Effect of inhalation of sevoflurane during cardiopulmonary bypass on early postoperative brain injury in patients undergoing cardiac valve replacement / 中华麻醉学杂志

Objective:To evaluate the effect of inhalation of sevoflurane during cardiopulmonary bypass (CPB) on early postoperative brain injury in the patients undergoing cardiac valve replacement.Methods:Forty-two American Society of Anesthesiaologists physical status Ⅱ or Ⅲ patients of either sex, aged 40-70 yr, weighing 47-86 kg, scheduled for elective single valve replacement under CPB, were divided into 3 groups ( n=14 each) using a random number table method: control group (group C), combined intravenous-inhalational anesthesia group (group CA) and sevoflurane group (group S). During CPB, propofol 4-6 mg·kg -1·h -1 was intravenously infused in group C, propofol 2-3 mg·kg -1·h -1 was intravenously infused, and 0.5 MAC sevoflurane was inhaled via the membrane oxygenator in group CA, and 1.0-1.5 MAC sevoflurane was inhaled via the membrane oxygenator in group S. The anesthesia and sedation index values were maintained at 40-60 during operation in the three groups.Blood samples were taken from arteries before anesthesia induction (T 1), at 30 min and 6 and 24 h after termination of CPB (T 2-4) for determination of plasma concentrations of neuron-specific enolase (NSE) and Tau protein. Results:Compared with group C, the plasma concentration of NSE was significantly decreased at T 2, 3, and plasma concentration of Tau protein was decreased at T 2-4 in group S, and the plasma concentration of Tau protein was decreased at T 2 in group CA ( P<0.05). Compared with group CA, the plasma concentration of NSE was significantly decreased at T 2, 3, and the plasma concentration of Tau protein was decreased at T 2-4 in group S ( P<0.05). Conclusions:Inhalation of sevoflurane during CPB can reduce early postoperative brain injury to a certain extent in the patients undergoing cardiac valve replacement.

Port-access minimally invasive versus sternotomy approach for aortic valve surgery / 中国医师杂志

Objective To compare early outcomes of the minimally invasive aortic valve surgery (MIAVS) through right parasternal mini-thoracotomy with conventional mitral valve surgery (AVS),and evaluate feasibility and safety of MIAVS.Methods From January 2017 to December 2017,60 patients undergoing elective AVS in Nanjing First Hospital were prospectively enrolled in this study.There were 32 male and 28 female patients with their age of 28-72 (46.5 ± 10.2)years.Using a random number table,all the patients were randomly divided into a port-access MIAVS group (MIAVS group,n =20) and a conventional AVS group (conventional group,n =60).MIAVS group patients received port-access cardiopulmonary bypass (CPB) establishment via femoral artery,femoral vein and right internal jugular vein cannulation through right the 3rd in tercostal space with 5-6 cm right parasternal incision in length.Special MIAVS operative instruments were used for mitral valve repair or replacement.Conventional group patients received mitral valve repair or replacement under conventional CPB through median sternotomy.Perioperative clinical data,morbidity and mortality were compared between the 2 groups.Results There was no death in-hospital or shortly after discharge in this study.CPB time [(106.0 ± 21.0) minutes vs (73.0 ± 15.0) minutes] and aortic cross-clamping time [(78.0 ± 10.0) minutes vs (47.0 ± 7.0) minutes] of MIAVS group were significantly longer than those of conventional group (P ≤ 0.05).Postoperative mechanical ventilation time [(7.0 ±4.2) hours vs (10.2 ±5.3)hours],length of intensive care unit (ICU) stay [(19.0 ± 4.0) hours vs (27.5 ± 8.0) hours] and postoperative hospital stay [(8.5 ± 2.5) days vs (13.0 ± 3.0) days] of MIAVS group were significantly shorter than those of conventional group (P ≤ 0.05).Chest drainage volume within postoperative 12 hours [(100.0 ±40.0)ml vs (410.0 ±80.0)ml] and the percentage of patients receiving blood transfusion (15.0％ vs 55.0％) of MIAVS group were significantly lower than those of conventional group (P ≤0.05).Patients were followed up for 1-12 months,and the follow-up rate was 96.7％.There was no statistical difference in postoperative morbidity or mortality between the 2 groups (P ＞ 0.05).Conclusions Minimally invasive aortic valve surgery through right right parasternal mini-thoracotomy is a safe and feasible procedure for surgical treatment of mitral valve diseases.MIAVS can achieve similar clinical outcomes as conventional AVS,with more quickly recovery and less blood transfusion,and is a good alternative to conventional AVS.

