Clinical profiles and outcomes of acute type A aortic dissection and intramural hematoma in the current era: lessons from the first registry of aortic dissection in China / 中华医学杂志(英文版)

BACKGROUND@#Acute type A aortic dissection (ATAAD) and acute type A intramural hematoma (ATAIMH) are life-threatening diseases with high mortality. To better understand their clinical features in the Chinese population, we analyzed the data from the first Registry of Aortic Dissection in China (Sino-RAD) to promote the understanding and management of the diseases.@*METHODS@#All patients with ATAAD and ATAIMH enrolled in Sino-RAD from January 1, 2012 to December 31, 2016 were involved. The data of patients' selection, history, symptoms, management, outcomes, and postoperation complications were analyzed in the study. The continuous variables were compared using the Student's t test for normal distributions and the Mann-Whitney U test for non-normal distributions. Categorical variables were compared using the Chi-square test or Fisher exact test.@*RESULTS@#A total of 1582 patients with ATAAD and 130 patients with ATAIMH were included. The mean age of all patients was 48.4 years. Patients with ATAAD were significantly younger than patients with ATAIMH (48.9 years vs. 55.6 years, P < 0.001). For the total cohort, males were dominant, but the male ratio of patients with ATAAD was significantly higher compared to those with ATAIMH (P = 0.01). The time range from the onset of symptom to hospitalization was 2.0 days. More patients of ATAIMH had hypertension than that of ATAAD (82.3% vs. 67.6%, P < 0.05). Chest and back pain were the most common clinical symptoms. Computerized tomography (CT) was the most common initial diagnostic imaging modality. 84.7% received surgical treatment and in-hospital mortality was 5.3%. Patients with ATAAD mainly received surgical treatment (89.6%), while most patients with ATAIMH received medical treatment (39.2%) or endovascular repair (35.4%).@*CONCLUSIONS@#Our study suggests that doctors should comprehensively use clinical examination and genetic background screening for patients with ATAAD and ATAIMH and further shorten the time range from symptoms onset to intervention, achieving early diagnosis and treatment, thereby reducing the mortality rate of patients with aortic dissection in China. We should standardize the procedures of aortic dissection treatment and improve people's understanding. Meanwhile, the curing and transferring efficiency should also be improved.

Initial experience of transcatheter implantation with a new aortic valve in sheep / 中华心血管病杂志

<p><b>OBJECTIVE</b>To evaluate the feasibility and short-term results of transcatheter aortic valve implantation (TAVI) using a new transcatheter valve.</p><p><b>METHODS</b>Twenty healthy adult sheep received general anesthesia. Under the guidance of X-ray and transthoracic echocardiography (TTE), the new anti-calcification transcatheter valve was released from delivery system and implanted at the level of native aortic annulus via left common carotid artery. Position and function of the new anti-calcification transcatheter valve were evaluated by angiography and TTE immediately after intervention. Thirty day survival rate of animals was obtained.</p><p><b>RESULTS</b>New transcatheter valves were implanted in all sheep. Fifteen sheep (75%) survived up to 30 days and post-operative examination showed that the transcatheter valve was in optimal position without migration and mitral valve impingement. The native coronary artery was patent in these animals. There was a slight paravalvular leak in 5 sheep. Postoperative echocardiography showed reflux percentage was significantly increased (P < 0.05) compared pre-intervention. Effective orifice area, aortic systolic pressure, diastolic aortic pressure, mean aortic pressure, left ventricular systolic pressure, left ventricular end diastolic pressure and heart rate were similar between post and pre-intervention (all P < 0.05). Five sheep died after TAVI within 30 days, including one fatal ventricular fibrillation occurred immediately after releasing the transcatheter valve and another sheep died of acute myocardial infarction due to left main coronary artery occlusion evidenced by angiography. Two sheep died of severe mitral regurgitation at 8 and 12 hours post-operation and one died of infective endocarditis at 26 days after intervention.</p><p><b>CONCLUSION</b>Our favorable preliminary results showed that it was feasible to perform TAVI using the new transcatheter valve.</p>

Clinical follow-up of staged hybrid approach for patients with ventricular septal defects combined with patent ductus arteriosus and pulmonary hypertension / 中华心血管病杂志

