Clinical analysis of 152 mitral valvuloplasty surgeries performed by a single surgical team in one year / 中华胸心血管外科杂志

Objective:To summarize the clinical data of mitral valve surgery completed in a single surgical team in one year, to discuss the etiologic characteristics, methods, results and early postoperative outcomes of mitral valvuloplasty surgeries, and to analyze the epidemiologic trends of mitral valve diseases admitted to the hospital.Methods:A total of 209 mitral valve surgeries completed by the same surgeon in the single surgical team at the Cardiovascular Surgery, First Medical Center, Chinese PLA General Hospital, from January 2021 to December 2021 were retrospectively analyzed. Mitral valve surgery accounted for 53.6% of all surgeries in this team during the same period. There were 100 cases(47.8%) in males and 109 cases(52.2%) in females, aged 11-85 years old, with a mean of(53.5±15.2) years old. There were 121 cases(57.9%) of NYHA class Ⅱ and 88 cases(42.1%) of class Ⅲ/Ⅳ.Results:Of the 152 mitral valvuloplasty surgeries, 117(77%) were performed with a totally Thoracoscopic approach. Annuloplasty rings were applied in 145 cases(95.4%), including semi-rigid closed Physio II annuloplasty rings in 118 cases(81.4%), Gore-Tex artificial chordae were applied in 89 cases(58.6%) for a total of 145, leaflet repair in 15 cases(9.9%), edge-to-edge repair in 2 cases(1.3%), commissure suture in 34 cases(22.4%), and chordae tendineae and papillary muscle splitting in 15 cases(9.9%). The repair rate of degenerative mitral valve disease was 100%, and the repair rate of rheumatic mitral valve disease was 48.1%. The echocardiogram was received about one week after surgery, and there was no or trace regurgitation in 91 cases(59.9%), mild in 58 cases(38.2%), and moderate in 3 cases(2.0%). There were 2 cases(1.3%) of all-cause death.Conclusion:Degenerative mitral valve disease have become the leading cause of mitral valve disease in our center, and the proportion of rheumatic mitral valve disease has decreased. Degenerative mitral valve disease has a very high repair rate, and rheumatic mitral valve disease has a relatively low repair rate due to its special pathologic and anatomic characteristics. Most mitral valvuloplasty procedure can be performed in a totally thoracoscopic approach. The application of a mitral valvuloplasty ring combined with Gore-Tex artificial chordae by an experienced surgeon can achieve reliable repair results.

Early clinical results of totally thoracoscopic repeat mitral valve surgery under hypothermic ventricular fibrillation / 中华胸心血管外科杂志

Objective:The aim of this study was to compare the perioperative outcomes of a totally thoracoscopic repeat mitral valve surgery under hypothermic ventricular fibrillation with those of a conventional median sternotomy approach for repeat mitral valve surgery and to explore the safety of the totally thoracoscopic repeat mitral valve surgery under hypothermic ventricular fibrillation.Methods:Patients requiring repeat mitral valve surgery admitted by the same surgeon at Cardiovascular Surgery, First Medical Center, Chinese PLA General Hospital from January 2018 to January 2022 were retrospectively enrolled. The patients were divided into the totally thoracoscopic group under hypothermic ventricular fibrillation and the conventional median sternotomy group according to the procedure, and the preoperative baseline data and perioperative outcomes were collected and statistically analyzed using SPSS 22.0.Results:A total of 91 patients matched the criteria for study enrollment, 25 in the totally thoracoscopic group and 66 in the median sternotomy group. There was no statistical difference in the preoperative baseline data between the two groups. The totally thoracoscopic group has advantages in mitral valvuloplasty rate(32.0% vs. 7.6%, P=0.008), transfusion rate(72.0% vs. 98.5%, P<0.001), mechanical ventilation time [(19.0±27.8)h vs.(43.3±58.3)h, P=0.009], chest drainage tube time [(2.2±1.9)days vs.(3.7±2.4)days, P=0.004], postoperative chest drainage volume [(489.6±319.1)ml vs.(913.6±568.4)ml, P=0.001], postoperative discharge time[(8.0±2.7)days vs.(13.9±12.8)days, P=0.026]. The totally thoracoscopic group had a longer cardiopulmonary bypass time [(180.8±41.7)min vs.(143.2±39.7)min, P<0.001], and it had an intraoperative ventricular fibrillation time of(100.2±42.5)min. There were no statistically significant differences in the postoperative complication rate(12.0% vs. 21.2%, P=0.481) and mortality(4.0% vs. 4.5%, P=1.000) between the two groups. Conclusion:The totally thoracoscopic approach has the characteristics of less invasion and faster recovery compared with the median sternotomy approach. Hypothermic ventricular fibrillation simplifies the procedure at the ascending aorta while reducing myocardial injury than conventional occlusion of the ascending aorta. Totally thoracoscopic mitral valve surgery under hypothermic ventricular fibrillation is a safe minimally invasive technique.