Impact of perioperative mild hypothermia on neurological function and prognosis of patients with acute type A aortic dissection / 中华胸心血管外科杂志

Objective To investigate the impact of perioperative mild hypothermia on the neurological function and prog-nosis of patients with acute type A aortic dissection. Methods This study enrolled 65 patients with acute aortic dissection un-derwent surgery during the period of February 2017 to February 2018 and randomly divided them into mild hypothermia group and control group. After the process of deep hypothermic circulatory arrest,patients in the mild hypothermia group were re-warmed to 34 ℃ - 35 ℃ and maintained until 24 h after the operation. While,the patients in the control group were rewarmed to 36 ℃ and were treated with routine rewarm therapy. Baseline characteristics were recorded before the operation and neuro-logical and prognosis related indexes were recorded after the operation for all the patients. At the same time,peripheral venous bloods of all the patients were collected preoperatively and at 1、6、 12 and 24 h after the operation. Serum S 100β and neuron-specific enolase(NSE)levels were measured by ELISA kit. Results Compared with the control group,patients in the mild hypothermia group had a significantly shorter recovery time[ 10. 6 h(IQR:7. 6, 19. 1)vs. 25. 8 h(IQR: 13. 3,54. 2),P =0. 007]. At the same time,serum levels of NSE at 1 h and 6 h after operation and serum levels of S 100β levels at 1、6、 12 and 24 h after operation in the mild hypothermia group were significantly lower than those in the control group(P < 0. 05). In addi-tion,the length of stay in the mild hypothermia group was significantly shorter than that in the control group[ 19 days(IQR: 17, 23)vs. 24 days(IQR: 17,28),P = 0. 036]. However,there was no statistically difference in the incidence of delirium and cerebrovascular accidents between the two groups. Conclusion Perioperative mild hypothermia therapy can significantly re-duce brain cell damage in the patients with acute type A aortic dissection and can shorten postoperative recovery time and hospi-talization time,and thus improve the prognosis of patients.

Late reoperations after repaired Stanford type A aortic dissection / 中华外科杂志

Objective@#To summarize the experience of reoperations on patients who had late complications related to previous aortic surgery for Stanford type A dissection.@*Methods@#From August 2008 to October 2016, 14 patients (10 male and 4 female patients) who underwent previous cardiac surgery for Stanford type A aortic dissection accepted reoperations on the late complications at Department of Thoracic and Cardiovascular Surgery, Nanjing Hospital Affiliated to Nanjing Medical University. The range of age was from 41 to 76 years, the mean age was (57±12) years. In these patients, first time operations were ascending aorta replacement procedure in 3 patients, ascending aorta combined with partial aortic arch replacement in 4 patients, aortic root replacement (Bentall) associated with Marfan syndrome in 3 patients, aortic valve combined with ascending aorta replacement (Wheat) in 1 patient, ascending aorta combined with Sun′s procedure in 1 patient, Wheat combined with Sun′s procedure in 1 patient, Bentall combined with Sun′s procedure in 1 patient. The interval between two operations averaged 0.3 to 10.0 years with a mean of (4.8±3.1) years. The reasons for reoperations included part anastomotic split, aortic valve insufficiency, false aneurysm formation, enlargement of remant aortal and false cavity. The selection of reoperation included anastomotic repair, aortic valve replacement, total arch replacement and Sun′s procedure.@*Results@#Of the 14 patients, the cardiopulmonary bypass times were 107 to 409 minutes with a mean of (204±51) minutes, cross clamp times were 60 to 212 minutes with a mean of (108±35) minutes, selective cerebral perfusion times were 16 to 38 minutes with a mean of (21±11) minutes. All patients survived from the operation, one patient died from severe pulmonary infection 50 days after operation. Three patients had postoperative complications, including acute renal failure of 2 patients and pulmonary infection of 1 patient, and these patients were recovered after treatment. Thirteen patients were finally recovered from hospital. The patients were followed up for 16 to 45 months, and no aortic rupture, paraplegia and death were observed in the follow-up.@*Conclusions@#Patients for residual aortic dissection after initial operations on Stanford type A aortic dissection should be attached great importance and always need emergency surgery, but the technique is demanding and risk is great for surgeons and patients, which need enough specification and accurate on aortic operation. More importantly, the Sun′s procedure also should be performed on the treatment of residual aortic dissection or distal arch expansion, and obtains the short- and long-term results in the future.

