Clinical experience of off-pump arch branches preferential reconstruction and whole brain perfusion in the treatment of type A / 中华胸心血管外科杂志

Objective:To introduce the early results of total aortic arch replacement (TAA) without cardiopulmonary bypass (CPB) and without interruption of cerebral blood supply, using the technique of arch branches preferential reconstruction and whole brain perfusion for brain protection.Methods:Between June 2020 and March 2021, a total of 9 Stanford type A aortic dissection patients we performed total arch replacement by using the technique of arch branches preferential reconstruction and whole brain perfusion without cardiopulmonary bypass and without interruption of blood supply to the brain. The method of this reconstruction technique is as follows: A 24F aortic cannula was inserted into the true lumen at the root of the transverse innominate artery (IA) to connect one end of the artery for cardiopulmonary bypass. The access was connected to 14F artery via Y-connector and inserted into IA cavity to maintain blood supply to brain. Without cardiopulmonary bypass, the 10 mm branch of the four branch artificial blood vessel was anastomosed with the innominate artery IA. The perfusion collateral was connected to the second end of the artery of CPB (single pump and double tubes) to continue to supply blood for IA. The left common carotid artery (LCA) and left subclavian artery (LSCA) were reconstructed by the same method. When IA and LCA were anastomosed, the distal blood supply was not interrupted. After the three branches of the aortic arch were anastomosed, we started to turn the machine, then cooled down and blocked the ascending aorta to further complete the operation of the aortic root and arch. During the period of lower body circulatory arrest, the whole brain was perfused with low flow.Results:No intraoperative death or perioperative complications occurred in all patients, and they were discharged smoothly. The cardiopulmonary bypass time was (192.4±58.1) min, the aortic clamping time was (128.3±52.4) min, the lower body circulatory arrest time was (29.1±1.3) min, and the postoperative awake time was (8.2±3.7) h.Conclusion:Off-pump arch branches preferential reconstruction can provide physiological whole brain perfusion, shorten the cardiopulmonary bypass time and aortic occlusion time, and the operation is safe and effective.

A multicenter retrospective study of renal cell carcinoma with Mayo level Ⅳ inferior vena cava tumor thrombus: comparison of different surgical approaches / 中华泌尿外科杂志

Objective:To explore the clinical efficacy and safety of different surgical procedures of Mayo level Ⅳ inferior vena cava tumor thrombus(IVC-TT).Methods:The clinical and pathological data of 36 patients with Mayo level Ⅳ tumor thrombus were collected in three large clinical centers in China, including 18 cases in PLA General Hospital, 7 cases in Nanfang Hospital, and 11 cases in Renji Hospital. There were 25 males and 11 females.The median age was 56.5 years (53-67 years old). The average body mass index was 24.18±2.55 kg/m 2. The average diameter of renal tumors was 8.24±3.25 cm. The average length of inferior vena cava tumor thrombus was 12.89±2.50 cm. Mayo level Ⅳ tumor thrombus were divided into level Ⅳa and level Ⅳb (301 classification) based on the criterion of whether the proximal end of the thrombus has invaded the right atrium. Among them, level Ⅳa patients underwent robot-assisted inferior vena cava thrombectomy without cardiopulmonary bypass(CPB-free group, 6 cases). Level Ⅳb patients underwent robot-assisted inferior vena cava thrombectomy with cardiopulmonary bypass(CPB group, 12 cases) or cardiopulmonary bypass with deep hypothermic circulatory arrest assisted inferior vena cava thrombectomy(CPB/DHCA group, 18 cases). The baseline data of the three groups of patients were comparable. The perioperative results and long-term survival data after surgery were compared with different surgical methods for grade Ⅳcancer thrombosis. Results:All operations were successfully completed. Compared with the CPB group, the CPB-free group had a shorter first portal blocking time[17.5(15-36)min vs. 36.5(12-102)min, P=0.044], less intraoperative bleeding [2 350(1 000-3 000)ml vs. 3 500 (1 500-12 000)ml, P=0.043] and a lower allogeneic blood transfusion [1 250(500-2 000)ml vs. 2 185(700-5 800)ml, P=0.049]. Compared with the CPB/DHCA group, the CPB-free group had an advantage in reducing intraoperative allogeneic blood transfusion [1 250(500-2 000)ml vs. 2 700(1 200-10 000)ml, P=0.003]. There were no significant differences between groups in terms of duration of surgery and postoperative hospital stay. Among the 36 patients in this group, 23(64%) developed major complications (level Ⅲ or above), including 9 (25%) grade Ⅲ, 12 (33%) grade Ⅳ, and 2 (6%) grade Ⅴ. The CPB-free group had a relatively low complication rate of grade Ⅳ or above [ 17% (1/6) vs.42% (5/12) vs.44% (8/18)]. There were no statistical differences in median progression-free survival (16.4 vs.12.3 vs.18.0 months, P=0.695) and overall survival (30.1 vs.30.2 vs.37.7 months, P=0.674) between the groups. Conclusions:Robot-assisted inferior vena cava thrombectomy without cardiopulmonary bypass has the advantages of short ischemia time of organs, less intraoperative bleeding, and low incidence of major complications, which can be used as a safe and feasible surgical strategy for selected level Ⅳ tumor thrombus.

