罗新锦
中国医学科学院阜外医院 血管外科
Leaflet durability and costs restrict contemporary trans-catheter aortic valve replacement (TAVR) largely to elderly patients in affluent countries. TAVR that are easily deployable, avoid secondary procedures and are also suitable for younger patients and non-calcific aortic regurgitation (AR) would significantly expand their global reach. Recognizing the reduced need for post-implantation pacemakers in balloon-expandable (BE) TAVR and the recent advances with potentially superior leaflet materials, a trans-catheter BE-system was developed that allows tactile, non-occlusive deployment without rapid pacing, direct attachment of both bioprosthetic and polymer leaflets onto a shape-stabilized scallop and anchorage achieved by plastic deformation even in the absence of calcification. Three sizes were developed from nickel-cobalt-chromium MP35N alloy tubes: Small/23 mm, Medium/26 mm and Large/29 mm. Crimp-diameters of valves with both bioprosthetic (sandwich-crosslinked decellularized pericardium) and polymer leaflets (triblock polyurethane combining siloxane and carbonate segments) match those of modern clinically used BE TAVR. Balloon expansion favors the wing-structures of the stent thereby creating supra-annular anchors whose diameter exceeds the outer diameter at the waist level by a quarter. In the pulse duplicator, polymer and bioprosthetic TAVR showed equivalent fluid dynamics with excellent EOA, pressure gradients and regurgitation volumes. Post-deployment fatigue resistance surpassed ISO requirements. The radial force of the helical deployment balloon at different filling pressures resulted in a fully developed anchorage profile of the valves from two thirds of their maximum deployment diameter onwards. By combining a unique balloon-expandable TAVR system that also caters for non-calcific AR with polymer leaflets, a powerful, potentially disruptive technology for heart valve disease has been incorporated into a TAVR that addresses global needs. While fulfilling key prerequisites for expanding the scope of TAVR to the vast number of patients of low- to middle income countries living with rheumatic heart disease the system may eventually also bring hope to patients of high-income countries presently excluded from TAVR for being too young.
Frontiers in cardiovascular medicine 2022
Objective: The duration of hypothermic circulatory arrest (HCA) is one of the important factors affecting the prognosis of arch surgery, which is still controversial. The purpose of this study was to investigate the effect of HCA duration on early prognosis in type A aortic dissection (TAAD) patients who underwent arch surgery in our center. Methods: All consecutive patients who underwent surgical treatment for TAAD in Fuwai Hospital from January 2013 to December 2018 were included in this study and divided into four quartile groups based on HCA time. Baseline characteristics, perioperative indicators, and early mortality were statistically analyzed by propensity score matching (PSM) and restricted cubic spline (RCS) method. Perioperative adverse events were confirmed according to the American STS database and Penn classification. Results: About 1,018 consecutive patients (mean age 49.11 ± 1.4 years, male 74.7%) with TAAD treated surgically were eventually included in this study. After PSM, with the prolongation of HCA time, the surgical mortality rates of group [2,15], (15,18], (18,22], and (22,73] were 4.1, 6.6, 7.8, and 10.9% with p = 0.041, respectively. As shown in RCS, the mortality rate increased sharply after the HCA time exceeded 22 min. And from the subgroup analysis, the HCA time of 22 min or less was associated with better clinical outcomes (OR 2.09, 95%CI 1.25-3.45, p = 0.004). Conclusions: The early mortality increases significantly with the duration of HCA time when arch surgery was performed. And multiple systems throughout the body can be adversely affected.
