Risk Factors for Acute Renal Failure after Thoracoabdominal Aortic Aneurysm Surgery / 中国医学科学院学报

To investigate the risk factors associated with acute renal failure (ARF) after thoracoabdominal aortic aneurysm (TAAA) surgery. A total of 156 patients underwent TAAA repair between January 2009 and December 2017. Renal failure was defined based on the Kidney Disease Improving Global Outcomes criteria. The patients were divided into ARF group and non-ARF group based on the presence/absence of postoperative ARF. The risk factors of ARF were analyzed by univariate analysis and multivariate logistic analysis. The subjects included 111 males and 45 females aged (40.4±10.9) years (range:19-65 years). The surgical reasons included aortic dissection (=130,83.3%),aneurysm (=22,14.1%),and pseudoaneurysm (=4,2.6%). The degrees of repair included Crawford extent I in 6 patients (3.8%),extent Ⅱ in 128 patients (82.1%),extent Ⅲ in 20 patients (12.8%),and extent Ⅳ in 2 patients(1.3%). There were 3 patients presented with aortic rupture and 6 patients received emergent operations. Nine patients (5.8%) died within 30 days after surgery,and 8 patients (5.1%) suffered from permanent paraplegia. Thirty-six patients (23.1%) had ARF after surgery,and 18 of them needed dialysis. Multivariate logistic analysis showed that smoking ( =2.637,95%=1.113-6.250,=0.028),packed red blood cell usage in operation (≥6 U) ( =5.508,95%=2.144-11.930,=0.000),reoperation for bleeding (=3.529,95%=1.298-9.590,=0.013) were independent risk factors for ARF after TAAA repair. Smoking,packed red blood cell usage in operation (≥6 U),reoperation for bleeding are the independent risk factors of ARF after TAAA surgery.

Early and Midterm Results of Thoracoabdominal Aortic Aneurysm Repair in Patients with Marfan Syndrome / 中国医学科学院学报

Objective To evaluate the early and midterm results of surgical repair of thoracoabdominal aortic aneurysm(TAAA)in patients with Marfan syndrome(MFS). Methods The clinical data of patients with MFS undergoing TAAA repair in Fuwai Hospital between January 2009 and December 2017 were retrospectively analyzed.These patients were divided into two groups:MFS group(=58)and non-MFS group(=98).The baseline data,early postoperative results,and midterm follow-up outcomes were compared between these two groups. Results MFS patients were significantly younger(32 years old 45 years old,=9.603,=0.000)and more frequently had a history of aortic aneurysm or dissection(19% 0,=19.996,=0.000)than non-MFS patients.However,the proportions of males and smokers were significantly lower when compared with non-MFS patients(55.2% 80.6%,=11.489,=0.001;13.8% 46.9%,=17.686,=0.001).There was no significant difference in proportion of emergency operation,prophylactic cerebrospinal fluid drainage,operation time,intra-operative circulation management,and intra-operative blood transfusion(all >0.05).The 30-day mortality rate was significantly lower in MFS group than in non-MFS group(0 9.2%, [Formula: see text]=5.034,=0.025). Conclusions For patients with MFS,TAAA repair provides lower 30-day mortality and comparative middle-term survival.However,the re-intervention rate is higher among MFS patients,highlighting the importance of close follow-up.

Reoperation on aortic disease in patients with previous aortic valve surgery / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>Aortic valve replacement (AVR) is a safe and effective method in the treatment of aortic valve diseases. This study aimed to increase the understanding on re-treatment of aortic diseases after aortic valve surgery through a retrospective analysis of 47 related cases.</p><p><b>METHODS</b>Forty-seven patients (38 males and 9 females) with previous aortic valve surgery have received reoperation on aorta from January 2003 to June 2012, and the mean interval time of re-intervention to aortic disease was 6 years ((6.0 ± 3.8) years). The secondary aortic surgery included aortic root replacement (14 cases), ascending aorta replacement (10 cases), aortic root/ascending aorta plus total arch replacement with stented elephant trunk implantation (21 cases), and total thoracoabdominal aorta replacement (2 cases). All these patients have received outpatient re-exams or follow-up by phone calls.</p><p><b>RESULTS</b>After the initial aortic valve replacement, patients suffered from aortic dissection (25 cases, 53%), ascending aortic aneurysm (12 cases, 26%) or aortic root aneurysm (10 cases, 21%). Diameter in ascending aorta increased (5.2 ± 7.1) mm per year and aortic sinus (3.3 ± 3.1) mm per year. The annual growth value of diameter in ascending aorta was higher in patients with rheumatic heart disease than that in Marfan syndrome (P < 0.05). All 47 patients have received reoperation on aorta. One patient died in operating room because aortic dissection seriously involved right coronary artery. Seven patients had renal insufficiency after operation; neurological complications occurred in 14 patients including 7 patients with stroke and the others with transient brain dysfunction. All patients were followed up, the mean survival time was (97.25 ± 17.63) months, 95% confidence interval was 55.24-73.33 months. Eight cases were died during follow-up and five-year survival rate was 83%.</p><p><b>CONCLUSION</b>To reduce the aortic adverse events after first aortic valve surgery, it is necessary to actively treat and strictly follow-up patients with previous aortic operation especially patients with Marfan syndrome and rheumatic heart disease.</p>