Robot-assisted supradiaphragmatic inferior vena cava thrombectomy without cardiopulmonary bypass: surgical experience with 4 case reports / 中华泌尿外科杂志

Objective:To explore the feasibility and safty of robot assisted trans-diaphragmatic intropericardial inferior vena cava occlusion and thrombectomy in treatment of Ⅳa grade tumor thrombus without cardiopulmonary bypass and thoracotomy.Methods:The clinical data of 4 patients with renal cell carcinoma and Ⅳa grade tumor thrombus by robot assisted trans-diaphragmatic intropericardial inferior vena cava occlusion and thrombectomy from January 2013 to June 2019 were retrospectively analyzed. The median age was 53.5 (53-70) years. The average body mass index was 23.25 (20.7-26.3) kg/m 2. The tumors were located on the right side in 2 cases. The average maximum diameter of the tumor was 8.1 (3.6-11.2) cm.Preoperative tumor thrombus of all patients was classified as Ⅳa. The average preoperative length of tumor thrombus in vena cava was 12.3 (11.8-18.0) cm. All the operations were performed under multidisciplinary cooperation of urology, hepatobiliary, cardiovascular, ultrasound and anesthesiologist team. Surgical procedure: Robot assisted liver mobilization was used to expose the inferior vena cava. Under the guidance of intraoperative ultrasound, the central tendon and pericardium of diaphragm were dissected until the inferior vena cava and right atrium in the superior pericardium were exposed. The first porta hepatis and inferior vena cava were blocked in turn.The vena cava thrombectomy and inferior vena cava reconstruction were performed. Results:All the operations were completed without conversion. The median operation time was 553.5 (338-642) minutes, and the median time of the first porta hepatis occlusion was 18.1 (14-32)minutes. The median blood loss was 1 900(1 000-2 600)ml. All patients were transferred to ICU after operation. The median length of stay in ICU was 7(4-8) days, and the median time of indwelling drainage tube was 8(4-12) days. The average postoperative hospital stay was 13(11-20) days. There were 1 case of grade Ⅱ and 3 cases of grade Ⅲ complications (Clavien classification). One case had paroxysmal supraventricular tachycardia, one case had lymphatic fistula, one case had pleural effusion with atelectasis, and one case had hepatic and renal insufficiency and lymphatic fistula. The complications were improved after treatment. There was no perioperative death.Conclusions:Robot assisted trans-diaphragmatic intropericardial inferior vena cava occlusion and thrombectomy is an alternative method for the treatment of Ⅳa grade inferior vena cava tumor thrombus. Using this method, Ⅳa grade tumor thrombus can be treated without cardiopulmonary bypass and thoracotomy, with controllable complications and zero perioperative mortality.

Aortic surgery through upper hemisternotomy / 中华胸心血管外科杂志

Objective:To summarize the feasibility and clinical experience of various types of aortic surgery through upper hemisternotomy.Methods:From June 2016 to October 2019, 63 patients underwent various types of aortic operations through upper hemisternotomy in our department. Among them, there were 51 males and 12 females with an average age of(49.7±12.7) years. All kinds of major vascular operations include: 33 cases of aortic dissection procedure; 9 cases of Bentall procedure; 7 cases of wheat procedure; 2 cases of Ross procedure; 2 cases of David procedure; 2 cases of simple ascending aorta replacement procedure; 3 cases of redo thoracic Bentall procedure; 2 cases of redo thoracic wheat operation; 1 case of redo thoracic aortic root leakage repair procedure; 2 cases of redo thoracic ascending aorta procedure, innominate artery, left common carotid artery replacement and removal of intravalvular vegetation procedure; 1 case of Bentall plus pulmonary valve and pulmonary artery replacement procedure. Among them, aortic dissection included 11 cases of ascending and total arch replacement plus descending aortic stent implantation procedure; 2 cases of AVR plus ascending and total arch replacement procedure; 5 cases of ascending and semi-arch replacement procedure; 4 cases of David plus ascending and total arch replacement plus descending aortic stent implantation procedure; 1 case of redo thoracotomy David plus ascending and total arch replacement with descending aortic stent implantation procedure; 1 case of David plus ascending and total arch replacement procedure; 6 case of AVP/AVR/Bentall plus ascending and total arch replacement and descending aortic stent implantation procedure; 2 cases of redo total arch replacement and descending aortic stent implantation procedure and aortic root vascular graft wrapping plus ascending aorta and 1 case of total arch replacement with descending aortic stent implantation procedure.Results:All 63 cases of operation were successfully completed without transforming to middle sternotomy; 1 case with acute renal failure was treated by dialysis, and then complicated with septic shock and intracranial hemorrhage, and died of ineffective rescue; 2 cases were treated by thoracotomy exploration and hemostasis; 9 cases with pericardial effusion needed pericardiocentesis; 2 cases with lower extremity muscle weakness after operation: one treated by drainage of spinal fluid and the muscle strength of the lower extremities was restored, another one complicated with infection, acute renal failure and hypoxemia was treated by anti-infection, continuous CRRT, gamma globulin infusion and rehabilitation exercise, the muscle strength of the lower extremities was eventually restored. Except for one death in hospital, all the other patients were cured and discharged.Conclusion:Well exposure of aortic root, ascending aorta and descending part of arch can be obtained through upper hemisternotomy and various types of aortic proceduer can be done with satisfactory results through this approach.