Analysis of the same valve position cardiac valve reoperation / 中华胸心血管外科杂志

Objective:To summarize the experience of surgical treatment of prosthetic valve dysfunction and evaluate the safety of operation.Methods:The clinical data of 142 patients admitted by the same cardiovascular surgeon from January 2015 to December 2019 at the first medical center of Chinese People's Liberation Army General Hospital. The clinical data were retrospectively analyzed, including 60 males (42.25%) and 82 females (57.75%), with an average age of 59.4 years old. Inclusion criteria: patients received redo-valvuloplasty or valve replacement after valvuloplasty or replacement, excluding mitral balloon dilatation and tricuspid valvuloplasty without implantation of annuloplasty ring.Results:The reasons of redo heart valve surgery in the same valve position including: bioprosthetic valve failure, mechanical prosthetic valve dysfunction, valve dysfunction after valvuloplasty, prosthetic valve infectious endocarditis, perivalvular leakage. There was 2 death in 142 cases, and the operative mortality rate was 1.41%. The reasons of the perioperative period death include cerebral hemorrhage, coagulation dfsfunction; perioperative complications include low cardiac output syndrome (LCOS), hypoxic-ischemic encephalopathy, respiratory failure, tracheal re-intubation, re-thoratomy for hemaostsis.Conclusion:There are many reasons for reoperation of prosthetic valve dysfunction, and the reoperation surgery is a difficult procedure. However, choosing the suitable surgical option, strengthening the perioperative management of such patients can effectively reduce the incidence of postoperative mortality and complications, minimally invasive surgery can reduce the mortality and complications.

Early clinical outcomes of thoracoscopic mitral valvuloplasty: a clinical experience of 100 consecutive cases / 中华胸心血管外科杂志

Objective:Reported our experience of 100 consecutive cases of thoracoscopic mitral valvuloplasty in the early period.Methods:Between September 2017 and December 2019, 100 consecutive cases of thoracoscopic mitral valvuloplasty had been completed in our institution. There were 56 males and 44 females. The mean age was(49.2±14.7) years old, ranging from 15 to 75 years old.The safety and feasibility of this technique was evaluated by its early clinical outcomes.Results:Mitral valve(MV) repair techniques included leaflet folding in 5 cases, cleft suture in 10, commissuroplasty in 15, edge to edge in 1, artificial chordae implantation in 76 cases with mean of(2.5±1.6)(1-4) pairs, and prosthetic annuloplasty in all cases. Intraoperative transoesophageal echocardiography(TEE) revealed no mitral regurgitation(MR) in 95 cases and a mild in 2 cases with all coaptation length more than 5 mm. The rest 3 cases with moderate or more MR were successfully reconstructed after being blocked again. The mean cardiopulmonary bypass(CPB) time was(164.4±51.0 )min and aortic clamping time was(119.7 ± 39.1) min, and the latest 10 cases were(140.2±45.3 )min and(96.3±25.4) min, the difference was statistically significant( P<0.05). There was one operative death for avulsion of left atrial suture after operation and 2 intraoperative re-exploration for bleeding. Severe MR was observed in 2 patients 3 months after operation, and mitral valve replacement(MVR) was performed through median sternotomy. Conclusion:Totally thoracoscopic mitral valvuloplasty is technically feasible, safe, effective and reproducible in clinical practice after crossing the learning curve. The short-term effect is satisfactory, however, further randomized and long-term follow-up studies are warranted to determine its clinical effects.