Stented elephant trunk and femoral artery bypass grafting surgery for extended aneurysmal dilation of Stanford A aortic dissection or aortic aneurysm / 中华外科杂志

<p><b>OBJECTIVES</b>To summarize the clinical experience of stented elephant trunk with femoral artery bypass grafting procedure to treat severe aneurysmal dilation of Stanford A aortic dissection or aortic aneurysm. To study the surgical indication and surgical strategy of chronic Stanford A aortic dissection and aneurysmal dilation, also to summarize the early follow-up results.</p><p><b>METHODS</b>From February 2006 to November 2011, 19 patients with Stanford A aortic dissection or aortic aneurysm with extented aneurysmal dilation (megaaorta) received stented elephant trunk with femoral artery bypass grafting procedure. There were 3 acute cases and 16 chronic cases with 14 male patients and 5 female patients. Average age of this group was (42 ± 8) years and average body weight was (70 ± 15) kg. One patient was aortic aneurysm and all the other were Stanford A aortic dissection. Eight patients were Mafan's syndrome. Ascending aorta replacement or Bentall's operation was done first and total arch replacement and stented elephant trunk operation was done under deep hypothermia and circulatory arrest. After the patient was weaned from cardiopulmonary bypass, bypass from ascending aorta to femoral artery was done subcutaneously using the 10 mm graft in the same femoral incision.</p><p><b>RESULTS</b>There was no operative mortality. One patient had chylothorax which recovered with medical treatment and one patient got paraplegia after surgery. The cardiopulmonary bypass time was (176 ± 42) minutes, aortic cross clamping time was (88 ± 25) minutes and deep hypothermia and low flow rate time was (23 ± 8) minutes. The blood pressure of the lower extremities were normal after operation. Follow-up time was (22 ± 19) months. All patients survived. False lumen closure rate at the stent level was 100%. CT scan at 3 to 6 months after operation showed no obvious dilation of the descending aorta. Two patient successfully received second stage operation of total (subtotal) thoracoabdominal aorta replacement.</p><p><b>CONCLUSIONS</b>Stented elephant trunk and aorta to femoral artery bypass is a safe procedure to treat aortic dissection or aortic aneurysm with extended aneurysmal dilation. This procedure can effectively increase the blood supply of the lower extremities due to small true lumen of the descending aorta, and may decrease the speed of dilation of the false lumen. It is also a practical procedure to lay the foundation for the second stage operation of normothemia thoracoabdominal aorta replacement.</p>

Risk analysis for hospital mortality after operations for type A aortic dissection / 中华外科杂志

<p><b>OBJECTIVE</b>To analyze the risk factors for hospital mortality after operations for type A aortic dissection.</p><p><b>METHODS</b>Totally 766 consecutive patients (586 male and 180 female patient, aged (45±12) years, ranging from 16 to 78 years), who underwent surgery for type A aortic dissection from January 2001 to December 2010, were studied retrospectively. Preoperative and operation related clinic factors were analyzed by univariate analysis, followed by Logistic regression model, to identify the risk factors of hospital mortality.</p><p><b>RESULTS</b>Overall, 37 patients (4.8%) died during hospitalization. On univariate analysis, significant risk factors for hospital mortality were male, acute status, renal dysfunction, cardiac dysfunction, cardiopulmonary bypass time, duration of operation, volume of blood transfusion, re-operation for bleeding (χ2=4.008-27.093, P<0.05). On Logistic regression model, independent risk factors were acute status (OR=2.784, 95%CI: 1.166-6.649, P=0.021), renal dysfunction (OR=6.285, 95%CI: 1.738 - 22.723, P=0.005), cardiac dysfunction (OR=3.052, 95%CI: 1.083-8.606, P=0.035), re-operation for bleeding (OR=3.690, 95%CI: 1.262-10.791, P=0.017), volume of blood transfusion (OR=1.033, 95%CI: 1.008-1.058, P=0.010). Additionally, male (OR=0.387, 95%CI: 0.177-0.848, P=0.018) was protective factor, and alternatively, female was indeed one of the independent risk factors for hospital mortality.</p><p><b>CONCLUSION</b>Female, acute status, renal dysfunction, cardiac dysfunction, re-operation for bleeding, volume of blood transfusion were independent risk factors for hospital mortality after operations for type A aortic dissection.</p>