Upper hemisternotomy versus full sternotomy access approach for Stanford A acute aortic dissection: a propensity score matching analysis / 中华胸心血管外科杂志

Objective:In comparison with full sternotomy, we explore the safety and clinical efficacy of upper hemisternotomy for Stanford A acute aortic dissection.Methods:Retrospective analysis of 78 patients with Stanford type A acute aortic dissection from January 2014 to December 2018(20 patients underwent UHS invasive, 58 patients underwent FS invasive). Based on variables including gender、age、BMI、LVEF、Euro SCORE Ⅱ and type of surgery, two matched cohorts including 18 patients respectively were constructed: group UHS and group FS, the baseline data and perioperative indicators were analyzed.Results:Operative mortality was 3.9%(3 of 78). The patients＇baseline data were nearly balanced between the two groups after matching( P>0.05), only 1 case died of infectious cerebral hemorrhage in the FS group. The UHS group had a shorter cardiopulmonary bypass time than the FS group[(202±41)min vs.(235±39)min, P=0.041]. There was no significant difference in aorta clamping time[(159±38)min vs.(158±59)min, P=0.918] and hypothermic circulatory arrest time[(40±10)min vs.(50±20)min, P=0.081] between the two groups. The bladder temperature in the UHS group was significantly higher than that in the FS group[(24.0±3.1)℃ vs.(28.2±2.3)℃, P=0.001]. Compared with the FS group, the UHS group had less red blood cell transfusion[(4.8±2.8)U vs.(7.2±3.9)U, P=0.038], less postoperative drainage[(855±657)ml vs.(1510±703)ml, P=0.007], shorter ventilation support time(22 h vs. 58 h, P=0.037), shorter intensive care unit retention time[(4.6±2.7) days vs.(7.2±2.8) days, P=0.009], and shorter postoperative hospital stay time[(8.2±3.8) days vs.(18.4±3.8) days, P=0.001], but the incidence of pericardial puncture was higher in the UHS group[7(33%) vs. 1(6%), P=0.041]. 3 cases had postoperative renal insufficiency(requires dialysis), 5 cases(13.9%)had neurological complications, 1 case received re-exploration in the two groups respectively. Conclusion:The upper hemisternotomy approach is safe and feasible for Stanford A acute aortic dissection, with excellent early outcomes.

Comparison of quality of life and long-term outcomes following mitral valve replacement through robotically assisted versus median sternotomy approach / 南方医科大学学报

OBJECTIVE@#To compare the mid- and long-term outcomes of patients receiving mitral valve replacement through robotically assisted and conventional median sternotomy approach.@*METHODS@#The data of 47 patients who underwent da Vinci robotic mitral valve replacement in our hospital between January, 2007 and December, 2015 were collected retrospectively (robotic group). From a total of 286 patients undergoing mitral valve replacement through the median thoracotomy approach between March, 2002 and June, 2014, 47 patients were selected as the median sternotomy group for matching with the robotic group at a 1:1 ratio. The perioperative data and follow-up data of the patients were collected, and the quality of life (QOL) of the patients at 30 days and 6 months was evaluated using the Quality of Life Short Form Survey (SF-12). The time of returning to work postoperatively and the patients' satisfaction with the surgical incision were compared between the two groups.@*RESULTS@#All the patients in both groups completed mitral valve replacement successfully, and no death occurred during the operation. In the robotic group, only one patient experienced postoperative complication (pleural effusion); in median sternotomy group, one patient received a secondary thoracotomy for management of bleeding resulting from excessive postoperative drainage, and one patient died of septic shock after the operation. The volume of postoperative drainage, postoperative monitoring time, ventilation time, and postoperative hospital stay were significantly smaller or shorter in the robotic group than in the thoracotomy group (@*CONCLUSIONS@#Robotically assisted mitral valve replacement is safe and reliable. Compared with the median sternotomy approach, the robotic approach is less invasive and promotes faster postoperative recovery of the patients, who have better satisfaction with the quality of life and wound recovery.

The experience of robot-assisted thrombectomy in treating renal tumor with Mayo level Ⅲ to Ⅳ inferior vena caval thrombus (report of 5 cases) / 中华泌尿外科杂志