Frontiers in cardiovascular medicine 2021
BACKGROUND:The clinical use of the radial artery (RA) in coronary artery bypass grafting (CABG) is still limited worldwide, although it has been recommended by several guidelines. Multidetector computed tomography (MDCT) is widely used to evaluate graft patency, as invasive coronary angiography could cause potentially serious risks including bleeding, dissection and stroke. This study aims to report the short-term results of the RA in CABG with MDCT.METHODS:The study population consists of 41 consecutive patients undergoing elective CABG with the RA graft between 2017 to 2018, with MDCT performed to evaluate graft patency during follow-up, and target vessels for the RA were non-left anterior descending coronary arteries with > 70% stenosis.RESULTS:A total of 150 grafts were assessed by MDCT during follow-up (mean, 8.9 ± 5.1 months). MDCT could clearly show the structure and patency of grafts, even for complex coronary artery revascularization. Graft patency of the left internal mammary artery was 92.9% (39/42), with the RA patency of 84.4% (38/45) and the patency of the saphenous vein graft of 81.1% (30/37). And the RA anastomosed to the left coronary artery system might have better patency than the RA anastomosed to the right coronary artery system (25/29, 86.2% vs 13/16, 81.3%, p = 0.686).CONCLUSIONS:The short-term patency rate of RA grafts is good, and the RA might be associated with better patency when anastomosed to the left but not the right coronary artery. MDCT could provide excellent visualization of grafts in CABG.
Journal of cardiothoracic surgery 2021
OBJECTIVE:To investigate a technical method for harvesting and using the descending branch of the lateral circumflex femoral artery (DLCFA) in coronary artery bypass grafting (CABG).METHODS:Between January 2017 and January 2019, 40 patients (36 in the planed selection group and 4 in the temporary decision group) with mean age of 49.1 ± 7.5 years received DLCFA as an arterial conduit in CABG. In all patients, the DLCFA was successfully harvested via an anterior thigh incision. Depending on the location of the target vessel, the DLCFA was used as a free graft or a composite graft.RESULTS:Of the 44 patients in the planned selection group, DLCFA harvesting was abandoned in 8 patients because computed tomographic angiography revealed anatomical variation or stenosis of the superficial femoral artery. Of the 5 patients in the temporary decision group, harvesting was abandoned in 1 because of short length and thin caliber. On an average, 3.7 ± 0.9 distal anastomoses were created during CABG, with no adverse effects. The length of the harvested DLCFA was 9.9 ± 1.7 cm, with an average proximal lumen diameter of 3.4 ± 0.7 mm. The DLCFA was used as a free graft in 26 patients and as a "Y"-shape composite graft in 14 patients. Total arterial CABG was performed in 75% of the patients.CONCLUSIONS:The DLCFA is an alternative conduit for CABG. It can be harvested easily and safely. However, preoperative computed tomographic angiography examination is necessary for the smooth application of the DLCFA, and an appropriate strategy for graft establishment should be considered.
The Journal of thoracic and cardiovascular surgery 2021
Aims: We describe a new aortic arch dissection (AcD) classification, which we have called the Fuwai classification. We then compare the clinical characteristics and long-term prognoses of different classifications. Methods: All AcD patients who underwent surgical procedures at Fuwai Hospital from 2010 to 2015 were included in the study. AcD procedures are divided into three types: Fuwai type Cp, Ct, and Cd. Type Cp is defined as the innominate artery or combined with the left carotid artery involved. Type Cd is defined as the left subclavian artery or combined with the left carotid artery involved. All other AcD surgeries are defined as type Ct. The Chi-square test was adopted for the pairwise comparison among the three types. Kaplan-Meier was used for the analysis of long-term survival and survival free of reoperation. Results: In total, 1,063 AcD patients were enrolled from 2010 to 2015: 54 patients were type Cp, 832 were type Ct, and 177 were type Cd. The highest operation proportion of Cp, Ct and Cd were partial arch replacement, total arch replacement, and TEVAR. The surgical mortality in type Ct was higher compared to type Cd (Ct vs. Cd = 9.38 vs. 1.69%, p < 0.01) and type Cp (Ct vs. Cp = 9.38 vs. 1.85%, p = 0.06). There was no difference in surgical mortality of type Cp and Cd (p = 0.93). There were no significant differences in the long-term survival rates (p = 0.38) and free of aorta-related re-operations (p = 0.19). Conclusion: The Fuwai classification is used to distinguish different AcDs. Different AcDs have different surgical mortality and use different operation methods, but they have similar long-term results.
