The anatomy features and surgical significance of the pulmonary circuits of pulmonary atresia with ventricular septal defect and major aortopulmonary collateral arteries / 中华外科杂志

<p><b>OBJECTIVES</b>To analyze the anatomy features of the pulmonary circuits in the patients with pulmonary atresia (PA) with ventricular septal defect (VSD) and major aortopulmonary collateral arteries (MAPCA), and discuss the clinical significance.</p><p><b>METHODS</b>From April 2002 to June 2010, the anatomy features of pulmonary circuits in 33 patients with PA/VSD/MAPCA were examined and analyzed. There were 21 male and 12 female patients. The age ranged from 11 months to 29 years. The anatomic types of PA/VSD included group B for 22 cases, group C for 11 cases. Thirty-one patients of them underwent 33 operative procedures. The operations included aorta-pulmonary shunt in 8 cases, one stage unifocalization with VSD open in 2 cases, complete repair in 23 cases.</p><p><b>RESULTS</b>Twenty-nine (87.9%) patients had native pulmonary arteries, 6 of them were normal size and 23 were hypoplastic size. Four patients (12.1%) had no native pulmonary arteries. The postoperative oxygen saturation of the patients undergone shunt and one stage unifocalization was increased to 83% to 90%. There was one early death after complete repair because of multiorgan function failure. There were 4 cases of severe low cardiac output and 3 cases of respiratory function failure. Sixteen patients after complete repair were followed up more than one year. The postoperative right ventricular pressure was 41 to 99 mmHg (1 mmHg = 0.133 kPa). The ejection fraction value was more than 50% in 14 patients and less than 50% in 2 patients. Two patients had medium pulmonary insufficiency.</p><p><b>CONCLUSIONS</b>An individualized approach based on the anatomy of the pulmonary circuits permits achievement in the patients with PA/VSD/MAPCA. The surgical strategy for PA/VSD/MAPCA mainly depends on the anatomy features of native pulmonary arteries, confluent pulmonary arteries and MAPCA.</p>

Diabetes counteracts the protective effect of the diazoxide preconditioning on ischemic reperfused rat heart / 中华外科杂志

<p><b>OBJECTIVE</b>To explore the impact of diabetic condition on the protective effect of diazoxide preconditioning (DPC) on ischemic-reperfused (I/R) myocardium in rats.</p><p><b>METHODS</b>Thirty normal male Sprague-Dawley rats were divided into 3 groups, including non-diabetic control group, non-diabetic I/R group, and non-diabetic I/R DPC group. Thirty diabetic male rats were also divided into the same 3 groups. The Langendorff isolated heart perfusion models were established. The control groups had a 90 min perfusion without any intervention. The I/R groups had a 30 min equilibration period, a 30 min ischemia, and a 30 min reperfusion. The I/R DPC groups had a 10 min equilibration, two cycles of 100 micromol/L diazoxide perfusion, 5 min each, followed by a 5 min diazoxide-free period before the 30 min ischemia and a 30 min reperfusion. The recovery rate of the left ventricular function, including cardiac output, left ventricular developed pressure (LVDP), and the maximum change rate of left ventricular pressure rise and fall (+/- dp/dt(max)) were recorded. The activity of creatine kinase in coronary outflow and activities of malonyldialdehyde, and superoxide dismutase in myocardium were detected. Myocardial water content was also assessed.</p><p><b>RESULTS</b>In non-diabetic rats, the content of creatine kinase, malonyldialdehyde and water content were significantly decreased in I/R DPC group compared with those in I/R group. Furthermore, in I/R DPC group, the activity of superoxide dismutase and the recovery rate of the left ventricular function, including cardiac output, LVDP and +/- dp/dt(max), were significantly increased compared with those in I/R group (P < 0.05). By contrast, there were no significant changes between I/R DPC group and I/R group in diabetic rats (P > 0.05).</p><p><b>CONCLUSION</b>Diabetes counteracts the protective effect of the diazoxide preconditioning on ischemic reperfused rat heart, which may be related with acute insulin resistance in cardiomyocytes.</p>