Objective To explore the feasibility of robot-assisted laparoscopic inferior vena cava (IVC) thrombectomy in treating renal tumor with Mayo level Ⅲ-Ⅳ inferior vena cava thrombus.Methods From November 2014 to January 2017,5 cases of renal tumor with Mayo level Ⅲ-Ⅳ inferior vena cava tumor thrombus were treated with robot-assisted surgery.There were 4 males and 1 female with the median age of 59 years (range 54-71 years).Four cases had the renal tumor on the right side and one on the left side.The mean tumor size was 6.8 cm (range 5-9 cm) with 3 cases of T3b and 2 cases of T3c.There were 4 cases of level Ⅲ and 1 case of level Ⅳ inferior vena cava thrombus with the median length of 9 cm (range 7-11 cm).The surgical procedure for Mayo level Ⅲ inferior vena cava thrombus included mobilization of both left and right robes of liver,subsequently controlling the suprahepatic infradiaphramatic IVC and first porta hepatis simultaneously.The surgical procedure for Mayo level Ⅳ inferior vena cava thrombus included cardiopulmonary bypass by multi-disciplinary cooperation among urologists,hepatobiliary and cardiovascular surgeons.The procedures included live mobilization,control of the superior vena cava and first porta hepatis and remove thrombus in the atrium and IVC respectively.Results All operations were completed successfully.The median operative time was 440 min (320-630 min).The blood recovery device was used and the intraoperative estimated blood loss was 2 500 ml (500-6 000 ml) and all cases required intraoperative blood transfusion.The median time of intraoperative occlusion of IVC was 35 min (25-50 min).All patients were transferred to the intensive care unit for median of 4 days (2-8 days) after surgery.The median time to remove the postoperative drainage tube was 9 days (7-12 days).Postoperative pathological diagnosis revealed 5 cases of clear cell carcinoma.Postoperative renal dysfunction occurred in 3 patients and liver dysfunction occurred in 2 patients who improved after medical therapy.During median 19.6 months (12-48 months) of follow-up,1 patient died and 1 patient progressed.Conclusions Despite the high risk of surgery,robot-assisted laparoscopic IVC thrombectomy for renal tumor with Mayo level Ⅲ-Ⅳ thrombus is feasible for experienced surgeons in selected patients.However,the oncological outcomes need further investigation.

Robotic mitral valve replacement: A single center, medium-long term follow-up of 43 cases / 解放军医学杂志

Objective To summarize the surgical experience gained from robotic mitral valve replacement (MVR), and demonstrate the long-term clinical follow-up results. Methods From Jan. 2007 to Jan. 2015, more than 700 patients underwent various types of robotic cardiac surgery in the Department the authors served in, and of them 43 patients underwent robotic MVR with da Vinci Surgical System (Intuitive Surgical, USA). Among the 43 patients, the average age was 47±11 years (ranged 19-65 years), and sex ratio (female to male) was 0.8:1. Six patients were with heart function of NYHA class Ⅰ, 30 patients were of NYHA class Ⅱ and 7 patients were of NYHA class Ⅲ. The left ventricular ejection fraction (LVEF) were 54%-78% (64.0%±7.1%), and 20 patients had atrial fibrillation on admission, and 35 patients were with rheumatic mitral stenosis (MS). Atrial septal defect (0.7cm in size) co-existed in 1 case and 1 patient had mild aortic regurgitation. Mechanical or bioprosthetic mitral valve was replaced via left atriotomy by using da Vinci robotic surgical system after cardiopulmonary bypass (CPB) set-up. Radiopaque titan clips was employed by Cor-Knot knot-tying device (LSI Solutions, Inc, Victor, NY) to anchor the prosthetic valve. Trans-esophageal echocardiography (TEE) was performed before and after surgery. The operative data were collected and patients were followed up at outpatient clinic regularly up to 6 years. Results All cases were performed successfully with the same surgery. No conversion to median sternotomy or operative mortality occurred. The average operation time was 292±62 minutes (ranged 140-450 minutes) with CPB time of 124±26 minutes and aortic occlusion time of 88±21 minutes. The postoperative mechanical ventilation support time was continued for 15±6 hours, and the average staying length in critical care unit was 4±1 days. No myocardial infarction, ventricular tachycardia or excessive bleeding was complicated. All patients were successfully followed up for a median of 3.5 years (ranged 1 month to 6 years). In the follow-up period, no incidence of death, stroke, re-operation due to prosthetic endocarditis or prosthetic failure was reported. However, 39.5% (n=17) patients still had atrial fibrillation after surgery. Conclusion Robotic MVR is a safe and effective procedure with excellent long term surgical outcome.

Short-term follow-up results of hybrid coronary revascularization by robotic coronary artery bypass grafting and stent implantation / 南方医科大学学报

<p><b>OBJECTIVE</b>To assess the short-term outcomes of staged hybrid coronary revascularization performed using robotic-assisted off-pump coronary bypass grafting followed by percutaneous coronary intervention (PCI) in a non-left anterior descending (LAD) coronary artery lesion.</p><p><b>METHODS</b>From January, 2007 to May, 2013, 35 patients (32 male and 3 female patients, mean age 56.7 ± 9.6 years) underwent staged hybrid coronary revascularization. Ten patients had double-vessel and 25 patients had triple-vessel coronary diseases, and the lesions involved an average of 2.7 ± 0.5 coronary vessels. Coronary artery bypass grafting was completed in robotic-assisted left internal thoracic artery (ITA) harvesting and LITA to LAD bypass. Coronary angiography or 64-MSCT was performed to evaluate the patency of the ITA and stents at 6 months and at 1 to 5 years postoperatively. The patients were followed for major adverse cardiac events (MACE) including cardiac death, acute myocardial infarction and target lesion revascularization.</p><p><b>RESULTS</b>Staged hybrid revascularization was completed successfully in all the patients without complications. The LITA to LAD anastomosis was completed in minimally invasive direct coronary bypass grafting (MIDCAB) or totally robotic coronary bypass grafting on beating heart (TECAB) with the assistance of da Vinci Surgical System. The mean artery graft flow was 36.0 ± 22.5 ml/min, and the graft had a 100% patency before discharge. A total of 49 stents were deployed in 35 patients within 2 weeks after robotic coronary bypass grafting, with a mean of 1.34 ± 0.6 stents per case (1 stent in 23 cases, 2 stents in 11 cases, and 3 stents in 1 case). The patients were followed up for 17.5 ± 11.6 months, and 1 patient had artery graft occlusion and another had in-stent occlusion at 6 months. All the other 33 patients had patent LITA-to-LAD anastomosis without angina or MACE.</p><p><b>CONCLUSION</b>Staged hybrid revascularization strategy has acceptable angiographic patency results for both LITA-LAD grafts and PCI interventions.</p>