Frontiers in cardiovascular medicine 2021
Background: This study investigates the optimal management for unruptured sinus of Valsalva aneurysms (USVAs) combined with other cardiovascular lesions. Methods: This retrospective study examined 33 USVA patients who underwent surgical repair from February 1, 2007 to January 31, 2012. We analyzed the surgical procedures and the patients' quality of life after surgery. Additionally, echocardiography follow-up was performed before and after the operation. Results: Most USVAs (87.8%) originated in the right coronary sinus. Aside from one patient who was preoperatively misdiagnosed as having a ruptured sinus of Valsalva aneurysm (SVA). USVAs of the right coronary sinus were addressed by reinforcing this sinus with a Dacron patch through the right ventricle. USVAs were corrected by aortotomy using an autogenous pericardium patch when they originated in the non-coronary or left coronary sinus. Thirty patients (90.9%) were followed up for 22-119 months. No early death, residual fistula or SVA recurrence were found during the follow-up period. They all had a good quality of life and good heart function (New York Heart Association class I-II). Conclusions: Active surgical repair of an USVA can be achieved with satisfactory results in patients combined with other cardiovascular lesions.
Frontiers in cardiovascular medicine 2021
BACKGROUND:This study evaluated the short- and middle-term outcomes of different aortic root managements in the setting of acute type A aortic dissection (ATAAD): aortic root repair (ARR group), untouched aortic root (UAR group), and Bentall procedure (Bentall group).METHODS:The study enrolled 673 patients (512 men; age 48.8 ± 11.2 years) between 2010 and 2015. Survival, aortic growth, reintervention, and valve function were compared between the 3 groups.RESULTS:The ages were 50.6 ± 9.9, 49.8 ± 12.2, and 44.0 ± 12.0 years for ARR, UAR, and Bentall groups, respectively (P < .01). The mean follow-up time was 3.0 years (range, 0.5-6.8 years). The aortic root diameters in the groups were 39.0 ± 5.1 mm in ARR, 38.2 ± 4.4 mm in UAR, and 50.3 ± 6.2 mm in Bentall (P < .01). The overall 30-day mortality was 11.7% (79 of 673). There was no difference in 30-day mortality between the 3 groups (P = .58). The estimated aortic root growth rate was 0.60 ± 0.17 mm/y for ARR and 0.50 ± 0.14 mm/y for UAR. During follow-up, 28 patients (4.1%) died. Differences in 5-year survival between the 3 groups did not reach statistical significance (P = .82). Aortic insufficiency greater than grade 2+ developed in 15 patients (2.2%). There was no significant difference between ARR and UAR in freedom from aortic insufficiency greater than grade 2+ (P = .56). None of the patients experienced new dissection or underwent proximal reoperation during the follow-up period.CONCLUSIONS:Conservative techniques (ARR and UAR) and aggressive root replacement can both be performed with excellent short- and middle-term outcomes in ATAAD. Thus, an individualized approach in managing the aortic root for ATAAD is recommended based on the patient's general condition, root pathology, and the surgeon's preference.
The Annals of thoracic surgery 2020
OBJECTIVE:In the absence of randomized trials, the optimal approach to managing coexisting severe carotid and coronary diseases remains controversial. The aim of this study was to present the midterm follow-up results of patients who received a coronary artery bypass graft (CABG) after carotid revascularization and to compare the risk-adjusted outcomes of two approaches to carotid revascularization in the CABG population in a single center.METHODS:From January 2011 to December 2016, 245 patients underwent carotid revascularization within 90 days before CABG in Fuwai Hospital, including 32 who received combined carotid endarterectomy (CEA) and CABG (CEA-CABG), 208 who received staged carotid artery stenting (CAS) before CABG (CAS before CABG), and 5 who underwent a hybrid procedure of carotid stenting and coronary surgery (combined CAS-CABG). The primary composite end points were all-cause death, stroke, and myocardial infarction (MI). Therefore, the multivariable logistic regression analyses and propensity score-adjusted multiphase hazard function model were used to analyze the association between the types of revascularization, complications, and risk-adjusted mortality.RESULTS:One patient (3.13%) died 6 months after the CABG surgery in the combined CEA-CABG group. In the staged CAS group, 9 patients (4.33%) died after CABG surgery, including 3, 2, and 4 patients who died within 30 days, 1 year, and after 1 year (mean time after CABG surgery, 39 months; adjusted odds ratio [OR], 2.188; 95% confidence interval [CI], 0.251-19.093; P = .479), respectively. Stroke was observed in three patients (9.38%) in the combined CEA group and in 12 patients (5.77%) in the staged CAS group (OR, 0.625; 95% CI, 0.133-2.935; P = .552). The rates of MI were 6.25% and 7.21% for the combined and staged groups, respectively (adjusted OR, 1.249; 95% CI, 0.250-6.324; P = .787). In addition, composite events occurred in five (15.63%) and 33 patients (15.87%) in the combined and staged groups, respectively (adjusted OR, 1.362, 95% CI, 0.455-4.077; P = .581). No statistically significant differences were observed in the overall midterm incidences of mortality, stroke, MI, and composite events.CONCLUSIONS:Carotid revascularization is a safe and effective treatment for patients with concomitant carotid and cardiac disease. Combined CEA-CABG and staged CAS-CABG are associated with similar risks of mortality, stroke, or MI in the midterm outcomes.