Early clinical outcomes of totally thoracoscopic repair with leaflet folding, multiple artificial chordae implantation and ring annuloplasty for mitral regurgitation in Barlow disease / 中华胸心血管外科杂志

Objective:To confirm the safety and feasibility of totally thoracoscopic repair with leaflet folding, multiple artificial chordae implantation and ring annuloplasty for mitral regurgitation(MR) in Barlow disease.Methods:From June 2018 to December 2019, 10 consecutive Barlow’s disease patients underwent totally thoracoscopic repair with leaflet folding, multiple artificial chordae implantation and ring annuloplasty. The safety and feasibility of this technique was evaluated by its early clinical outcomes.Results:8 males and 2 females. The mean age was(33.5±11.0) years.There was no operative death and related complications. The mean cardiopulmonary bypass(CPB) time was(142±26)(112-194)min, and the aortic clamping time was(96±18)(78-128) min. The average number of artificial chordae implantation was(3.4±0.7)(2-4) pairs/case. Intraoperative transesophageal echocardiography(TEE) showed the mean mitral valve coaptation length and transvalvular pressure gradient was(1.2±0.2)(0.8-1.5) cm and(1.2±0.4) mmHg(1 mmHg=0.133 kPa), respectively, without MR or systolic anterior motion(SAM). During a follow-up of 1-18 months, there were 7 cases with no MR and 3 with trace MR, with a mean transvalvular pressure gradient of( 1.5±0.6 )mmHg.Conclusion:Totally thoracoscopic repair with leaflet folding, multiple artificial chordae implantation and ring annuloplasty was a safe and effective procedure with satisfied early clinical outcomes for MR in Barlow’s disease. However, further randomized and long-term follow-up studies were warranted to determine its clinical effects.

Clinical characteristics and safety of valvular surgery in elderly patients aged over 75 years / 中华胸心血管外科杂志

Objective:To study the clinical characteristics and surgical conditions of valve surgery in elderly patients over 75 years old.Methods:Datas of patients over 75 years old with valve surgery in our hospital from January 2014 to January 2019 were retrospectively analyzed. 73 cases were analyzed, accounting for 5.3%(73/1 372) of the cardiac valve operations performed during the same period.There were 46 males and 27 females, with an average age of 77.35 years(75-88 years). The main diagnoses were MR 28 cases(38.3%), MS 8 cases(11.0%), AR 7 cases(9.6%), AS+ AR 7 cases(9.6%) and AS 6 cases (8.2%). There were 28 cases(38.4%) of MVR+ TVP, 20 cases(27.4%) of AVR, and 11 cases(15.1%) of MVR.Pacemakers were installed in 2 patients(2.7%) and coronary artery bypass grafting was performed in 14 patients(19.2%).Results:There were statistically significant differences in left atrial end-diastolic diameter(LA), left ventricular end-diastolic diameter(LV), right atrial end-diastolic diameter(RA) and ejection fraction(EF) before and after surgery( P<0.05). There were no statistically significant differences between the two groups( P>0.05) in surgical interception time, extracorporeal circulation time, postoperative ventilator time, ICU time, surgical complications, postoperative liver and kidney functioninsufficiencyand mortality, as compared with 150 cases of valve surgery under 60 years old( P>0.05). Conclusion:Mitral regurgitation is the most common valvular disease in senile patients over 75 years old, the cardiac structure is improved significantly after surgery, and the risk of surgery is the same as that in normal age groups. Therefore, valvular surgery issafe in elderly patients over 75 years old.