<p><b>OBJECTIVE</b>To evaluate the safety and efficacy of staged hybrid approach in treating ventricular septal defect (VSD) patients combined with patent ductus arteriosus (PDA) and pulmonary artery hypertension (PAH).</p><p><b>METHODS</b>From July 2004 to July 2009, 22 VSD patients with PDA and PAH were enrolled and received staged hybrid approach treatment (transcatheter PDA occlusion and elective open surgery for VSD several days after PDA occlusion). All patients were followed up to examine rhythm change, residual shunt, shape of occlude, possible valve regurgitation, and aortic stenosis by echocardiography.</p><p><b>RESULTS</b>After transcatheter PDA occlusion, pulmonary arterial systolic pressure decreased from (76.2 ± 25.8) mm Hg (1 mm Hg = 0.133 kPa) to (55.4 ± 20.6) mm Hg (P = 0.005), mean pulmonary artery pressure decreased from (53.5 ± 23.5) mm Hg to (36.2 ± 17.8) mm Hg (P = 0.049), total pulmonary resistance decreased from (8.2 ± 4.9) wood units to (6.9 ± 4.3) wood units (P = 0.037), and pulmonary-to-systemic flow ratio (Qp/Qs) increased from 2.8 ± 2.3 to 3.4 ± 1.7 (P = 0.045) post transcatheter interventional PDA occlusion. After VSD repair, pulmonary arterial systolic pressure decreased from (64.5 ± 22.3) mm Hg to (43.1 ± 18.9) mm Hg (P = 0.001) and mean pulmonary artery pressure decreased from (40.2 ± 18.7) mm Hg to (29.5 ± 15.8) mm Hg (P = 0.040). There was no death or right heart failure during the follow-up.</p><p><b>CONCLUSION</b>Staged hybrid approach is an effective and safe strategy for treating VSD patients with PDA and PAH.</p>

Study on the influence of the configuration of porcine aortic root on the stentless valve design / 中华外科杂志

<p><b>OBJECTIVE</b>To provide the reference for the stentless aortic valve design with the study of the inner configuration of porcine aortic root.</p><p><b>METHODS</b>The orifice areas of porcine aortic root at 4 levels (OA1 to 4), the average area of leaflets (Sa), the area analogue of leaflets (AA, AA = 1/2PH), the average area analogue of leaflets (AAa), the value PH of the left, right, non coronary leaflets (PHl, PHr, PHn) and the sums of PHs of the left and non-coronary leaflets (PHln) in the fresh and glutaraldehyde and epichlorohydrin-treated porcine aortic valves (20 respectively) were measured and calculated. The linear correlation and regression analysis by SPSS 12.0 was used to analyze the correlation between Sa and AAa, OA and Sa, OA and AAa, PHl, PHr and PHn, PHln and PHr in both groups.</p><p><b>RESULTS</b>The coefficient correlation between Sa and AAa in fresh and treated groups were 0.886 and 0.872 respectively (P < 0.05). The coefficient correlation between OA1 to 4 and AAa were 0.810, 0.851, 0.900, and 0.815 respectively in fresh group (P < 0.05), and were 0.852, 0.888, 0.836, and 0.817 respectively in treated group (P < 0.05). This showed that the degree of correlation between the average area analogue of leaflets and the average area of leaflets, the orifice areas of aortic root were relatively large. Additionally, the equation of linear regression existed between PHln and PHr in treated group as follows: PHr = -1.665 + 0.688 PHln (r = 0.907, P < 0.05), thereby PHr could be predicted by PHln.</p><p><b>CONCLUSION</b>The value of PH of leaflets could represent the spatial configuration of the aortic root, which provided a referred index for the stentless bioprostheses design.</p>

Construction of an acellular porcine aortic valve / 南方医科大学学报

<p><b>OBJECTIVE</b>To prepare a porcine aortic valve (PAV) free of the cellular components.</p><p><b>METHODS</b>The cellular components of porcine PAV were completely removed using trypsin and Triton X-100, and the acellular PAV was examined microscopically with HE staining with its physical and chemical properties assessed. Transmission electron microscopy was used to observe the integrity of the collagen and elastin and the DNA contents in the PAV was detected to confirm the total removal of the cellular components. With the fresh PAV as the control, small pieces of the acellular PAV were implanted into the subcutaneous tissues of 4 rabbits, and 4 weeks after the implantation, the implants were harvested for microscopic observation.</p><p><b>RESULTS</b>The cellular components were effectively removed from the cusps and roots of the PAV by trypsin and TritonX-100, with marked soluble protein loss [(0.24-/+0.04)% vs (0.48-/+0.12)%] and significantly increased water content [(92.2-/+1.5)% vs (89.2-/+1.6)%]. The acellular PAV still maintained good fibrous scaffold structure and the shrinkage temperature and tension at fracture underwent no significantly changes [(67.9-/+1.0) degrees celsius; vs (68.8-/+0.8) degrees celsius; and (489.3-/+19.0) g/mm2 vs (540.7-/+19.5) g/mm2, respectively]. The PAVs implanted in rabbits showed only mild tissue reaction with a few infiltrating neutrophils, lymphocytes and plasmocytes observed 4 weeks later. The accelular PAV caused obviously milder inflammatory reactions than fresh PAV.</p><p><b>CONCLUSIONS</b>The acellular PAV prepared by treatment with trypsin and Triton X-100 retains good fibrous scaffold structure and mechanical strength with low antigenicity.</p>