Outcome of surgery for sinus of Valsalva aneurysm with discrete membranous subaortic stenosis / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>Sinus of Valsalva aneurysm (SVA) is a rare cardiac anomaly, and SVA with discrete membranous subaortic stenosis is even rarer. The aim of the study was to make sure the incidence of SVA with discrete membraneous subaortic stenosis in SVA and their surgical results. We retrospectively analyzed 234 patients receiving surgical repair of SVA and reported the incidence of ventricular septal defect, aortic regurgitation, and discrete membranous subaortic stenosis. We also reported seven cases of SVA combined with discrete membranous subaortic stenosis and their surgical results.</p><p><b>METHODS</b>Between January 1999 and December 2009, seven patients of SVA with discrete membranous subaortic stenosis underwent surgical repair of SVA and resection of subaortic discrete membrane. There were six male and one female patients. The mean age was (33.71 ± 13.25) years (range 16 - 52 years). Associated cardiovascular lesions were aortic regurgitation (n = 7), ventricular septal defect (n = 5), coarctation of aorta (n = 1), bicuspid aortic valve (n = 1), patent ductus arteriosus (n = 1), and aortic valve stenosis (n = 1). The aortic valve was replaced in four patients and valvuloplasty was done in three. The other co-existing anomalies were corrected at the same time. All the seven patients were followed up from 18 to 125 months (mean (63.14 ± 39.54) months). Among 234 SVA patients who underwent surgical repair, the number of cases with coexisting ventricular septal defect, aortic regurgitation, and discrete membranous subaortic stenosis was 129, 108, and 7, respectively.</p><p><b>RESULTS</b>There was neither early death after operation nor late death during the follow-up period. All the seven patients were in the New York Heart Association (NYHA) functional classes I and II. There was no recurrence of discrete subaortic membrane during the follow-up period. The incidence of ventricular septal defect, aortic valve incompetence, and discrete membranous subaortic stenosis among 234 SVA patients was 55.13%, 46.15%, and 2.99%, respectively.</p><p><b>CONCLUSIONS</b>Surgical repair of SVA with discrete membranous subaortic stenosis showed good mid-term results. Resection of discrete subaortic membrane should be done actively while repairing SVAs. Long-term results need to be followed up.</p>

Aortic valve preservation and root reconstruction in Marfan syndrome / 中华外科杂志

<p><b>OBJECTIVE</b>To explore the experiences of aortic valve preservation and root reconstruction in patients with Marfan syndrome.</p><p><b>METHODS</b>From July 2003 to Dec 2007, 22 patients with Marfan syndrome were treated by aortic valve preservation and root reconstruction. There were 12 male and 10 female, the age ranged from 10 to 57 years old with a mean of (28 +/- 10) years. The operation procedures included reimplantation technique in 9 patients, remodeling technique in 8 patients, and patch technique in 2 patients. In addition, reimplantation technique + total aorta replacement in 1 patient, remodeling technique + "aortic arch replacement + stent-elephant trunk" in 1 patient, patch technique + "aortic arch replacement + stent-elephant trunk" in 1 patient. The patients were followed-up by 17 to 64 months with a mean of (46 +/- 16) months.</p><p><b>RESULTS</b>No in-hospital and follow-up period death occurred. There was one reexploration for bleeding 1 d postoperative. No valve-related complication occurred during the follow-up. At the end of follow-up, no aortic regurgitation was demonstrate in 16 patients, but mild regurgitation in 4 patients, moderate regurgitation in 1 patient and severe regurgitation in 1 patient. Two patients with moderate and severe aortic regurgitation need reoperation 1 year postoperative.</p><p><b>CONCLUSION</b>The early and mid-term results of aortic valve preservation and root reconstruction operations in Marfan syndrome were favorable.</p>