Surgical treatment of patients with Behcet's disease complicated with aortic regurgitation / 中华胸心血管外科杂志

Behcet's disease with aortic regurgitation as its initial or prominent manifestation is relatively rare. The progno-sis of these patients is poor and the death rate is high. Perivalvular leakage and pseudoaneurysm often occur after surgery due to clinicians failed to diagnose Behcet's disease before surgery . At present, the etiology of the disease is not clear , and there is lack of experience and consensus in drug control, selection of operation timing and methods, or prediction of postoperative com-plications. This review summarizes the pathophysiological changes, clinical manifestations, diagnosis and treatment methods and prognosis of the disease, with a view to improve the level of cognition and treatment of this disease and improving the quali-ty of life of patients.

Uni-port totally thoracoscopic surgery in tricuspid insufficiency patients after previous left-sided valve surgery / 中华外科杂志

Objective@#To examine minimally invasive tricuspid valve operations applied in tricuspid valve insufficiency patients with previous left-sided valve surgery.@*Methods@#Between September 2017 and June 2019, thirty-six consecutive patients received minimally invasive totally thoracoscopic tricuspid surgery through right thoracotomy at Department of Cardiovascular Surgery, Fisrt Medical Center, People′s Liberation Army General Hospital. There were 13 males and 23 females, aging (56±11) years (range: 43 to 79 years). All the patients had isolated significant tricuspid regurgitation after previous left-sided cardiac surgeries. A right anterolateral thoracotomy incision about 4 cm was made from the fourth intercostal space as main operating port. The arterial cannula was placed in femoral artery. The venous cannula was placed in femoral vein using Seldingger technique. Tricuspid valve operation was performed on beating heart by assist of vena vacuum.@*Results@#Tricuspid valve repair was performed in 7 patients. Tricuspid valve replacement with bioprosthesis was performed in 29 patients. The operation time was (2.9±0.3) hours (range:2.5 to 3.6 hours). There was no conversion to sternotomy during operation. There was no severe complications during operation period. There were no complications related to this cannulation technique. The time of cardiopulmonary bypass establishment was (22±5) minutes (range: 12 to 24 minutes) and pump time was (82±16) minutes (range: 62 to 93 minutes). The length of hospital stay was (9±3) days after operation (range: 5 to 13 days). There was no early death in hospital. All patients were followed up for 3 to 22 months. No patient died.@*Conclusions@#One single port-based minimally invasive approach seems to be safe, feasible, and reproducible in case of redo tricuspid valve operations. Only cannulation of inferior vena cava significantly simplified the complexity of isolated redo tricuspid surgery.

The procedure choice for the reoperation of tricuspid valve lesion after left heart valve surgery / 中华外科杂志

Tricuspid insufficiency late after left-sided heart valve surgery is not uncommon. These patients usually suffer from severe right heart insufficiency and poor general condition due to untimely surgical intervention, and are often complicated with hepatic and renal insufficiency and hemopoietic dysfunction. The choice of strategy for reoperation and perioperative management are still the major challenges for contemporary cardiac surgeons. This article introduces the clinical characteristics and operation timing of patients with severe tricuspid insufficiency after previous left-sided heart valve surgery, and focuses on the selection of operation approach and operation methods.

Surgical treatment of patients with Behcet's disease complicated with aortic regurgitation / 中华胸心血管外科杂志

Behcet's disease with aortic regurgitation as its initial or prominent manifestation is relatively rare. The prognosis of these patients is poor and the death rate is high. Perivalvular leakage and pseudoaneurysm often occur after surgery due to clinicians failed to diagnose Behcet's disease before surgery . At present, the etiology of the disease is not clear , and there is lack of experience and consensus in drug control, selection of operation timing and methods, or prediction of postoperative complications. This review summarizes the pathophysiological changes, clinical manifestations, diagnosis and treatment methods and prognosis of the disease, with a view to improve the level of cognition and treatment of this disease and improving the quality of life of patients.

