林野
中国医学科学院阜外医院 心脏外科
OBJECTIVES:Coronary artery atresia is a rare coronary artery anomaly in children and has a high rate of misdiagnosis. We aimed to summarize the profile and early outcomes after the surgical reconstruction of coronary artery atresia in children.METHODS:A retrospective analysis was performed in 12 consecutive patients with coronary artery atresia who were admitted to the Department of Paediatric Cardiac Surgery of Fuwai Hospital between October 2016 and September 2020. Ten patients underwent surgical reconstruction of the coronary artery with the pulmonary artery anterior wall, and 8 patients underwent concomitant mitral valvuloplasty.RESULTS:There were 6 females and 6 males, with an age of 1.75 years [interquartile range (IQR), 1.0-3.5] and weight of 10.0 kg (IQR, 8.9-14.75). There were 10 cases of left coronary artery atresia and 2 cases of right coronary artery atresia. All the patients were initially misdiagnosed in the outpatient clinic, but further nonselective coronary angiography confirmed the diagnosis of coronary artery atresia. In all 10 patients with mitral regurgitation, echocardiogram of the mitral valve chordae and papillary muscle revealed ischaemic changes. The clamp time was 89.0 min (IQR, 75.0-101.0), the pump time was 126.0 min (IQR, 119.0-132.0) and the intensive care unit stay time was 1.5 days (IQR, 1.0-3.0). No perioperative deaths were noted. After 9.5 months (IQR, 5.5-13.5) of follow-up, 2 patients with fractional shortening that significantly decreased to 14.1% and 14.8% died and 1 patient had moderate pericardial effusion that improved after treatment with oral diuretics. Coronary artery ultrasound and enhanced computed tomography showed a patent main coronary artery in all the patients.CONCLUSIONS:Coronary artery atresia in children is often associated with mitral regurgitation, and mitral valve chordae and papillary muscle exhibit ischaemic changes. Coronary artery reconstruction is safe and effective in children with coronary artery atresia.
European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery 2022
BACKGROUND:The outcomes, therapeutic strategies, and risk factors of congenital corrected transposition of great arteries (ccTGA) unoperated before adulthood are unclear.METHODS:From October 2009 to January 2018, 117 adult ccTGA patients, classified into ccTGA with intact ventricular septum, ventricular septum defect, and pulmonary valve or subpulmonary outflow tract stenosis (PS) groups, were reviewed. Statistical analysis was performed with SPSS 19.0 (IBM, Armonk, NY).RESULTS:At the first visit, no patients suffered operation. The PS group had the least systemic atrioventricular valve regurgitation and the greatest systemic ventricular ejection fraction. All 49 patients underwent surgery. From the first visit to last follow-up, systemic ventricular ejection fraction of unoperated ccTGA decreased significantly. In the intact ventricular septum group, patients receiving systemic atrioventricular valve replacement/valvuloplasty had a significantly increased systemic ventricular ejection fraction and statistically more freedom from death and transplant than unoperated. In the ventricular septum defect group the late systemic ventricular ejection fraction of operated patients was not statistically different from their basic data at first visit. In the PS group patients receiving physiologic repair had significantly decreased systemic ventricular ejection fractions. Severe systemic atrioventricular valve regurgitation, physiologic repair, and systemic ventricular dysfunction (ejection fraction <40%) were risk factors for mortality, transplant, and congestive heart failure.CONCLUSIONS:PS protects against systemic atrioventricular valve regurgitation and ventricular dysfunction. Systemic atrioventricular valve replacement/valvuloplasty improved systemic ventricular function for ccTGA with an intact ventricular septum. Physiologic repair was not ideal for ccTGA with PS. Severe systemic atrioventricular valve regurgitation and systemic ventricular dysfunction were associated with suboptimal outcomes.