The effect of surgical revascularization on different timing after ST-elevation myocardial infarction on patients with ischemic heart disease and left ventricular dysfunction / 中华外科杂志

<p><b>OBJECTIVE</b>To analysis the influence of surgical revascularization on different timing after ST-elevation myocardial infarction (STEMI) on patients with coronary artery disease and left ventricular dysfunction.</p><p><b>METHODS</b>Clinical data of 225 patients admitted from January 2003 to July 2012 with history of STEMI and left ventricular dysfunction (ejection faraction<50%) who underwent isolated coronary artery bypass grafting was retrospectively reviewed. There were 186 male and 39 female patients. According to the timing of surgical revascularization after STEMI, the patients were divided into early revascularization group (ER group, <21 days), mid-term revascularization group (MR group, 21 to 90 days) and late revascularization group (LR group, >90 days). There were 20 male and 9 female patients in ER group with mean age of (63 ± 10) years, 48 male and 16 female in MR group with mean age of (63 ± 8) years, 118 male and 14 female in LR group with mean age of (62 ± 10) years, respectively. Thirty-day post-operative mortality and major complications were determined as the endpoints to evaluate the early results of operation.</p><p><b>RESULTS</b>The 30-day post-operative mortality were 3.4%,0 and 2.3% among three groups respectively and there was no statistic difference between groups (χ(2) = 2.137, P = 0.330).Low cardiac output syndrome mortality were 13.8%, 3.1% and 2.3% among three groups respectively and there was statistic difference between groups (χ(2) = 8.344, P = 0.015). The ejection fractions was significantly improved in all the three groups from 42% ± 6%, 41% ± 6% and 42% ± 6% preoperatively to 46% ± 7%, 45% ± 10% and 45% ± 9% postoperatively (t = -3.378 to -2.339, all P < 0.05). The left ventricular end diastolic dimension were significantly reduced in MR group and LR group from (54 ± 6) mm and (55 ± 6) mm preoperatively to (47 ± 8) mm and (49 ± 9) mm postoperatively (t = 5.634, 5.885; P = 0.000). There was no significant change in ER group pre- and postoperatively ((51 ± 6) mm vs.(49 ± 7) mm, t = 1.524, P = 0.133).</p><p><b>CONCLUSIONS</b>The patients with coronary artery disease and left ventricular dysfunction can benefit from surgical revascularization on different timing after STEMI, presenting as the reverse of left ventricle remodeling and the improvement of left ventricle function. The short-term results are mainly determined by the patients' condition, surgical technique and the level of perioperative management.It is recommended for this patient cohort to accept surgical revascularization three weeks after STEMI.</p>

Emergency coronary artery bypass grafting for acute coronary syndrome: mid-term follow-up results / 南方医科大学学报

<p><b>OBJECTIVE</b>To summarize the experience with emergency coronary artery bypass grafting (ECABG) for management of acute coronary syndrome and analyze the mid-term follow-up results.</p><p><b>METHODS</b>Forty-five ECABG surgeries were performed in 34 male and 11 female patients (aged 65.6∓5.8 years) for cardiogenic shock (5 cases), acute heart failure (6 cases) and refractory unstable angina (34 cases). Twenty patients received the operation within one week after acute myocardial infarction (AMI) and 18 were preoperatively supported by intra-aortic balloon pumping (IABP). All patients had triple-vessel disease and 15 had left main stenosis. Ten patients experienced two myocardial infarctions and 6 had chronic renal dysfunction including two requiring hemodialysis. On-pump operations were performed in all cases with a mean CPB time of 104.2∓29.7 min and cross clamping time of 69.0∓21.3 min. Cold blood or HTK cardioplegia was used for myocardial protection. The left internal mammary artery (LIMA) was routinely anastomosed to the left anterior descending artery (LAD), and the great saphenous vein (GSV) to other target vessels. The mean number of grafts was 2.9∓0.6.</p><p><b>RESULTS</b>Forty-one patients were cured and discharged and 4 patients died with an in-hospital mortality of 8.9%, including one associated with cardiac event (2.2%). IABP was weaned off within 28.5∓10.6 h after surgery except for one patient who died of multiple organ and system failure (MOSF). Thirty-eight patients (92.7%) were followed up for a mean of 37.3∓16.7 months, during which 2 patients died with a mid-term survival rate of 94.7%. Thirty-five (92.1%) patients had New York Heart Association (NYHA) class I and II. The freedom from cardiac event was 90.5%. Follow-up echocardiography showed significantly improved left ventricular dimension and ejection fraction in these cases (P<0.05), and graft patency was 95.8% for the LIMA and 90.5% for the GSV.</p><p><b>CONCLUSION</b>Despite a slight increase of the in-hospital mortality, ECABG can improve the mid-term survival, freedom from cardiac event, and cardiac function when the indications and timing for surgery are well controlled with optimal perioperative management.</p>