Research on application of modified polyethylene glycol hydrogels in the construction of tissue engineered heart valve / 中华外科杂志

<p><b>OBJECTIVE</b>To explore the effect of the polyethylene glycol (PEG)-hydrogels to enhance the seeding-cells adhesion to the biomaterial scaffolds.</p><p><b>METHODS</b>Sixteen porcine aortic valves were decellularized with Triton X-100 and trypsin, then divided into A and B group, eight in each group. Group A: the donor goat's autologous bone marrow mesenchymal stem cells (BMSCs) Selected as the seeding-cells were encapsulated into the modified PEG-hydrogels to complete the process of the cells attaching to the acellular porcine aortic valves. Non-PEG but reservation of BMSCs was modified in Group B. After static culture for 7 d, the mono semilunar tissue engineering heart valve (TEHV) were implanted respectively into each donor goat's abdominal aortas. Gross and histology examination, ultrasonic scanning, electron microscopy observation and biomechanics detection were performed at 16 weeks after operation. The 8 native goat aortic valves from the donor goats were selected at the same time as control group (Group C).</p><p><b>RESULTS</b>There were much more improvements compared Group A to Group B (P < 0.05) in tensile strength [(12.9 +/- 1.3) MPa vs. (8.8 +/- 0.4) MPa], ratio of re-endothelial (84.6% vs. 14.8%) and mural thrombosis (0/8 vs. 8/8). The data illustrated the critical importance of BMSCs differentiation to endothelial and myofibroblast for remodeling into native tissue in microenvironment in vivo.</p><p><b>CONCLUSIONS</b>It is feasible to reconstruct TEHV efficiently by combining modified PEG-hydrogels with acellular biomaterial scaffold and autologous MSCs cells. It can improve the integration of the seeding-cells and scaffold. It can also protect the growth and differentiation of the BMSCs in the systemic circulation effectively.</p>

Reoperation about recurrent heart valve disease in 221 cases / 中华外科杂志

<p><b>OBJECTIVE</b>To retrospectively review the experience of reoperation after closed mitral commissurotomy, valvuloplasty, perivalvular leakage and dysfunction of bioprosthetic valve in 221 cases.</p><p><b>METHODS</b>Two hundred and twenty-one patients underwent heart valve reoperation from January 1998 to August 2005. Among them, 8 cases was emergency operation. The reasons of reoperation included 105 cases suffered from mitral valve restenosis after closed mitral commisurotomy, 37 cases suffered from valve lesion after mitral or aortic valvuloplasty, 29 cases suffered from perivalvular leakage after valve replacement. Eighteen cases suffered from bioprosthetic valve decline, 9 cases suffered from dysfunction of machine valve, 7 cases suffered from tricuspid insufficiency of Ebstein, 5 cases suffered from prosthetic valve endocarditis and 11 cases suffered from other valve disease. The re-operations were mitral valve replacement, mitral and aortic valve replacement, aortic valve replacement and tricuspid valve replacement. The interval from first operation to next operation was 1 - 21 years.</p><p><b>RESULTS</b>The early-stage postoperative mortality was 8.6% (19/221). And the reasons were low cardiac output syndrome, arrhythmia, multiple organ dysfunction failure (MODF) and renal failure. Among these the emergency operative mortality was 3/8. And the mortality was 14.5% (9/62) in class IV of cardiac function (NYHA).</p><p><b>CONCLUSIONS</b>The risk factors of reoperation about heart valve disease include emergency operation, low preoperative cardiac function, MODF, long time of cardiopulmonary bypass and aortic blocking. Therefore it is emphasized that mastering and treating the risk factors promptly, which could decrease the mortality and incidence of complication.</p>

Fontan operation with extracardiac conduit on beating hearts / 中华外科杂志

<p><b>OBJECTIVE</b>To evaluate the results of Fontan operation with extracardiac conduit on beating hearts.</p><p><b>METHODS</b>Forty-two patients (31 males and 11 females) age ranged from 3 to 19 years old included in this study. There were 19 double inlet-ventricle, 10 tricuspid atresia, and 3 patients with mitral atresia, 10 patients with other complex congenital cardiac malformations. Fontan operations with extracardiac conduit were performed in all patients with the help of cardiopulmonary bypass without hypothermia in this study. Atrial septal fenestration was performed in 8 patients. In one patient, bi-directional cardiopulmonary procedure was performed 2 years before Fontan operation.</p><p><b>RESULTS</b>There was one early death caused by acute hepatic function failure and one late death caused by repeated lung infections. The follow-up of 1 to 4.5 years showed that all patients' cardiac functions were grade I to II, and arterial oxygen saturation was 92% - 96%.</p><p><b>CONCLUSIONS</b>The early and mid-term outcome of Fontan operation with extracardiac conduit on beating hearts is good and the method can be used in the single ventricle repair.</p>