The Annals of thoracic surgery 2021
BACKGROUND:Left main coronary arterial (LMCA) atresia is a rare coronary arterial anomaly with extremely limited data on the optimal management. We aimed to report our single-surgeon experience of the ostioplasty in patients with LMCA atresia.METHODS:From July 2018 to December 2019, pediatric patients who presented with LMCA atresia and subsequently underwent surgical coronary ostioplasty were recruited into this retrospective study. Concomitant mitral repair was applied when the regurgitation was moderate or more severe.RESULTS:A total of 9 patients diagnosed with LMCA atresia were included. Mitral regurgitation was found in all of them, including 6 (66.7%) severe, 1 (11.1%) moderate, and 2 (22.2%) mild. In addition to ischemic lesions, which were found in 7 (77.8%) patients, structural mitral problems were also common (presented in 7 [77.8%] patients). All the patients underwent coronary ostioplasty with autologous pulmonary arterial patch augmenting the anterior wall of the neo-ostium. Mean aortic cross clamp time and cardiopulmonary bypass time was 88.1 ± 18.9 and 124.6 ± 23.6 minutes, respectively. During a median of 10.9 (range: 3.3 to 17.2) months' follow-up, there was only 1 death at 5 months after surgery. All survivors were recovered uneventfully with normal left-ventricular function; however, with 4 (50.0%) having significant recurrence of mitral regurgitation.CONCLUSIONS:With favourable surgical outcomes, coronary ostioplasty for LMCA atresia may be an option of revascularization. Structural mitral problems presented in majority patients, resulting in the requirement of concomitant mitral repair. However, the optimal technique of mitral repair remains unclear.
The Canadian journal of cardiology 2021
To introduce a standardized strategy and reproducible procedures of mitral repair for mitral regurgitation in the pediatric population with leaflet plication as a principal technique. Consecutive patients who had undergone mitral repair by our standardized repair-oriented strategy in our institution from January 2016 to December 2019 were included retrospectively. The standardized repair strategy included 3-step inspections and repair from the subvalvular to leaflet, and then to the annular level. The main surgical techniques included chordae detachment, papillary muscle splitting, leaflet plication, and posterior annuloplasty. The indication for leaflet plication was that the distance between 2 adjacent chordae tendineae was greater than 4 mm. A total of 113 patients were enrolled. During 22.6-month (range, 2-50 months) follow-up period, primary endpoint was documented in 15 (13.3%) patients, including 1 (0.9%) death, 0 transplantation, and 14 (12.4%) functional mitral failure. Freedom form primary endpoints at 6 months, 1 year, and 3 years was 94.7%, 94.7%, and 82.3%, respectively. Significant independent predictors of functional mitral valve failure were younger age (hazard ratio [HR], 0.28; 95% confidence interval [CI], 0.04-0.72; P = 0.037) and ischemic mitral regurgitation (MR) (HR, 24.34; 95% CI, 4.52-47.33; P < 0.001). Leaflet plication was significantly associated with well-functioned mitral valve (HR, 7.42; 95% CI, 2.35-30.54; P = 0.004). Compared with nonischemic MR group, ischemic MR group was noted with higher occurrence of primary endpoint events (11/28 vs 4/85, P < 0.001). The short- to mid-term outcomes of standardized mitral repair technique with leaflet plication were favorable, among which, however, repair for mitral regurgitation with ischemic lesions is comparatively challenging.
Seminars in thoracic and cardiovascular surgery 2020
To evaluate the feasibility and efficacy of external suspension with absorbable poly-l-lactic acid material shaping microplates for infants with severe bronchomalacia and congenital heart disease. From November 2017 to January 2019, 11 continual patients with severe bronchomalacia and congenital heart disease underwent bronchial membrane external suspension together with cardiovascular surgery. An absorbable plate made with poly-l-lactic acid material was used as the shaping fixation material in all patients. Data included the details of the operation, and clinical results were collected. The mean age was 1.2 ± 1.0 years, and the mean weight was 7.7 ± 2.9 kg. The patients with cardiac malformations were operated on under low-temperature cardiopulmonary bypass (CPB) through median sternotomy. There were no in-hospital deaths. The CPB time, mechanical ventilation time, and length of intensive care unit stay were 123.9 ± 36.9 min, 20.7 ± 19.4 h, and 71.6 ± 54.9 h, respectively. Two patients underwent surgery through a left posterolateral incision without CPB. One was a double aortic arch repair, and the other was only bronchial membrane external suspension with prior IAA repair. No patients needed ECMO support. The mean follow-up time was 12.1 ± 5.6 months, and no patients were lost to follow-up. No cases of late death were noted, and no patients needed reoperation. According to the CT scans, no patients had bronchial restenosis. External bronchial membrane suspension with an absorbable poly-l-lactic acid material shaping plate, which had better histocompatibility, for infants with severe bronchomalacia and congenital heart disease was a safe and feasible procedure.