Changes of circulating hematopoietic progenitor cells in patients undergoing coronary artery bypass graft surgery / 南方医科大学学报

<p><b>OBJECTIVE</b>To evaluate the changes of circulating hematopoietic progenitor cells (cHPCs) in patients undergoing coronary artery bypass graft (CABG) surgery.</p><p><b>METHODS</b>Fifty-one patients scheduled to undergo elective CABG surgery were prospectively enrolled in this study. Blood samples were collected at baseline and at 1, 3, and 5 days after the surgery. CD34⁺ CD45dim, CD133⁺ CD45dim, and CD34⁺ CD133⁺ CD45dim cells were measured by flow cytometry. The functionality of the circulating progenitor cells were studied in vitro using clonogenic and migration assays.</p><p><b>RESULTS</b>All the elective patients showed a significant postoperative increase of CD34⁺ CD45dim (1.51 ± 1.26 vs 2.02 ± 1.16, P=0.036) and CD133⁺ CD45dim cells (1.16 ± 0.85 vs 1.65 ± 0.99, P=0.008) irrespective of on-pump or off-pump CABG. The perioperative changes of the cHPCs was more significant in patients undergoing on-pump surgery than those having off-pump surgery.</p><p><b>CONCLUSION</b>In patients undergoing elective cardiac surgery, cHPC level increased early after the surgery but recovers the normal level over time.</p>

Establishment of a chronic left ventricular aneurysm model in rabbit / 老年心脏病学杂志（英文版）

Objectives To establish a cost-effective and reproducible procedure for induction of chronic left ventricular aneurysm (LVA) in rabbits. Methods Acute myocardial infarction (AMI) was induced in 35 rabbits via concomitant ligation of the left anterior descending (LAD) coronary artery and the circumflex (Cx) branch at the middle portion. Development of AMI was co n-firmed by ST segment elevation and akinesis of the occluded area. Echocardiography, pathological evaluation, and agar i n-tra-chamber casting were utilized to validate the formation of LVA four weeks after the surgery. Left ventricular end systolic pressure (LVESP) and diastolic pressure (LVEDP) were measured before, immediately after and four weeks after ligation. D i-mensions of the ventricular chamber, thickness of the interventricular septum (IVS) and the left ventricular posterior wall (LVPW) left ventricular end diastolic volume (LVEDV) and systolic volume (LVESV), and ejection fraction (EF) were recorded by echo-cardiography. Results Thirty one (88.6%) rabbits survived myocardial infarction and 26 of them developed aneurysm (83.9%). The mean area of aneurysm was 33.4% ± 2.4% of the left ventricle. LVEF markedly decreased after LVA formation, whereas LVEDV, LVESV and the thickness of IVS as well as the dimension of ventricular chamber from apex to mitral valve annulus significantly increased. LVESP immediately dropped after ligation and recovered to a small extent after LVA formation. LVEDP progressively increased after ligation till LVA formation. Areas in the left ventricle (LV) that underwent fibrosis included the apex, anterior wall and lateral wall but not IVS. Agar intra-chamber cast showed that the bulging of LV wall was prominent in the area of aneurysm. Conclusions Ligation of LAD and Cx at the middle portion could induce develo pment of LVA at a mean area ratio of 33.4%±2.4%which involves the apex, anterior wall and lateral wall of the LV.

Analysis of blood flow in sequential and individual saphenous vein grafts in off-pump coronary artery bypass grafting / 中南大学学报(医学版)

OBJECTIVE@#To compare the blood flow in sequential and individual saphenous vein grafts (SVGs) and to analyze the influence of the location of the target vessel in off-pump coronary artery bypass grafting (OPCAB).@*METHODS@#A total of 464 SVGs in 412 patients receiving OPCAB were nested into individual SVG (n=206), double (n=241) or triple sequential SVG (n=15), and analyzed.@*RESULTS@#The blood flow in double and triple SVGs was significantly higher than in individual SVGs [(43.4±22.5), (43.7±19.2) and (28.9±18.7) mL/min, respectively, P<0.001, P=0.047]. There were no differences between flow in double and triple SVGs (P=0.96). Pulsatility index (PI) of the three groups were similar (2.6±1.2, 2.5±1.6, 2.8±0.9, respectively, P=0.49, P=0.49). In individual SVGs to right coronary artery, the blood flow was higher than in the posterior descending branch (PDA) (P=0.047) and posterior branch of left ventricle (PBLV), the flow-time in systole period was longer than diagonals (P=0.003), obtuse marginal (OM) (P=0.013) and PDA (P=0.002), PI was significantly lower than PDA (P=0.033) and PBLV (P=0.032). The blood flow in individual SVGs to diagonals was significantly lower than in other target vessels except for PBLV (P<0.05). Flow in double SVGs to PDA-PBLV was significantly lower than in PDA-OM.@*CONCLUSION@#The mean blood flow in double and triple sequential SVGs is about 1.5 times higher than in individual SVGs. Individual, double, and triple SVGs have similar pI. Flow in individual SVGs to diagonals was significantly lower than in other target vessels except for PBLV.