Surgical repair of ruptured sinus of Valsalva aneurysm to right atrium / 中华外科杂志

<p><b>OBJECTIVES</b>To summarize the experience of surgical repair of ruptured sinus of Valsalva aneurysm to right atrium and to compare the difference between through right atrium repair and transaortic combined with right atrium approach.</p><p><b>METHODS</b>Between January 2004 and December 2009, 53 patients with ruptured sinus of Valsalva aneurysm to right atrium underwent surgical repair. There were 35 male and 18 female, aged from 15 to 63 with a mean of (33 ± 9) years. Repair through right atrium had undergone in 40 patients (group I), while transaortic combined with right atrium approach in 13 patients (group II). Surgical results between the two group and group were compared in cardiopulmonary bypass time, clamp aorta time, mechanical ventilation time, ICU time and postoperative stay time.</p><p><b>RESULTS</b>There were no significant differences between two groups in cardiopulmonary bypass time [(86 ± 29) min vs. (96 ± 30) min], clamp aorta time [(59 ± 29) min vs. (71 ± 25) min], mechanical ventilation time [(9 ± 4) h vs. (16 ± 23) h], ICU time [(35 ± 23) h vs. (35 ± 23) h], postoperative stay time [(7.1 ± 0.9) d vs. (7.7 ± 2.8) d] (P > 0.05). Follow-up was performed from 1 to 64 months, with a mean of (32 ± 21) months. There was no death during follow up. One needed operation due to severe aortic valve regurgitation. One combined with coronary artery disease used medication. Heart function (NYHF) of the other patients were I and II degree during follow up.</p><p><b>CONCLUSIONS</b>Surgical repair of ruptured sinus of Valsalva aneurysm to right atrium shows good result. There is no significant difference between through right atrium repair and transaortic combined with right atrium approach.</p>

Midterm outcome of one stage total or subtotal aortic replacement / 中华外科杂志

<p><b>OBJECTIVE</b>To summarize the experience of one-stage total and subtotal aortic replacement for aneurysm evolving the entire aorta and show the midterm results of the operation.</p><p><b>METHODS</b>From February 2004 to July 2008, 22 patients (17 men and 5 women, age ranged from 19 to 47 years old) underwent one-stage total or subtotal aortic replacement under deep hypothermic circulatory arrest and selective antegrade cerebral perfusion. Seven patients received subtotal aortic replacement (from the aortic valve to the abdominal aorta). Fifteen patients underwent total aortic replacement (from the aortic valve to the aortic bifurcation). Patients were opened with a mid-sternotomy and a thoracoabdominal incision. First, the ascending aorta was replaced; following which the aortic arch was reconstructed. Finally, the thoracoabdominal aorta was fully replaced.</p><p><b>RESULTS</b>Thirty-day mortality was 4.5% (1/22). One patient died of multiple organ failure 11 days postoperatively. Two patients had cerebral infarction secondary to embolism. Spinal neurological deficits didn't occur. Twenty-one patients survived the operation and were followed up for 3 to 56 months (35.0 +/- 16.9 months). There was no late death. One patient received aortic valve replacement due to aortic valve regurgitation one year after David and total aortic replacement.</p><p><b>CONCLUSION</b>One-stage total and subtotal aortic replacement is an effective operation for aneurysm evolving the whole length of the aorta with acceptable mortality and morbidity. Midterm follow-up showed satisfactory results.</p>

Bilateral bidirectional superior cavopulmonary shunt is more beneficial in medium and long term clinical outcomes than unilateral shunt / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>The present study was aimed to compare the effects of bilateral and unilateral bidirectional superior cavopulmonary shunt (b-BDG and u-BDG) on pulmonary artery growth and clinical outcomes.</p><p><b>METHODS</b>The 51 subjects enrolled in this study were divided into two groups: those receiving b-BDG (n = 21) and those receiving u-BDG (n = 30). Clinical records were reviewed retrospectively at a mean of 43.3 months after BDG procedures. Chi square and t-tests were performed to analyze the data.</p><p><b>RESULTS</b>Left and right pulmonary artery diameters increased 27% - 37% in both groups. The pulmonary artery index increased 37.2% after b-BDG and 27.0% after u-BDG. b-BDG patients experienced a significant decrease in mean hemoglobin concentration and hematocrit value, and a correlated change in postoperative diameter of left pulmonary artery (LPA) and pulmonary artery index (y = 0.2719, x = -1.8278; R = 0.564, P = 0.008). The change ratio of hemoglobin and postoperative LPA were also correlated in b-BDG patients (y = -0.0522x + 0.3539; R = -0.479, P = 0.028). Only one b-BDG patient versus twelve u-BDG patients needed total cavopulmonary connections 31.8 months after BDG surgery (P = 0.0074). Moreover, only one (4.8%) b-BDG patient but eight u-BDG patients (26.7%) developed pulmonary arteriovenous malformations.</p><p><b>CONCLUSIONS</b>b-BDG increases bilateral pulmonary blood flow and promotes growth of bilateral pulmonary arteries, with preferable physiological outcomes to u-BDG. Results may imply that subsequent Fontan repair may not always be needed.</p>

Relationship between clinical pathophysiology and pulmonary pathology in patients with congenital heart defects and decreased pulmonary artery blood flow / 中华儿科杂志