Journal of vascular surgery 2019
More than 6 billion people live outside industrialized countries and have insufficient access to cardiac surgery. Given the recently confirmed high prevailing mortality for rheumatic heart disease in many of these countries together with increasing numbers of patients needing interventions for lifestyle diseases due to an accelerating epidemiological transition, a significant need for cardiac surgery could be assumed. Yet, need estimates were largely based on extrapolated screening studies while true service levels remained unknown. A multi-author effort representing 16 high-, middle-, and low-income countries was undertaken to narrow the need assessment for cardiac surgery including rheumatic and lifestyle cardiac diseases as well as congenital heart disease on the basis of existing data deduction. Actual levels of cardiac surgery were determined in each of these countries on the basis of questionnaires, national databases, or annual reports of national societies. Need estimates range from 200 operations per million in low-income countries that are nonendemic for rheumatic heart disease to >1,000 operations per million in high-income countries representing the end of the epidemiological transition. Actually provided levels of cardiac surgery range from 0.5 per million in the assessed low- and lower-middle income countries (average 107 ± 113 per million; representing a population of 1.6 billion) to 500 in the upper-middle-income countries (average 270 ± 163 per million representing a population of 1.9 billion). By combining need estimates with the assessment of de facto provided levels of cardiac surgery, it emerged that a significant degree of underdelivery of often lifesaving open heart surgery does not only prevail in low-income countries but is also disturbingly high in middle-income countries.
Global heart 2018
BACKGROUND:The aim of this study was to investigate whether nighttime surgical procedures contribute to higher in-hospital mortality in patients with acute type A aortic dissection.METHODS:All patients with acute type A aortic dissection who underwent surgical procedures at Fuwai Hospital in Beijing, China from 2010 to 2015 were included in the present study. Depending on the start and end time of the surgical procedures, patients were divided in daytime and nighttime groups. Propensity-matching analysis was used to compare in-hospital mortality and postoperative complications between these groups.RESULTS:A total of 698 patients with acute type A aortic dissection underwent operation. Of these, 321 (45.98%) patients underwent nighttime surgical procedures, whereas 377 (54.02%) patients underwent daytime procedures. The operation time, cardiopulmonary bypass time, and aortic cross-clamp time showed statistical differences between the two groups (p < 0.01). There was a significant difference between the daytime and nighttime groups in in-hospital mortality (6.42% vs 12.08%; p < 0.05). The nighttime group had a higher incidence rate of reintubation and continuous renal replacement therapy compared with the daytime group (p < 0.05). Furthermore, patients who underwent nighttime operations had significantly higher adjusted in-hospital mortality than patients who underwent daytime operations (odds ratio, 2.13; 95% confidence interval, 1.19 to 3.81; p = 0.01).CONCLUSIONS:Patients with acute type A aortic dissection and certain serious medical conditions were more likely to die in the hospital if they underwent emergency nighttime surgical procedures.
The Annals of thoracic surgery 2018
