without in-hospital mortality. None died during the follow-up, nor did any have recurrence of the symptoms or giant coronary artery aneurysm.CONCLUSION:Giant coronary artery aneurysm is a rare entity that is commonly caused by congenital malformation and combined with other cardiac anomalies. An optimal surgical operation should be based on the specific cardiac anomaly of the individual patient.
The Journal of thoracic and cardiovascular surgery 2005
OBJECTIVES:To investigate the effect of chitosan biodegradable external stent (CES) on the early changes of rabbit vein graft (VG).METHODS:Rabbit vein grafting models were divided into S group (with perivenous CES) and NS group (without perivenous CES). The VG were harvested in 1 week, 2 weeks, 4 weeks after operation, respectively. The expression of proliferating cell nuclear antigen (PCNA) was used for evaluating the proliferation of the smooth muscle cell (SMC). The thickness, area of neointima and media of the VG were calculated by computer imaging analysis system.RESULTS:CES began to degrade in 2 weeks after operation. The thickness, area of both neointima and media of the VG in S group, increased mildly in 1 week after operation, and kept steady in 1 or 2 weeks after grafting, which was significantly less than NS group (both P < 0.01), then increased mildly in 4 weeks after grafting but still less than NS group (P < 0.05). The expression of PCNA of SMC decreased significantly in comparison with NS group though increasing mildly in four weeks after operation. Both neointimal formation and cell proliferation in the graft wall were significantly reduced by external stenting as compared to the results with unstented grafts.CONCLUSIONS:CES may reduce early intimal and medial hyperplasia, and may be beneficial in improving the long term patency of the VG. The biodegradable characteristics of the CES may influence its effect.
Zhonghua wai ke za zhi [Chinese journal of surgery] 2003