Pediatric cardiology 2020
To evaluate the feasibility and efficacy of the right subaxillary vertical mini-incision (RAVI) used for the closure of doubly committed subarterial ventricular septal defect (SAVSD) through tricuspid approach only. From June 2015 to September 2016, 32 SAVSD patients (mean age 2.4 ± 1.9 years, range 0.7-8 years) underwent surgical repair with either RAVI (incision length 3-4 cm) through tricuspid (group A, n = 16) or conventional median sternotomy incision through the main pulmonary artery approach (group B, n = 16). A retrospective 1:1 matched-pair analysis was performed with the group B matched for defect size, body weight, gender, patching, and operation year. The demographic characteristics in both groups were similar. No patient died and only 1 patient in group B needed reoperation for sternal infection. The mean cardiopulmonary bypass (CPB) time and aortic cross-clamp time were 48.6 ± 12.6 min, 29.3 ± 8.5 min in the group A and 57.8 ± 14.1 min (p = 0.03), 34.3 ± 12.1 min ( p = 0.18) in the group B. There was no significant difference between the two groups in the ICU stay (17.8 ± 8.9 h in group A, 18.7 ± 9.5 h in group B, p = 0.79), mechanical ventilation support time (2.7 ± 1.7 h in group A, 3.6 ± 1.5 h in group B, p = 0.11), postoperative hospital stay (6.3 ± 1.5 days in group A, 7.4 ± 1.7 days in group B, p = 0.06), and chest tube drainage (6.4 ± 4.3 ml/kg in group A, 8.5 ± 3.8 ml/kg in group B, p = 0.16). No significant residual defects were found in both groups. The post-operation pressure gradient across the right ventricular outflow tract (RVOT) was significantly different between the two groups with 4.6 ± 1.8 mmHg in group A and 10.0 ± 6.8 mmHg in group B (p = 0.004) even if no significant difference was found between both groups before operation. No arrhythmia was found after operation. All the patients or the parents (100%) in the group A were satisfied with the cosmetic results, while the number in B group was 7 (43.8%) in questionnaire. The RAVI through tricuspid approach to repair doubly committed subarterial ventricular septal defect is a safe and feasible procedure with better hemodynamic performance of RVOT and less CPB time because of keeping pulmonary artery intact comparing to conventional approach. More importantly, the RAVI through tricuspid approach can be performed with favorable cosmetic results.
Pediatric cardiology 2019
OBJECTIVE:To retrospectively evaluate the results of deep sternal wound infection (DSWI) after cardiac surgery.METHODS:Between January 2010 and September 2013, 139 patients suffering from DSWI after median sternotomy. The incidence of DSWI was 0.47% (139/29 574). There were 111 (79.9%) male and 28 (20.1%) female patients. The mean age was (61 ± 11) years, the mean body weight was (74 ± 14) kg. The incidence of postoperative DSWI was 0.88% (91/10 341) after isolated coronary artery bypass grafting (CABG), 0.70% (15/2 143) after valve surgery or other cardiac surgery plus CABG, 0.21% (24/11 429) after valve surgery, 0.15% (3/2 002) after thoracic aortic surgery, and 0.19% (6/3 158) after congenital heart disease. The sternotomy was re-opened and extensive debridement of the wound was performed in all patients. When the wound was clean and there was a bed of fresh granulation tissue, the sternum was rewired. The surgical procedure performed included debridement, drainage, sternal wire reclosure and pectoralis major muscular transpositions depended on the clinical condition of the patient.RESULTS:The in-hospital mortality was 9.3%. Failure of secondary sternal refixation appeared in 15 (10.8%) patients, the reoperation procedure of these 15 patients was pectoralis major muscular transpositions. Other complications included sepsis in 13 patients, perivalvular leakage in 3 patients, and cardiac rupture during the surgical procedure in 3 patients. The mean hospitalization was (39 ± 30) days.CONCLUSION:Deep sternal wound infection is a life-threatening complication after cardiac surgery associated with high morbidity and mortality.