Resurgery for recurrent heart valve diseases / 解放军医学杂志

Objective To summarize the experience with resurgery for recurrent valvular heart diseases.Methods From June 2004 to June 2015, 28 patients (15 males and 13 females) with ages ranging from 44 to 67 years (55.6±6.5 years) with recurrent heart valve disease underwent resurgery. The reasons for resurgery included perivalvular leakage (7 cases), bioprosthetic valve decline (6 cases in mitral valve and 3 in tricuspid valve), mechanical prostheses dysfunction (2cases), infective endocarditis after valve replacement (2 cases), restenosis of repaired native valve (1 case), and severe tricuspid insufficiency after left-side valve surgery (7 cases). Resurgery included mitral valve replacement in 18 patients and tricuspid valve replacement in 10. All the patients underwent third or fourth or even fifth cardiac surgery for valve replacement.Results There were 2 hospital deaths with a mortality of 7.1% (2/28). The main causes of early-stage deaths were low cardiac output syndrome. The main postoperative complications were respiratory failure in 3, low cardiac output syndrome in 2, reexploration for bleeding in 2 and serious infectious shock in 1. All the patients were found with the great improvement in heart function and the re-implanted prostheses worked well during follow-up.Conclusions Although resurgery for recurrent heart valve disease poses a continuing challenge to cardiac surgeon, it could be performed with the satisfactory results. The keys to a successful cardiac resurgery include appropriate operational timing, refined surgical technique and reasonable perioperative managements.

Clinical performance of mechanical versus bioprosthetic valves in patients aged 60-70 years / 解放军医学杂志

Objective To compare the mortality,valve-related morbidity and reoperation rate between mechanical prostheses and bioprostheses in patients aged 60 to 70 years.Methods The pre-operative characteristics of 119 patients who received mechanical prostheses and 181 those with bioprosthesis implantation in our department between January 2006 and December 2014 were analyzed,and their mortality,valve-related morbidity and reoperation rate were compared.Results Followup revealed mechanical prostheses had a lower all-cause mortality after mitral valve replacement than bioprostheses at 6 years after the operation (P=0.033),but there was no statistical difference in valve-related mortality (P=0.277).The complications after mechanical prosthesis replacement had embolism (8.4％) and bleeding (5.0％),bioprosthesis' those consisted of structural valvular deterioration (2.2％),nonstructural dysfunction (1.1％),thrombosis (2.8％),embolism (5.0％),bleeding (0.6％) and operated valvular endocarditis (1.1％).There was no statistically significant difference in total complication rate between the two groups (P=0.318).Biological group had 3 patients receiving reoperation in 8 years,while there was no reoperation in the mechanical group,but without statistical group difference.Conclusion Patients aged 60-70 years old could have a similar valve-related mortality,morbidity and reoperation rate after mitral valve replacement between mechanical and biological valves.

Clinical features of 82 patients with brucellosis in Liaoning Province / 中华传染病杂志

Objective To identify the clinical features of patients with brucellosis in Liaoning Province in recent 5 years, and to improve the diagnostic level of the disease.Methods The clinical data including epidemiology, clinical features, laboratory data and diagnosis of 82 hospitalized patients who were diagnosed with brucellosis in the First Affiliated Hospital of China Medical University from 2011 to 2015 were collected and reviewed retrospectively.Results The majority of the 82 patients were middle-aged (45-59 years old) (47.6%) and male gender (63.4%).Fever (90.2%), muscle and joint pain (61.0%), hepatosplenomegaly (36.6%), lymphadenopathy (24.4%) and weight lose (32.9%) were the main complaints.The peripheral leucocyte counts were usually normal (70.7%).C-reactive protein (81.3%), procalcitonin (81.8%) and erythrocyte sedimentation rate (64.2%) increased in most cases.The results of the serum agglutination test in 67 patients were all positive (100.0%).The pathogen isolation was conducted in 60 patients and 49 patients were positive for Brucella species.Among them, 35(71.3%) isolates were identified as Brucella melitensis.A total of 90.2%(74/82) cases were firstly diagnosed with fever of unknown origin and were hospitalized.Misdiagnosis accounted for 52.4(43/82)%.Conclusions Contact history with cow and sheep should be inquired thoroughly in patients with clinical manifestations of fever, muscle and joint pain and hepatosplenomegaly.Pathogen isolation, agglutination test and other specific tests should be performed as soon as possible to diagnose the disease early.