Intraoperative transesophageal echocardiography in patients undergoing robotic mitral valve replacement / 中南大学学报(医学版)

OBJECTIVE@#To retrospectively assess the value of intraoperative transesophageal echocardiography (TEE) during robotic mitral valve (MV) replacement.@*METHODS@#Intraoperative TEE was performed in 21 patients undergoing robotic MV replacement for severe rheumatic mitral stenosis between November 2008 and December 2010. During the procedure, TEE was performed to document the mechanism of rheumatic mitral stenosis (leaflet thickening and calcification, commissural fusion or chordal fusion) before cardiopulmonary bypass (CPB). During the establishment of peripheral CPB, TEE was used to guide the placement of the cannulae in the inferior vena cava (IVC), superior vena cava (SVC), and ascending aorta (AAO). After weaning from CPB, TEE was performed to evaluate the effect of the procedure.@*RESULTS@#Accuracy of TEE was 100% for rheumatic mitral stenosis. All the cannuli in the SVC, IVC and AAO were located in the correct position. In all patients, TEE confirmed successful procedure.@*CONCLUSION@#TEE is useful in the assessment of robotic MV replacement.

Good outcomes from cardiac valve surgery in the elderly over 70 years / 中华胸心血管外科杂志

ObjectiveTo evaluate the outcomes for elderly( ＞70 years) patients undergoing valvular heart surgery and determine the early mortality and major morbidity associated with cardiac valve surgery in the elderly.MethodsBetween 2005and 2011,1366 patients underwent cardiac valve surgery in our department.115 patients(65 males,50 females) were 70 or older [aged (74.3 ± 3.1 ) years].Rheumatic valvular disease presented in 68 ( 59.1％ ),degenerative valvular disease in 33(28.7 ％),congenital heart disease in 6 (5.2 ％) and the others in 8 (7.0％).20 cases( 17.4％ ) had hypertention,17 cases( 15.8 ％ ) had diabetes mellitus,18 (15.7％) had coronary heart disease.Chronic obstructive pulmonary disease was found in 25 cases(21.7 ％ ),and renal insufficiency was found in 9(7.8 ％ ).6 patients(5.2％ ) had the history of cerebrovascular disease.72 (62.6 ％) had atral fibrillation and 11 cases(9.6％ ) had the history of cardiac valve surgery previously.75(65.2 ％ ) cases were in New York Heart Association(NYHA) functional class Ⅲ-Ⅳ.Left ventricular ejection fraction (LVEF) was 0.28-0.72 (0.53 ± 0.01 ).All the patients receieved coronary angiography preoperatively.All the operations were performed on cardiac-pulmonary bypass (CPB) with moderate hypothermia.During CPB,the perfusional pressure was maintained between 60-70 mm Hg and the oxygen saturation for mixed venous blood was kept above 0.70.Artificial ultrafilitration was performed for all the patients during the time of CPB.55 ( 47.8 ％ ) patients had mitral valve replacement ( MVR),3 (2.6％) had mitral valve repair( MVP),33 (28.7 ％) had aortic valve replacement (AVR),16 ( 13.9 ％ ) had AVR +MVR,5(4.3％ ) had AVR + MVP,and 3 had tricuspid replacement.The concomitant procedures included left atrial thrombus scavenging in 18( 15.7％ ),tricuspid valvularplasty in 71 (61.7 ％ ),bental procedure in 6 (5.2 ％ ),and coronary artery bypass grafting(CABG) in 15 ( 13.0 ％).ResultsThe early mortality was 0.87 ％.The major complications included sever low cardiac output syndrome in 6 patients,transient atrial fibrillation in 17,acute renal failure requiring dialysis in 3,delayed ventilation assistance in 12,and stroke in 3.112 (97.4％) patients survived during 6 months period of follow-up,in whom only 8(7.14％) were in NYHA functional class Ⅲ-Ⅳ which was lower significantly compared with that preoperatively.ConclusionHeart valve surgery for elderly patients can get satisfactory result and early mortality and major mortality is low for them.Concerns over the risk of cardiac valve surgery in the elderly should not prevent referral,and elderly patients can do well.