Role of nitric oxide during early phase myocardial ischemic preconditioning in rats / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>To date, there have been no reports on altered nitric oxide (NO) content in ischemia/reperfusion with regard to in vivo preconditioning procedures. These studies are important for understanding the mechanisms of NO during early myocardial ischemic preconditioning. The aim of the present study was to investigate the mechanisms of NO during early myocardial ischemic preconditioning by measuring levels of NO and cyclic guanosine monophosphate (cGMP), as well as activity of nitric oxide synthase (NOS) in ischemia/reperfusion with respect to preconditioning in rats.</p><p><b>METHODS</b>Sixty-six female Sprague-Dawley rats were randomly divided into four groups: ischemic preconditioning group (IP), ischemia/reperfusion group (I/R), control group (CON), and preconditioning procedure group (PC). In the PC group, rats were further divided into PC1-, PC1 +, PC2-, PC2 +, PC3-, and PC3 + subgroups. Rats underwent left coronary artery occlusion and reperfusion, and subsequently, NOS activity and levels were assessed with spectrophotometric analysis. cGMP contents were measured with radioimmunoassay.</p><p><b>RESULTS</b>The level of NO and cGMP, as well as the activity of NOS, were significantly higher in the IP group compared to the I/R and CON groups (P < 0.05). During preconditioning prior to prolonged ischemia, NO and cGMP levels varied markedly with ischemia and reperfusion. The levels of NO repeatedly increased when the heart was exposed to three episodes of 5-minute ischemia, and were almost completely reversed during each reperfusion period. NO and cGMP levels were significantly different between the 5-minute period of ischemia and the same period of reperfusion during preconditioning.</p><p><b>CONCLUSIONS</b>NO plays an important role during early phase myocardial ischemic preconditioning in rats. NO and cGMP could be triggers and mediators of early phase myocardial ischemic preconditioning. Altered NOS activity following ischemic stress could be the primary inducer of higher NO levels detected. NO and cGMP fluctuations might be the trigger for protection during early phase myocardial ischemic preconditioning.</p>

Clinical analysis of surgical procedures and outcomes for corrected transposition of great arteries with heart anomaly / 中华外科杂志

<p><b>OBJECTIVE</b>To determine the outcome of anatomically corrective repair and traditional repair of corrected transposition of great arteries (c-TGA) with heart anomaly.</p><p><b>METHODS</b>From April 2002 to December 2006, nineteen patients including fourteen male and five female with c-TGA, underwent operations, age ranged from 2 to 22 years old and weight ranged from 10 to 48 kg. Fifteen of them received anatomically corrective repair and the other four received traditional repair. Eighteen patients were referred to SLL (segmental anatomy) in situs solitus while fifteen of them with levocardia and three with dextrocardia. One patient was referred to IDD (segmental anatomy) in situs inversus with levocardia. Associated cardiac lesions included ventricular defect in eighteen patients, double outlet of right ventricle in one patient, pulmonary stenosis in seventeen patients and pulmonary hypertension in two patients. The operative procedures to anatomically correct atrioventricular discordance included an atrial switch plus a ventricle-arterial switch. The atrial switch was performed using the modified Senning procedure (n=13), Senning procedure (n=1) and Mustard procedure (n=1). The ventricle-arterial switch was performed using a Rastelli procedure (n=13) or an arterial switch (n=2). The patients underwent Mustard and Rastelli procedure had received bi-direct Gleen shunt due to postoperative high pressure of superior vena cava. Three patients underwent traditional cardiac repair because of small ventricular septal defect and one patient was reoperated to undergo traditional cardiac repair because of left ventricular failure after received anatomically corrective repair.</p><p><b>RESULTS</b>In the patients received anatomically corrective repair, there was one early operative death received a modified Senning atrial switch and an arterial switch. The cause of death was acute myocardial failure due to imperfect coronary transfer. The postoperative complications included severe low cardiac output syndrome (n=1), temporary atrioventricular block (n=1) and thorax cavity fluidify (n=1). The survivors were followed up for 6 months to 4 years. All were sinus cardiac rhythm and in NYHA class I or II. There was no death in the patients received traditional repair. Four patients were followed up for 1 year. Three patients were in NYHA I or II class and one patient in class II.</p><p><b>CONCLUSIONS</b>Anatomically corrective repair of c-TGA can be performed with good operative survival and intermediate-term outcome. The patients with good right ventricular function and well developed tricuspid valve who were difficult to undergo anatomically corrective repair might be fit to receive traditional repair.</p>

Study of cardiopulmonary adaptation during exercise in patients after extracardiac conduit total cavopulmonary connection / 中华外科杂志