Research progress on mechanisms of calcific aortic valve disease / 中华胸心血管外科杂志

Calcific aortic valve disease(CAVD) is the most common valvular disorder.There is no medical treatment to prevent and/or reverse the progression of CAVD and the etiology still requires further study.CAVD has long been described as a degenerative disease related to aging.In the past few years,our comprehension of the etiology and mechanisms leading to CAVD has progressed at a fast pace.In this article,we review the latest discoveries of CAVD,from aspects of lipid retention,inflammation,calcification,osteogenic transition and their basic molecular processes.

Offer early attention and intervention to patients with valvular heart disease / 中华外科杂志

As a key feature of the updates, early intervention of valvular heart disease is highlighted in the 2014 AHA/ACC guideline for the management of patients with valvular heart disease. This article reviewed the new guideline in regards to the issue of early intervention of diseases such as aortic stenosis, aortic insufficiency, mitral stenosis, mitral insufficiency, tricuspid insufficiency, and infective endocarditis, with discussion on the related topics according to the authors' understanding and practical experience in China. We conclude that valvular heart disease should receive early intervention and attention should also be paid on the progress of disease.

Early results of left atrial appendage closure in cerebral ischemic stroke reduction in patients with mitral valve replacement / 中华外科杂志

<p><b>OBJECTIVE</b>To investigate the role of left atrial appendage (LAA) closure for cerebral ischemic stroke prevention following mitral valve replacement.</p><p><b>METHODS</b>Retrospective data on 860 consecutive adult patients undergoing mitral valve replacement between January 2008 and January 2013 were analyzed. There were 414 male and 446 female patients, with a mean age of (53 ± 12) years. The patients were divided into two groups according to whether the left atrial appendage was closed during operation: LAA closure group (n = 521) and non-LAA closure group (n = 339).Early mortality, postoperative cerebral ischemic stroke and the risk factors for cerebral ischemic stroke were assessed. Multivariate analysis was performed using logistic regression analysis.</p><p><b>RESULTS</b>Compared with non-LAA closure group, LAA closure group had higher proportion of female gender, higher percentage of patients with cardiac insufficiency, pulmonary hypertension and left atrial thrombus, higher incidence of mechanical valve implantation and concurrent tricuspid surgery, and larger preoperative diameter of left atrium, but lower proportion of hypertension and patients undergoing coronary artery bypass surgery, and shorter aorta cross clamping time (χ² = 6.807 to 122.576, t = -2.818 and 3.756, all P < 0.05). There were no differences in exploratory thoracotomy for bleeding and in-hospital mortality between the two groups. Postoperative cerebral ischemic stroke occurred in 12 patients (1.4%). The incidence of cerebral ischemic stroke in LAA closure group was significantly lower than in non-LAA closure group (0.6% vs.2.7%, χ² = 6.452, P = 0.011).Logistic regression analysis showed that LAA closure was a significant protective factor for postoperative cerebral ischemic stroke (OR = 0.189, 95% CI: 0.039 to 0.902, P = 0.037) while history of cerebrovascular disease (OR = 4.326, 95% CI:1.074 to 17.418, P = 0.039) and preoperative diameter of left atrium (OR = 1.509, 95% CI: 1.022 to 1.098, P = 0.002) being the independent risk factors for postoperative cerebral ischemic stroke. The subgroup analysis showed that, for atrial fibrillation patients, LAA closure was a strong protective factor (OR = 0.064, 95% CI: 0.006 to 0.705, P = 0.025), but LAA closure was not a significant predictive factor (OR = 1.902, 95% CI: 0.171 to 21.191, P = 0.601) in non-atrial fibrillation patients.</p><p><b>CONCLUSION</b>Concurrent LAA closure during mitral valve replacement is safe and effective to reduce the early postoperative risk of cerebral ischemic stroke in atrial fibrillation patients.</p>