Robotic-assisted endoscopic atrial septal defect closure: analysis of 115 cases in a single center / 南方医科大学学报

<p><b>OBJECTIVE</b>To summarize the experience with the application of robotic technique in totally endoscopic atrial septal defect closure in a single center.</p><p><b>METHODS</b>Between January 2007 and September 2011, 115 patients with the diagnosis of secundum type atrial septal defects underwent robotic atrial septal defect repair with the assistance of da Vinci surgical system. The patients had a median age of 35 years and a median defect diameter of 28 mm. Cardiopulmonary bypass was established via peripheral cannulation. Via three 8-mm ports and one 15-mm port in the right chest, the surgeon manipulated the microinstruments to complete the defect closure with or without tricuspid valve plasty. Echocardiography was performed intraoperatively, before discharge and at 30 days after the operation.</p><p><b>RESULTS</b>Atrial septal defect closure was completed on arrested heart in 44 patients and on beating heart in 61 patients. No deaths or conversions to alternate techniques occurred in these cases. No residual shunt was detected by intraoperative or postoperative echocardiography. The mean operating time and cardiopulmonary bypass time on bearing heart group were significantly shorter than those on arrested heart group. The median ventilation time, intensive care unit stay, drainage volume, or length of hospital stay showed no significant differences between the two groups.</p><p><b>CONCLUSION</b>Secundum type atrial septal defect closure can be successfully performed with the assistance of the robotic system with good surgical results.</p>

Totally robotical atrial septal defect repair: learning curves and correlate analysis / 中华胸心血管外科杂志

Objective The aim of this study is to address learning curve and clinical outcomes of totally robotic atrial septal defect repair on the basis of a single - center experience.Methods 54 cases of atrial septal defect (ASD) were repaired using “da Vinic S surgical system on arrested ( group Ⅰ,54 cases) or beating heart ( group Ⅱ,40 cases) from January 2007 to December 2010.Learning curves were assessed by means of regression analysis with logarithmic curve fit.The effect of operative variables on clinical outcome was analyzed by linear by regression using the Spearman's rho coefficient.Results All cases were accomplished successfully without complications.No residual shunt was detected at intraoperative or postoperative echocardiography.Significant learning curves were noted for corss clamp time in group Ⅰ:y (min) =68.741 -8.283 (n) (x)( r2 =0.489 ; P ＜ 0.01 ) ; the operation time in group Ⅱ:y (min) =355.51 - 56.29 (n) (x) ( r2 =0.581 ; P ＜ 0.01 ).No correlation was detected between operation time,cardiopulmonary bypass time,or cross clamp time and intubation time,intensive care unit stay,or total length of stay.Conclusion The robotic atrial septal defect repair can be performed safely.The learning curves is steep and the longer cardiopulmonary bypass times,operation time or cross clamp time had no negative impact on intraoperative and postoperative outcome.

The observation of 40 cases of totally robotic myxoma resection / 中华胸心血管外科杂志

Objective Objective This study is to discuss a surgical approach for ideal and safe resection of atrial myxoma using da Vinci S surgical system. Methods Forty consecutive patients underwent resection of atrial myxoma with the da Vinci S Surgical System. Mean age of the patients was(48 ± 13) yeas. Mean tumor size was 2. 3 cm ×4. 6 cm ～4. 3 cm ×7. 4 cm. 36 tumors were in the left atrium, of which 31 tumors arose form the interatrial septum, 2 from the postercaudal wall, 2 from the root of the anterior leaflet of the mitral valve, and 1 from the left atrial roof. In 34 patients, exploration was conducted through a left atriotomy anterior to the pulmonary veins and excision was achieved by dissecting a plane through the atrial muscle at the point of attachment. In the first 2 patients, exploration and excision were conducted through an oblique right atriotomy.Four tumors were in the right atrium, all of which were resected from the beating heart. The da Vinci instrument arms were inserted through three 0. 8 cm trocar incision in the right side of the chest via 4 port incision and 2 cm working port, all the procedures were completed with 30 o angled endoscopic facing upward with da Vinci S robot. Results Resection were successful in all patients. There were no operative deaths, strokes or other complication. All the patients were discharged. No recurrences of tumor or septal learkag were found in the follow-up. Conclusion The excision of atrial myxomas with the da Vinci S Surgical System is feasible, efficacious, and safe. Surgical results are excellent.

Intraoperative transesophageal echocardiography in robot-assisted minimally invasive cardiac surgery / 中华胸心血管外科杂志

Objective To delineate the utility and results of intraoperative transesophageal echocardiography (TEE) in the evaluation of patients undergoing robot-assisted cardiac surgery. Methods Intraoperative TEE was performed in 193 patients undergoing robot-assisted procedures in cardiac surgery over a period of 4 years. (1) Before CPB, a comprehensive TEE was performed to document the lesions and their precise localization. ( 2 ) During establishment of peripheral CPB, a arterial cannula was placed percutaneously into the right internal jugular vein and passed into the superior vena cava; a venous cannula was inserted into the right common femoral vein and passing it into the inferior vena cava with its tip just inferior to the inferior vena cava-right atrium junction; a arterial perfusion cannula was passed into the ascending aorta with its tip approximately 3 cm from the aortic valve under TEE guidance. (3) After weaning from CPB, TEE was performed to evaluate the efficiency of the procedure. Results (1) The concordance with surgical findings concerning the lesions and precise localization was 100% and 98. 8% among all the patients, respectively. (2) All cannulae were located in the correct position. (3) TEE confirmed successful procedures with no concomitant complication in all the patients. Conclusion Intraoperative TEE is a valuable adjunct in the assessment of robot-assisted cardiac surgery.