<p><b>OBJECTIVE</b>To investigate the relationship between pulmonary pathological features and clinical physiology of congenital heart defects (CHD) with decreased pulmonary artery blood flow.</p><p><b>METHODS</b>Between July 2001 and May 2006, 18 patients with CHD with decreased pulmonary artery blood flow undergoing palliative or definitive repair and having lung biopsy intraoperatively were enrolled in this study. The patients' age was 0.4 - 8.0 years, and body weight was 6.0 - 20.0 kg. The method of semi-quantitative morphometric technique and an image analyzer were applied to measure the following indices of pulmonary microvessels: the percentage of media thickness (MT%), the percentage of media section area (MS%) and numbers of microvessels per square centimeter (VPSC). The diameters of left pulmonary artery (LPA) and right pulmonary artery (RPA) were measured with two-dimensional echocardiography. The percutaneous oxygen saturation (SpO(2)), hemoglobin concentration (HB) and hematocrit value (HCT) were examined and recorded preoperatively.</p><p><b>RESULTS</b>There was a significant negative correlation between SpO(2) and HCT or Hb (R(2) = 0.4914, P = 0.001 and R(2) = 0.5505, P < 0.001), the variation trend of these three variables was linked. There was a negative correlation between SpO(2) and the body weight (R(2) = 0.2208, P = 0.049), which is in accordance with clinical features of aggravated process of cyanosis and hypoxia. The morphological observation of lung biopsy specimens indicated that most of peripheral pulmonary arteries were distended, irregular and their walls were uneven, and "lake" type of pulmonary AV malformations were observed. There was a positive correlation between VPSC and the body weight or BSA (R(2) = 0.5472, P < 0.001 and R(2) = 0.5233, P = 0.001). There was a significant correlation between VPSC and LPA or RPA (R(2) = 0.4312, P = 0.003 and R(2) = 0.2463, P = 0.036). It was shown that the diameter of central pulmonary arteries could be a reflection of peripheral pulmonary artery growth. The diameter of LPA also correlated with the diameter of RPA (R(2) = 0.286, P = 0.022).</p><p><b>CONCLUSIONS</b>For patients with congenital heart defects with decreased pulmonary blood flow, the pulmonary pathological changes are the bases of their clinical physiologic features. It is suggested that they should be treated in their earlier stage of life.</p>

Lung pathology of complex congenital heart defect with diminished pulmonary blood flow but without aortopulmonary collateral artery and patent ductus arteriosus in infants and young children / 中国当代儿科杂志

<p><b>OBJECTIVE</b>The development of pulmonary vascular bed is strongly flow-dependent. Abnormal pulmonary blood flow leads to pulmonary pathological changes. This study aimed to observe the pathological changes of small pulmonary arteries and alveoli in complex congenital heart defect with diminished pulmonary blood flow but without aortopulmonary collateral artery (APCA) and patent ductus arteriosus (PDA) in infants and young children.</p><p><b>METHODS</b>Autopsy pulmonary specimens obtained from 5 children who died of non-cardiovascular diseases were used as the control group (age: 4-18 months). Fifty-six children (age: 4-36 months) with complex congenital heart defect with diminished pulmonary blood flow but without APCA and PDA served as the study group, including 34 cases of tetralogy of Fallot, 7 cases of double outlet right ventricle with pulmonary stenosis, 9 cases of single ventricle with pulmonary stenosis, 4 cases of tricuspid atresia with pulmonary stenosis and 2 cases of complete atrioventricular septal defect with pulmonary stenosis. Pulmonary specimen sections were stained by hematoxylin-eosin and Weigert-Van Gieson. Percentage of media thickness (MT%), percentage of media section area (MS%), number of small arterial per square centimeter (APSC), mean alveolar number (MAN), mean linear intercept (MLI), proportion of parenchyma area in total area (PPA%) and alveolar to small arterial ratio per unit area (AAR) were measured by morphologic quantitative analysis.</p><p><b>RESULTS</b>MT% (10.93+/-2.87% vs 15.08+/-2.51%), MS% (18.97+/-5.56% vs 25.04+/-3.87%) and APSC (202.43+/-67.45 vs 441.69+/-65.29) decreased significantly in the study group compared with the control group (P<0.01). The internal diameter of small pulmonary artery (80.26+/-21.57 microm vs 58.53+/-10.29 microm; P<0.05), AAR (46.59+/-14.43 vs 34.46+/-4.98; P<0.01) and MLI (144.98+/-44.87 microm vs 108.39+/-20.76 microm; P<0.05) increased significantly compared with the control group.</p><p><b>CONCLUSIONS</b>The media of small pulmonary arteries becomes thinner, the lumen of small pulmonary arteries becomes larger, and the number of small arterial per square centimeter and the mean alveolar number are reduced in infants and young children with complex congenital heart defect with diminished pulmonary blood flow but without APCA and PDA.</p>

Further development of pulmonary artery after Glenn procedure: effect of different antegrade pulmonary blood flows on cyanotic congenital heart defects / 中国医学科学院学报