Zhonghua wai ke za zhi [Chinese journal of surgery] 2014
OBJECTIVE:To analyze the in-hospital mortality and factors affecting in-hospital mortality for patients with transposition of the great arteries (TGA) undergoing arterial switch operation (ASO).METHODS:Between January 2004 and December 2007, ASO was performed in 169 patients [129 male, 40 female; mean age (11.71 ± 26.3) months] with TGA. The patients were divided in intact ventricular septum group (n = 56): TGA with intact ventricular septum and ventricular septal defect group (n = 113): TGA with ventricular septal defect. Multiple logistic regression analysis was performed to identify the risk factors of in-hospital mortality.RESULTS:The overall in-hospital mortality was 11.24% (19/169). The yearly in-hospital mortality was similar between intact ventricular septum group and ventricular septal defect group. With the improvement of perioperative treatment, the in-hospital mortality decreased from 16.67% in 2004 to 3.92% in 2007. The multivariate analysis revealed that body weight ≤ 3 kg (OR: 4.571, P = 0.0409), complicating ventricular septal defect (OR: 4.444, P = 0.0406), complex TGA (OR: 4.321, P = 0.0140), coronary anomalies (OR: 4.867, P = 0.0104) and non-type A coronary arteries (OR: 3.045, P = 0.0243) were independent predictors for poor early postoperative survival.CONCLUSION:Body weight ≤ 3 kg, complicating ventricular septal defect, complex TGA, coronary anomalies are independent predictors for increased in-hospital mortality in patients with transposition of TGA and undergoing arterial switch operation.
Zhonghua xin xue guan bing za zhi 2011
OBJECTIVE:We introduce a simple classification of the non-coronary sinus of Valsalva aneurysm, and suggest a different approach for the corresponding type of non-coronary sinus of Valsalva aneurysm.METHODS:Between October 1996 and December 2009, 45 patients with non-coronary sinus of Valsalva aneurysm underwent surgical repair. Twenty-three were male and 22 female. The mean age was 32.80±11.77 years (range, 13-67 years). We divided them into two types, type I: rupture or protrusion into right atrium; and type II: rupture or protrusion into right atrium or right ventricle near or at the tricuspid annulus. For type I (n=32), the right atrium approach was chosen, using direct suture with patch repair. For type II (n=13), the transaortic approach with right atrium incision was chosen, with patch repair through an aortic incision and direct suture through a right atrium incision. Surgical results between types I and II were compared as regards cardiopulmonary bypass time, clamp aorta time, mechanical ventilation time, and intensive care unit time, and postoperative stay time.RESULTS:There was no early death after operation. There were no significant differences in cardiopulmonary bypass time, mechanical ventilation time, intensive care unit time, and postoperative stay time between two types (p>0.05). There was significant difference in clamp aorta time, with type II being longer than type I (p<0.05). Forty-three patients (93.33%) were followed up; one case of coronary artery disease using medication occurred, and there was no late death.CONCLUSIONS:Approach through the right atrium or right atrium with aortotomy showed the same early surgical results. Our classification of non-coronary SVA is simple and practical for clinical usage.
European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery 2011
OBJECTIVE:To compare the predictive value of glomerular filtration rate (GFR) estimated by the Cockcroft-Gault formula or the modification of diet in renal disease (MDRD) equation and serum creatinine for in-hospital and long-term mortality post coronary artery bypass graft surgery (CABG).METHODS:Clinical data of 5559 consecutive patients undergoing isolated CABG were retrospectively analyzed. The main outcomes were in-hospital mortality and long-term mortality. Estimated GFR was calculated by the Cockcroft-Gault formula and MDRD equation respectively. Receiver-operating characteristic curves and Cox's analysis were used for the comparison.RESULTS:Follow-up was complete in 5485 patients (97.6%). Analysis of receiver-operating characteristic curves showed that GFR estimated by the Cockcroft-Gault formula had a maximal accuracy for predicting in-hospital mortality (area under the curve: 0.755, P < 0.01). Multivariate logistic analysis and the Cox's analysis results indicated estimated GFR < 60 mlxmin(-1)x1.73 m(-2) base on the Cockcroft-Gault formula was an independent risk factor for in-hospital and long-term mortality (hazard ratio 4.51 for in-hospital mortality, P < 0.01; hazard ratio 1.54 for long-term mortality, P < 0.01), both Cockcroft-Gault formula and MDRD equation were superior to serum creatinine for predicting in-hospital and long-term mortality post CABG.CONCLUSION:GFR estimated by the Cockcroft-Gault formula was superior to GFR estimated by the MDRD equation for predicting in-hospital mortality, and estimated GFR was superior to serum creatinine for predicting in-hospital and long-term mortality.
Zhonghua xin xue guan bing za zhi 2010