<p><b>OBJECTIVE</b>To study cardiopulmonary physiology during exercise in patients after extracardiac total cavopulmonary connection (ECTCPC).</p><p><b>METHODS</b>Twenty-six patients were studied after ECTCPC by exercise testing with bicycle treadmill protocol. Heart rate (HR), blood pressure (BP), respiratory frequency (RF) and pulse oxygen saturation (SpO(2)) were measured continuously; twenty-six patients suffered from Fallot 4 underwent biventricular repair were also studied as control group.</p><p><b>RESULTS</b>In ECTCPC group, HR, BP, SpO(2) and RF all increased with exercise below 3 grade; when exceed 4 grade, BP, SpO(2) decreased and RF kept increasing. Compared with control group, HR, RF were higher (t = 2.13, P < 0.05; t = 2.31, P < 0.05), SpO(2) was lower (t = 2.46, P < 0.05) under the quiescent condition; When exceed 3 grade, HR, BP, SpO(2) decreased more significantly, but RF increased continuously. In fenestration group after ECTCPC, HR reached the top at 5 grades, but in group without fenestration it reached the top at 3 grades; In the whole process of exercising, RF kept higher and SpO(2) kept lower in fenestration group.</p><p><b>CONCLUSIONS</b>The ECTCPC patients showed obviously exercise limitation. Totally bypass of sinoatrial node in this operation may have some adverse effects on the integer regulation of HR.</p>

Clinical analysis on surgical treatment of single atrium / 中华外科杂志

<p><b>OBJECTIVE</b>To summarize the experience of surgical treatment of single atrium.</p><p><b>METHODS</b>From August 1984 to August 2004, there were 33 patients with single atrium in our study. Plastic surgery for mitral valves were performed for 30 cases with mitral insufficiency. Plastic surgery for tricuspid valves were performed for 18 cases with tricuspid valve insufficiency. There were 3 cases only with complete absence of atrial septum. There were 14 cases with left superior vena cava. All new atrial septums were made with patches including 24 autologous pericardial patches and 9 terylene patches. Complicate abnormalities were corrected in the same time. Tow suture techniques were used in operations to prevent conductive system block, and plastic surgery for mitral valves were performed until the mitral valves were sufficiency.</p><p><b>RESULTS</b>There weren't death and conductive system block after operation in the group. One case was low-grade mitral insufficiency and the others weren't mitral insufficiency. Twenty-five cases were followed up from 3 months to 11 years, and they could work and study normally.</p><p><b>CONCLUSIONS</b>Single atrium should be operated as early as possible. The key of surgery is to prevent conductive system block, to properly correct mitral insufficiency and to drastically correct complicated abnormality. The new atrial septum should be made by patch and an autologous pericardial patch is the first selection.</p>

Surgical treatments and results of pulmonary atresia with ventricular septal defect / 中华外科杂志

<p><b>OBJECTIVE</b>To evaluate the indication and operative program of ventricular septal defect with pulmonary atresia (VSD-PA).</p><p><b>METHODS</b>From June 1984 to March 2005, there were 32 patients with VSD-PA, which underwent 33 operations. Among them, 15 were males and 17 were females. The ages ranged from 6 months to 9 years. There were 9 patients with aortopulmonary collateral arteries. The operations included central aorta-pulmonary shunts 3 cases, one stage complete repair 27 cases and one stage unifocalization with VSD open 2 cases.</p><p><b>RESULTS</b>There were early 5 death including one death after aorta-pulmonary shunt and 4 deaths after one stage complete repair. The causes of death were severe low cardiac output (2 patients), respiratory function failure (1 patient), multiorgan function failure (1 patient) and severe infect (1 patient). Twenty-one patients were followed up from 3 months to 15.5 years. Heart function (NYHA) was class I or II in 19 cases and class III or IV in 2 cases.</p><p><b>CONCLUSIONS</b>The operative indication and methods mainly depend on the developing of pulmonary arteries and aortopulmonary collateral arteries. Completely surgical repair of patients with VSD-PA can be achieved with acceptable mortality.</p>

The effects of inhaled nitric oxide on pulmonary vascular resistance in patients after total cavopulmonary connection / 中华外科杂志