<p><b>OBJECTIVE</b>To compare the effect of different antegrade pulmonary blood flow on the further development of pulmonary artery after Glenn procedure in cyanotic congenital heart defects (CHD) patients.</p><p><b>METHODS</b>Between October 2000 and December 2006, 132 CHD patients with decreased pulmonary artery blood flow underwent bidirectional Glenn shunt, among them 18 patients received intraoperative lung biopsy. Patients were divided into two groups according to their different sources of antegrade pulmonary blood flow: antegrade arterial blood flow group (n = 33) and antegrade venous blood flow group (n = 99). The percutaneous oxygen saturation (SpO2), hemoglobin (Hb) concentration, and hemotocrit (Hct) value were examined and recorded before and after operation. The diameters of left pulmonary artery (LPA) and right pulmonary artery (RPA) were measured with two-dimensional echocardiography and the results were used to calculate the pulmonary artery index (PAI). The method of half-quantitative morphometric technique and an image analyzer were used to measure the following indicators of pulmonary microvessels: the percentage of media thickness (MT%), the percentage of media section area (MS%), vascular numbers of per square centimeter (VPSC), and mean alveolar number (MAN).</p><p><b>RESULTS</b>Before the operation, obvious cyanosis was found in both groups, while SpO2, Hct, and Hb were not significantly different (P > 0.05). LPA, RPA, and PAI were not significantly different between two groups (P > 0.05). The MT% and MS% in antegrade venous blood flow group were significantly less than those in antegrade arterial blood flow group (P < 0.05), but VPSC and MAN were not significantly different (P > 0.05). After Glenn procedure, hypoxia and cyanosis were remarkably improved in both two groups. There was a significantly negative correlation between SpO2 and Hct (r = -0.49, P < 0.01) or Hb (r = -0.196, P < 0.01 ). The PAI increased by 22% in antegrade arterial blood flow group and 44% in antegrade venous blood flow group (P < 0.05). The diameters of LPA and RPA in antegrade venous blood flow group were significantly larger than those in antegrade arterial blood flow group (P < 0.05) and the growth of RPA in antegrade arterial blood flow group was not significant.</p><p><b>CONCLUSION</b>A better pulmonary artery growth occurs in the patients of pulmonary stenosis after Glenn shunt than in those of pulmonary atresia, and it contributes to an earlier completion of Fontan procedure.</p>

Relationship between the quantitative structural study of lung and the right ventricle outflow tract reconstruction in infants with tetralogy of Fallot / 中国医学科学院学报

<p><b>OBJECTIVE</b>To analyse the relationship between the quantitative structural study of lung and right ventricle outflow tract reconstruction in infants with tetralogy of Fallot.</p><p><b>METHODS</b>Lung biopsies were taken during the operations in 16 infants suffered from tetralogy of Fallot. Autopsy specimens were obtained from 5 infants died of non-cardiovascular diseases as normal control group. All patients underwent one staged repair. The techniques of right ventricular outflow tract reconstruction included pulmonary valve commissurotomy (n = 3), transanular pericardial patch (n = 4), and transannular homologous monocuspid valve patch (n = 8); homograft was used in one patient because of the abnormal coronary artery. The diameters of main pulmonary artery (MPA), left pulmonary artery (LPA), and right pulmonary artery (RPA) were measured during operation. The tissue was fixed with buffered formalin and routinely impregnated in wax. Sections were stained by hematoxylin-eosin, and Weigert's elastic stain counter-stained by van Gieoson's method. Seven parameters of the small pulmonary arteries were obtained, including percentage of media thickness (% MT), percentage of media section area (% MS), numbers of pulmonary small artery per square centimeter (APSC), mean alveolar number (MAN), mean linear intercept (MLI), proportion of parenchyma area in total area (% PPA), and alveolar/ small arterial ratio per unit area (AAR) by a computer-based image processor for quantitative analysis.</p><p><b>RESULTS</b>In the TOF group, % MT, % MS, and APSC significantly decreased, while MLI and AAR significantly increased (P < 0.05, compared with the control group). APSC decreased in turn after separately using three different techniques of right ventricular outflow tract reconstruction (i. e. pulmonary valve commissurotomy, transannular pericardium patch, and transannular homologous monocuspid valve patch), which was paralleled with the diameters of MPA, LPA, and RPA. RPA correlated with APSC (r = 0.754, P = 0.001).</p><p><b>CONCLUSIONS</b>The development of pulmonary small arteries and alveoli are directly affected by the diminished pulmonary flow in infants with tetralogy of Fallot. Right ventricle outflow tract reconstruction may be indicated according to the developmental degree of central pulmonary artery.</p>