Application and comparison of moderate and deep hypothermic circulatory arrest during adult aortic arch surgery / 中华胸心血管外科杂志

Objective To compare the effects of moderate and deep hypothermic circulatory arrest (DHCA) during aortic arch surgery in the adult patients,to offer the evidence for the detection of which temperature provides best brain protection in the subjects who accept the great aortic surgery.Methods A total of 109 patients undergoing the surgery of aortic arch were divided into the moderate hypothermic circulatory arrest group and deep hypothermic circulatory arrest group.We recorded the characters of the patients and their cardiopulmonary bypass time,aortic clamping time,cerebral perfusion time and postoperative recovery time,tracheal intubation time,time of intensive care unit (ICU) and postoperative cognitive dysfunction.Results Patients' characteristics were similar in two groups.All the patients were cured.There were no significant differences in aortic clamping time of each group [(111.4 ± 58.4) min vs.(115.9 ± 16.2) min];selective cerebral perfusion time [(27.4 ± 5.9) min vs.(23.5 ±6.1) min] of the moderate hypothermic circulatory arrest group and deep hypothermic circulatory arrest group.There were significant differences in the cardiopulmonary bypass time[(207.4 ± 20.9) min vs.(263.8 ± 22.6) min],the postoperative recovery time [(19.0 ± 11.1) h vs.(36.8 ± 25.3) h],intubation time [(46.4 ± 15.1) h vs.(64.4 ± 6.0)h];length of ICU [(4.7 ± 1.7) d vs.(8.± 2.3) d],and postoperative cognitive dysfunction of the two groups.Conclusion Compared to the deep hypothermic circulatory arrest,the moderate hypothermic circulatory arrest can provide better brain protection and achieve good clinical results.

The stented elephant trunk transplantation combined with total arch replacement for acute type A aortic dissection / 中华胸心血管外科杂志

Objective To summanrize the operative method and follow-up data of total aortic arch replacement combined with transaortic stented graft implantation into the descending aorta (Sun's procedure) for acute Stanford type A aortic dissection.Methods Between August 2004 and March 2012,73 patients with acute type A aortic dissection underwent this procedure.60 males and 13 females ranging in age from 26 to 79 years (mean age,49,6 years).Right axillary or femoral artery cannulation was routinely used for cardiopulmonary bypass.Cerebral protection was achieved by bilatero-antegrade or selected hrain perfusion.The stented elephant trunk was implanted throuugh the aortic arch under hypothermic circulatory arrest.The stented elephant trunk was a 10cmlong self expandable graft.Patent false lumina were evaluated using computed tomography 3 months and once each year after discharge to evaluate the postoperative time course of the residual false lumen.Results Mean cardiopulmonary bypass time was (248.1±69.8)min,and selected cerebral perfusion time was (38.2±10.5)min.Hospital morality was 6.85 ％ (5/73).Thrombus obliteration of the residual false lumen in the descending thoracic aorta was observed in 9 1.7％ of the aortic dissections 3 months postoperatively.The mean follow-up time was(36.4 ± 31.6)months (range,2 to91 months).Survival at 1,5,7 years was 97％,87％ and 81％,respectively.Conclusion Total aortic arch replacement combined with transaortic stented paft implantation into the descending aorta is an effective treatment and n more promising choice for acute type A aortic dissection.