<p><b>OBJECTIVE</b>To study the effects of inhaled nitric oxide (NO) on pulmonary vascular resistance in patients after total cavopulmonary connection (TCPC).</p><p><b>METHODS</b>Fifty-two patients after TCPC were evaluated, of them 24 patients were administered with inhaled nitric oxide in the early postoperative period. The cardiac index (CI) and pulmonary vascular resistance (PVR) were compared before and after inhaled NO.</p><p><b>RESULTS</b>In experimental group, after inhaled NO, partial pressure of oxygen in artery/fraction of inspired oxygen increased from 161 +/- 17 to 193 +/- 23 (t = 2.75, P < 0.01); CI from (2.86 +/- 0.24) L.min(-1).m(-2) to (3.13 +/- 0.22) L.min(-1).m(-2) (t = 2.25, P < 0.05); PVR decreased from (4.2 +/- 0.5) U/m(2) to (3.8 +/- 1.4) U/m(2) (t = 2.29, P < 0.05); central venous pressure (CVP) from (17.0 +/- 1.8) mm Hg to (15.0 +/- 1.1) mm Hg, decreased 11.7%. Compared with the control group, respirator time decreased from (86 +/- 27) h to (54 +/- 18) h (t = 2.29, P < 0.05); ICU time from (6 +/- 2) d to (4 +/- 2) d (t = 2.32, P < 0.05); But hydrothorax drainage and length of stay had no significant difference.</p><p><b>CONCLUSIONS</b>Though inhaled NO, there is no significant long-term effects in patients after TCPC, but it may play an important role in the management of low cardiac output syndrome and high cava pressure caused by reactive elevated pulmonary vascular resistance in the early postoperative period of TCPC.</p>

The treatments and results of tetralogy of Fallot with major aortopulmonary collateral arteries / 中华外科杂志

<p><b>OBJECTIVE</b>To evaluate the indication and operative program of complete repair of tetralogy of Fallot with major aortopulmonary collateral arteries (TOF-MAPCA).</p><p><b>METHODS</b>From January 2000 to May 2004, 9 patients with TOF-MAPCA including 5 patients with pulmonary atresia underwent complete surgical repair, 6 of them were male and 3 were female. The ages ranged from 3 to 9 years. All patients underwent corrected operations with moderate hypothermia and cardiopulmonary bypass. Transcatheter occlusion of MAPCA was performed in 5 patients just before corrected operation. Ligation of MAPCA was performed in 1 patient in the same time of cardiac corrected operation. Midline one-stage complete unifocalization and repair were performed in 3 patients with pulmonary atresia.</p><p><b>RESULTS</b>There was one early death. The cause of death was spinal cord hemorrhage. There was no death then. Eight patients were followed up from 3 month to 4 years. Heart function (NYHA) was class I or II in 7 patients and III in 1 patient.</p><p><b>CONCLUSIONS</b>Completely surgical repair of patients with TOF-MAPCA should be performed as early as possible, which can achieve with satisfactory results by transcatheter occlusion of MAPCA or one-stage unifocalization.</p>

Electrophysiologic study of f-wave amplitude in chronic atrial fibrillation associated with rheumatic heart disease / 第二军医大学学报

To investigate the electrophysiologic characteristics of f-wave amplitude and to evaluate its role in development and persistence of chronic atrial fibrillation (AF) associated with rheumatic heart disease (RHD). Methods: Epicardial mapping was performed in 44 patients with chronic AF of RHD who underwent heart valve surgery. Ten patients with supraventricular tachycardia served as the control group. Results:The f-wave amplitude of left atrium (LA) and middle and low LA posterior regions were significantly lower than those of the control group. The f-wave amplitudes of the upper, middle and low sections in LA posterior region were significantly lower than those in right atrium (RA) (P<0.05). The f-wave amplitudes were compared before and after electrocardioversion in 14 patients with chronic AF. The mean atrial electrogram amplitude during sinus rhythm was significantly higher than that during AF (P<0.01).The f-wave amplitude in left appendage was higher than that in LA posterior region (the upper,middle and the lower part),P<0.05.The f-wave amplitude in the upper section of LA was significantly higher than that in the middle section. The f-wave amplitude in AF group was not correlated to the diameter or volume of both atria. Conclusion: There are amplitudes differences between the upper, middle and lower LA,suggesting that the middle and lower sections of LA posterior wall may be the region producing anisotropy and reentrant circle.