The application of modified classification of the aortic dissection / 中华外科杂志

<p><b>OBJECTIVE</b>To determine the indication, optimal operative procedures, plan and the estimation of the prognosis depending on the subtype of aortic dissection defined by the extension and extent of dissection.</p><p><b>METHODS</b>The outcome of 708 patients with aortic dissection between January 1994 and December 2004 was analyzed. Among them 477 patients suffered from Stanford type A aortic dissection were treated. Type A dissection can be classified into 3 subtypes based on the pathological change of the aortic root. Type A1 (No pathological change type): 212 patients underwent ascending aorta replacements; Type A2 (mild pathological change type): 63 patients underwent ascending aortic replacement with concomitant aortic valve and valsalva sinus plasty and David procedure was performed in 9 patients; Type A3 (severe pathological change type): 193 patients underwent Bentall procedure. The method of aortic arch repair was determined by the pathological type of distal aorta. Total aortic arch replacement was performed in 78 patients with complex type (type C). There hundred and ninety-nine patients with simple type (type S) underwent partial aortic arch replacement. 231 patients suffered from Stanford type B aortic dissection. Type B dissection can be classified into 3 subtypes based on dilated extension of proximal descending aorta. Type B1 (no dilation was confined in the proximal of thoracic descending aorta): endoluminal stent graft repair was performed in 103 patients. Replacement of the partial proximal thoracic descending aorta and replacement combined with stented elephant trunk procedure were performed in 32 and 12 patients respectively; Type B2 (aneurysm in thoracic descending aorta): 32 patients underwent the part proximal thoracic descending aorta replacement combined with aorta plasty. 21 patients underwent the replacement of entire thoracic descending aorta; Type B3 (aneurysm in thoracic descending and abdominal aorta): thoracoabdominal aortic replacement was operated in 31 patients with deep hypothermia circulatory arrest; Type BC (complex type): 44 patients were performed the operation with the use of deep hypothermia circulatory arrest because their left subclavian arteries or distal aortic arch were affected by the dissection; Type BS (simple type): 103 patients were underwent endoluminal stent graft repair. In the 60 patients, the operations were performed by using the technique which preserved blood was transfused back by pump via the femoral artery. Femoro-femoral bypass was performed in 24 patients.</p><p><b>RESULTS</b>Type A: the operative mortality was 4.6% (27/477), and the hospital morbidity was 14.5% (69/477). Type B: the hospital mortality of endoluminal stent graft repair was 1.9% (2/103). 9.7% (10/103) had mild leakage from proximal communications. The morbidity was 2.9% (3/103) in stent group. The mortality was 3.1% (4/128), and the hospital morbidity was 18.8% (24/128) in the operative group.</p><p><b>CONCLUSION</b>The subtype of aortic dissection is much useful in determining the optimal procedure, operative indication and plan, estimating the prognosis.</p>

Dexterously use four branch vessel prosthesis on aortic surgery / 中华外科杂志

<p><b>OBJECTIVE</b>To review the experience of various positions aortic replacement by four branch prosthesis vessel.</p><p><b>METHODS</b>From August 2003 to May 2005, we finished aortic procedures with four branch prosthesis vessel for 142 patients, aged (44 +/- 12) (22-78) years, weighted (72 +/- 20) kg (49-130 kg). We performed ascending aorta and total aortic arch replacement for 85 cases during right axillary artery cannulation for cardiopulmonary bypass and selected antegrade cerebral perfusion. 38 patients underwent one-stage total thoracoabdominal aortic replacement during deep hypothermic bypass and subsection circulatory arrest. 8 patients underwent one-stage total or subtotal aortic replacement during deep hypothermic bypass and selected antegrade cerebral perfusion and subsection circulatory arrest. We performed totally aortic arch replacement without utilizing cardiopulmonary bypass and hypothermic for 11 cases.</p><p><b>RESULTS</b>The mortality was 4.2%. Cerebral complications occurred in 16 (11.3%). 2 patients suffered from permanence spinal cord dysfunction. 4 patients suffered from temporary spinal cord dysfunction.</p><p><b>CONCLUSION</b>The four branch vessel prosthesis can be used on aortic surgery dexterously. The approach may shorten she time of aortic arrest and arterial construction.</p>

Clinical application of total or subtotal aortic replacement on the one stage / 中华外科杂志