Surgical treatment of aortic paravalvular abscess by infective endocarditis / 中华外科杂志

<p><b>OBJECTIVE</b>To summarize the clinical features, pathology and surgical treatment experiences in the patients with aortic paravalvular abscess by infective endocarditis.</p><p><b>METHODS</b>The study consisted of a retrospective analysis of 29 cases with aortic paravalvular abscess by infective endocarditis underwent surgical treatment between January 2001 and June 2013. Among the 29 patients, 22 were male and 7 were female, and the mean age was (37 ± 16) years (range from 11 to 63 years). The primary cardiac disease was congenital aortic valve malformation in 16 patients. There were 15 patients with a history of severe heart failure. Of 29 cases, 8 abscess cavities, 13 pseudoaneurysms and 6 fistulas were found, and complete aortoventricular discontinuity was present in 5 patients with serious infections. Of them, the abscess was above the annulus in 14 patients and below the annulus in 10 patients, and simultaneously involved the annulus above and below in 5 patients. 19 patients were culture positive either positive preoperative blood cultures or positive cultures of surgical specimens, including 9 patients with Staphylococcus infection. The paravalvular defect was repaired by patch in 19 cases, and by local closure in 10 cases. The valvular annulus was reconstructed simultaneously in 16 patients. Aortic valve replacement was performed in 26 patients, and Bentall procedure in 2 patients, including 23 with prosthetic mechanical valve and 5 with biological valve.</p><p><b>RESULTS</b>Of the total 29 patients, 28 patients were recovered, and 1 patient was died of sepsis. During 3 months to 13 years postoperative follow-up (average 4.5 years), one was died of non-cardiac cause, and no patient had recurrent endocarditis and paravalvular leakage.</p><p><b>CONCLUSIONS</b>Aortic paravalvular abscess by infective endocarditis is not uncommon, prone to heart failure. According to the different pathological manifestations, the appropriate surgical approach and strategy can achieve satisfactory outcomes.</p>

Surgery in patients of severe aortic stenosis with low transvalvular gradients and severe left ventricular dysfunction / 中华胸心血管外科杂志

Objective To assess the result of aortic valve replacement(AVR) for patients of severe aortic stenosis(AS)with low transvalvular gradients(TVG) and severe left ventricular dysfunction,and try to identify the determinants of survival,functional status and change in left ventricular ejection fraction(LNEF) during follow-up.Methods From 2005 to 2011,35patients with aortic valve area(AVA) ＜ 1 cm2,LN EF ＜ 0.40 and mean TVG ＜ 30 mm Hg underwent AVR in our hospital.The average age of the patients was 58 yeats old,and 88.6％ of the patients were in New York Heart Association (NYHA) functional class Ⅲ/IV at admission to the hospital.The AVA was (0.70 ± 0.09) cm2,LVEF was 0.276 ± 0.020,TVG was (26.0 ± 2.3) mm Hg,and left ventricular end-diastolic diameter (LNEDD) was (6.3 ±0.4) cm respectively.35 prosthetic valves were implanted,including 20 mechanical prostheses and 15 biological prostheses with the mean sizs of (23 ± 1) mm.Concomitant procedures included mitral valvularplasty in 5.tricuspid valve repair in 3 and coronary artery bypass grafting in 4.Results The perioperative mortaiity was 8.6％.Follow-up period was 3 to 60 monthes.The survival rates were:1-year 78％,2-year 68％,5-year 60％.LVEF increased significantly to 0.358 ± 0.047 one week postoperatively (P =0.008) and 0.426 ± 0.031 six months later (P ＜ 0.01)).LNEDD decreased to (5.7 ± 0.4) cm one week later(P =0.062) and (5.3 ±0.3)cm 6 months postoperatiwely (P ＜ 0.01).NYHA functional class improved from 88.6％ in class Ⅲ/Ⅳ to 35％ (P ＜0.01).Compared with those who surviwd during follow-up,the patients who died during follow-up were older in the year of operation[(63 ± 10) vs (54 ± 11),P =0.017],their NYHA functional class was higher[(3.9 ±0.2) vs (2.9 ±0.3),P =0.003]and the LVEDD for them in one week postoperatively was larger[(6.0 ± 1.0) cm vs (5.5 ± 0.3) cm,P =0.031].Conclusion The left ventricle contractile reserve seems to play an essential role for surgery in patients of severe aortic stenosis with low transvalvular gradients and severe left ventricular dysfunction.AVR can be performed for them with acceptable results.