Electrophysiologic study of f-wave amplitude in chronic atrial fibrillation associated with rheumatic heart disease / 第二军医大学学报

To investigate the electrophysiologic characteristics of f-wave amplitude and to evaluate its role in development and persistence of chronic atrial fibrillation (AF) associated with rheumatic heart disease (RHD). Methods: Epicardial mapping was performed in 44 patients with chronic AF of RHD who underwent heart valve surgery. Ten patients with supraventricular tachycardia served as the control group. Results:The f-wave amplitude of left atrium (LA) and middle and low LA posterior regions were significantly lower than those of the control group. The f-wave amplitudes of the upper, middle and low sections in LA posterior region were significantly lower than those in right atrium (RA) (P<0.05). The f-wave amplitudes were compared before and after electrocardioversion in 14 patients with chronic AF. The mean atrial electrogram amplitude during sinus rhythm was significantly higher than that during AF (P<0.01).The f-wave amplitude in left appendage was higher than that in LA posterior region (the upper,middle and the lower part),P<0.05.The f-wave amplitude in the upper section of LA was significantly higher than that in the middle section. The f-wave amplitude in AF group was not correlated to the diameter or volume of both atria. Conclusion: There are amplitudes differences between the upper, middle and lower LA,suggesting that the middle and lower sections of LA posterior wall may be the region producing anisotropy and reentrant circle.

Surgical treatment of secundum atrial septal defects in adults over 30 years old / 中华外科杂志

<p><b>OBJECTIVE</b>To summarize the experience of surgical treatment of secundum atrial septal defects in adults over 30 years old.</p><p><b>METHODS</b>There were 469 patients with secundum atrial septal defects in our study (male 144, female 325; ages 30-68, mean 38.6 years old). There were 105 cases with pulmonary hypertension and 458 cases with arrhythmia in the group. Surgical closure of defects were performed in all patients. Surgical closure of 358 cases were done by patches including 305 autologous pericardial patches. The low dose (6 x 10(-6)) nitric oxide inhalation was used in 25 postoperative patients with pulmonary hypertension. Right sided maze procedures were done in 5 cases with atrial fibrillation.</p><p><b>RESULTS</b>Surgical mortality was 0.6% (3 cases), the others were healed. In the group, there were 180 cases with arrhythmia, 27 cases with left ventricular function amyoplasia, 28 cases with low cardiac output syndrome, 12 cases in secondary operation for bleeding and 1 case with air-embolism. The level of mean pulmonary artery pressure of 25 postoperative patients with pulmonary hypertension inhaled nitric oxide was down 28.5%. After right sided maze procedures were done in 5 cases with atrial fibrillation, atrial fibrillation disappeared. 352 cases were followed up from 3 months to 20 years (mean 5.6 years). Twenty-nine cases were in class I-II of cardiac function, and the others were better than class I of cardiac function.</p><p><b>CONCLUSIONS</b>Atrial septal defects in adult should be operated as early as possible. When patch is needed, an autologous pericardial patch is the first selection. Inhaled nitric oxide is an effective method to postoperative pulmonary hypertension. The maze operation should be performed for atrial septal defect with atrial fibrillation while the surgical closure of defect was done. During and after operation, much attention should be paid to preventing and curing arrhythmia and protecting and supporting left heart function.</p>

Surgical treatment on residual shunt after repair of ventricular septal defect / 中华外科杂志

<p><b>OBJECTIVE</b>To summarize the experience in surgical treatment of residual shunt after repair of ventricular septal defect and investigate the position of the residual shunts.</p><p><b>METHODS</b>Between January 1979 and May 2003, re-operations on residual shunt after repair of ventricular septal defect were performed in 37 patients with congenital heart disease including ventricular septal defect, tetralogy of Fallot, double outlet right ventricle in 19, 17 and 1 patients, respectively. It accounted for 0.21% (37/18000) of open heart operations performed during these years. The patients included 26 males and 11 females with age from 3 months to 53 years (mean 16 +/- 12 years). The residual shunt was diagnosed by postoperative murmur and echocardiography. Twenty-six cases were repaired with patch and 11 cases were closed directly with mattresses sutures.</p><p><b>RESULTS</b>Two patients (2/37, 5%) died within 48 hrs postoperatively. The results in other 35 patients followed up after surgery from 3 months to 15 years were satisfactory.</p><p><b>CONCLUSIONS</b>Most of the residual shunts occurred in base of septal leaflet of tricuspid valve, the second and the first transfer suture respectively. Effects of reoperations on residual shunts were satisfactory.</p>