<p><b>OBJECTIVE</b>To summarize the experience of the application of total and subtotal aortic replacement on the one stage in the treatment of the patients with extensive aortic aneurysm and chronic Stanford type A dissecting aneurysm.</p><p><b>METHODS</b>From February to November 2004, 8 patients (7 male and 1 female; ranging from 23 to 47 years old) underwent one-stage total or subtotal aortic replacement under deep hypothermic circulatory arrest and selective antegrade cerebral perfusion. Two patients received subtotal aortic replacement (from the aortic valve to the abdominal aorta). Six patients underwent total aortic replacement (from the aortic valve to the aortic bifurcation), of which 3 patients had aortic valve replacement. Patients were with mid-sternotomy and thoracoabdominal incision. The ascending aorta was firstly replaced, following which the aortic arch was reconstructed. Finally, the thoracoabdominal aorta was fully replaced.</p><p><b>RESULTS</b>There was no operative or early postoperative death. One patient had cerebral infarction secondary to embolism. Spinal neurological deficits didn't occur. All 8 patients were alive and had good functional status 2 to 12 months after operation.</p><p><b>CONCLUSION</b>The patients performed with one-stage total and subtotal aortic replacement achieves good results. It can eliminate the risk of remnant aneurysm rupture in staged total aortic replacement.</p>

Pulmonary artery perfusion with hypothermic solution inhibits the apoptosis of lung parenchymal cells during cardiopulmonary bypass / 中华外科杂志

<p><b>OBJECTIVE</b>To study effects of pulmonary artery perfusion with hypothermic solution on the apoptosis of lung parenchymal cells during cardiopulmonary bypass.</p><p><b>METHODS</b>Forty children with tetralogy of Fallot were divided into control group (n = 20) and protective group (n = 20). The patients in control group were performed using routine approaches. Patients' pulmonary artery were infused with 4 degrees C protective solution during cardiopulmonary bypass in protective group. Lung biopsy specimens were obtained after operations in order to study the apoptosis of lung parenchymal cells using tunnel techniques. At same time, patients' pulmonary functions and clinic index were monitored.</p><p><b>RESULTS</b>The rate of apoptosis cells of lung parenchymal cells was (18 +/- 7)% in control group, whereas (10 +/- 2)% in protective group. There was significant difference between both groups (t = -2.95, P < 0.05). Index O(2) in protective group was higher than that in control group at 0, 6 and 12 hours after operations [(492 +/- 172), (444 +/- 104), (489 +/- 58) mm Hg versus (369 +/- 126), (347 +/- 107), (340 +/- 119) mm Hg, t = 2.59, P < 0.05; t = 2.88, P < 0.01; t = 5.06, P < 0.01, respectively)]. The time of mechanical ventilation was significantly shorter in protective group than in control group [(15 +/- 11) hours versus (26 +/- 15) hours, t = -2.76, P < 0.01].</p><p><b>CONCLUSION</b>Pulmonary artery perfusion with hypothermic solution can inhibit the apoptosis of lung parenchymal cells and relieve cardiopulmonary bypass-induced lung injury.</p>

Quantitative structural study of pulmonary artery in patients with pulmonary atresia with ventricular septal defect / 中国医学科学院学报

<p><b>OBJECTIVE</b>In order to provide pathologic reference for therapeutic rationale, the pathological changes of the pulmonary vasculature in patients with pulmonary atresia with ventricular defect and patent ductus arteriosus were observed by contrast with normal control group.</p><p><b>METHODS</b>Lung biopsies were taken in the operation in 10 children suffered from pulmonary atresia with ventricular septal defect associated with patent ductus arteriosus (PA group). Autopsy specimens were obtained from 10 children died of non-cardiovascular diseases as normal control group. The tissue was fixed with buffered formalin, routinely prepared by impregnated in wax. Sections were stained by hematoxylin-eosin, Weigert's elastic stain counter-stained by van Gieoson's method. Seven parameters were obtained including percentage of media thickness (MT%), percentage of media section area (MS%), numbers of vascular per square centimeter (VPSC), mean alveolar number (MAN), mean linear intercept (MLI), proportion of parenchyma area in total area (PPA), and alveolar/vascular ratio per unit area (AVR) by a computer image processor by quantitative analysis.</p><p><b>RESULTS</b>There were significant difference between the two groups in MAN, VPSC, and AVR (P < 0.05). VPSC was significantly lower in PA group than in control group (P < 0.01). Other parameters had no significant difference. The mean alveolar diameter had an increased trend in PA group, although there was no significant difference. MS% of nearly 50% patients was closed to the normal value in PA group. The shape of pulmonary arteriole was irregular. There were few muscular arteries in a field of vision.</p><p><b>CONCLUSIONS</b>The density of muscular arteries decreases in patients with pulmonary atresia with ventricular septal defect and patent ductus arteriosus, but percentage of media thickness and percentage of media section area of pulmonary arterioles are close to the normal value. Diminished flow in pulmonary circulation has a significant effect on numbers of pulmonary arterioles per square centimeter that impact the selection of surgical method and the effect of operation because of the reduction pulmonary arterioles. The decrease of mean alveolar number results in compensatory enlargement of alveolar diameter. The impaired lung development is a major cause of abnormal lung function. Feasible and earlier operation, which can increase pulmonary flow and promote development of pulmonary vasculature will be helpful to restore lung function.</p>