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.

A modified tricuspid annuloplasty for functional severe tricuspid regurgitation / 中华胸心血管外科杂志

ObjectiveTo retrospectively analyze clinical data of patients who has left-side valvular disease combined with severe tricuspid regurgitation and evaluate the effect of our modified tricuspid annuloplasty with enforcement of artificial felt strip.Methods76 patients who had left-side valvular disease combined with severe tricuspid regurgitation received operations between Jan.2008 and Jun.2010.The average age of the patients was 53.5 years old (32 male and 44 female).Besides the severe tricuspid regurgitation, other combined cardiac impairments included mitral valvar disease (52 cases), aortic valvar disease(5 cases), double valvar disease(19 cases) and left atrial thrombosis(22 cases).6 patients had grade II cardiac function according to the NYHA criteria, while 47 and 23 were in grade III and IV, respectively.Other signs included cyanosis(5cases), jaundice(11 cases), neck vein engorgement(48 cases) , ascites(22 cases), hepatomegaly(41 cases) and pitting edema in the lower limbs(68 cases).The concomitant operative procedures included mitral valve replacement in 52 patients,aortic valve replacement in 5 patients, double valve replacement in 19 patients, removal of left atrial thrombus in 22 patients,left atrium folding in 21 patients and left atrium appendage suture in 68 patients.Left-sided valve disease were corrected first,TAP was performed on the beating heart after the heart had been defibrillated.The anteroseptal commissure was plicated first.A double-armed 3-0 pledgeted suture was taken through the base of the septal leaflet, 5-6 mm from the commissure, extending along the annulus, and out from the point in the anterior annulus 10-12 mm from the anteroseptal commissure.Both ends of the suture was tied until the two Teflon pledgets approximated each other near the commissure.Then a semicircular De Vega type of plicating with a 3-0 prolene was taken, starting just from the anterior annulus near the anteroposterior commissure, and extending clockwise to a point just cephalad to the posteroseptal commissure.The suture was tied with positioning a 27-29 mm valve siser across the tricuspid valve.At last, a 3-5 mm width felt strip was prepared and was sutured to the plicated posterior annulus region with interrupted mattress sutures of 2 to 3 2-0 prolene.A favorable result was considered when TR was not marked by saline injection.Echocardiography was routinely examined one week postoperatively and patients were followed up 6 month after discharge.ResultsThere is no death in all patients.The CVP diminished significantly from 16mmHg preoperatively to 8mmHg postoperatively (P = 0.0021).The systomic pulmonary pressure diminished from 59 mmHg preoperatively to 41 mmHg postoperatively (P = 0.038).Echo one week postoperative showed no tricuspid regurgitation in 56 patients and mild in 18 patients, while 2 had moderate tricuspid regurgitation.The diameter of right atrium diminished significantly postoperatively, too.The ejection fraction was improved even though there was not significant difference as compared with preoperative data.The cardiac function of all patients improved and the signs of right heart failure were alleviated or disappeared.Follow up 1 to 36 months showed no change of the regurgitation except for one become moderate from mild when discharged.No hepatic congestion or edema was observed in all patients.ConclusionThese new modifications make the technique more selective in the remodeling of the tricuspid annulus.It could achieve better coaptation of the anterior leaflet with the others, successful annular reduction, better maintenance of the contractile property of the tricuspid ring, better distribution of pursing force in the more dilated region.It could prevent the tear of the endocardium in the posteroseptal region in the long period of time postoperatively.