del Nido cardioplegia in surgery for aortic root disease: a historically controlled study.

BACKGROUND: To determine the safely and effectively of del Nido cardioplegia (DNC) in surgery for aortic root disease, with mild hypothermic cardiopulmonary bypass (CPB). METHODS: From July to December 2017, all patients undergoing the surgery for aortic root disease (total aortic root replacement, valve-sparing aortic root replacement and replacement of aortic valve plus ascending aorta), with mild hypothermic CPB, were retrospectively reviewed at our institution. Patients were divided into two groups based on the type of cardioplegia: the classical blood cardioplegia (CBC group) and del Nido cardioplegia (DNC group). Demographics, operative details, perioperative data and postoperative complications were recorded and compared. A propensity score matching was performed in this study. RESULTS: The preoperative data in DNC group were similar to CBC group. The volume of ultrafiltration was lower in DNC than CBC group (2,053.49±806.62 DNC vs. 2,666.00±967.14 CBC, P=0.001), when matched. The use of temporary pacemaker was more in DNC group (n=20, 46.5%, P=0.023), and the rate of automatic heart resuscitating was higher in the CBC group (92.0% vs. 72.1% DNC group, P=0.024, unmatched).There were no differences in in-hospital mortality, troponin T (mean 0.66 ng/mL for CBC group vs. 0.49 ng/mL for DNC group, P=0.152), left ventricular ejection fraction (mean 58.37% for CBC group vs. 60.07% for DNC group, P=0.395) or other postoperative complications between two groups, after matching. In subgroup analysis, the ultrafiltration volume was lower in DNC than CBC group (1,932.26±749.39 DNC vs. 2,640.00±996.24 CBC, P=0.004), when ACC time less than or equal to 90 minutes. The apache score was better in DNC group (4.75±3.41, P=0.041), when ACC time greater than 90 min. There were no statistical significances in other characteristics between groups. CONCLUSIONS: DNC is safe and effective for surgery for aortic root disease, not inferior to the CBC.

Single-dose del Nido cardioplegia used in adult minimally invasive valve surgery.

BACKGROUND: To analyze the protective effect of single-dose del Nido cardioplegia (DNC) in adult minimally invasive valve surgery. METHODS: From January to December 2017, 165 consecutive adult patients who underwent minimally invasive valve surgery by the same team of surgeons were divided into two cohorts based on the type of cardioplegia administered during surgery: (I) single-dose DNC (DNC group (n=76, male 41, female 35) used in patients from May to December, 2017 and (II) intermittent standard 4:1 blood cardioplegia based on St.Thomas solution (SBC group, n=89, male 45, female 44) used in patients from January to April, 2017. Preoperative baseline demographics, preoperative comorbidities, operative variables, postoperative complications, and patient outcomes were collected and compared between the two groups. RESULTS: Preoperative characteristics were shown to be similar between the two groups before and after propensity matching. Patients in the DNC group required a significantly lower volume of cardioplegia. The volume of ultrafiltration in the DNC group was substantially higher than that in the SBC group. The spontaneous return of heartbeat rate in the DNC group was considerably higher than that in the SBC group (97.0% vs. 78.8%, P=0.006). The Euroscore II in the DNC group was markedly lower than that in the SBC group (2.00 vs. 3.00, P<0.05). The level of blood urea nitrogen (BUN) in the DNC group was significantly lower than that in the SBC group (6.20 vs. 6.95, P<0.05). There were no differences in surgery procedure, cross-clamp time, bypass time, Apache score, troponin T (cTnT), brain natriuretic peptide (BNP), liver and renal function, postoperative complications or patient outcomes between two groups. Regression analysis showed that cTnT increased with the prolongation of myocardial ischemia time, and was closely related to the type of operation, but had no significant correlation with the type of cardioplegia. CONCLUSIONS: In our initial experience, single-dose DNC in adult minimally invasive valve surgery in which the cross-clamp time was mostly less than 90 min, achieved equivalent myocardial protection and clinical outcomes when compared with standard whole blood cardioplegia. In addition, single-dose DNC made the minimally invasive valve surgery procedure progress in a smoother and more convenient fashion.

A New Venous Drainage Technique in Minimally Invasive Redo Tricuspid Surgery: Vacuum-Assist Venous Drainage via a Single Femoral Venous Cannula.

OBJECTIVE: To summarise the experiences of applying vacuum-assist with a single femoral venous cannula drainage technique in minimally invasive isolated redo tricuspid surgery. METHODS: Eight consecutive patients underwent minimally invasive redo tricuspid surgery through a right thoracotomy at our institute. All of the patients had isolated significant tricuspid regurgitation after previous cardiac surgeries, and received minimally invasive redo tricuspid surgery. The arterial cannula was inserted into the femoral artery, and at the same time, the venous cannula was placed into the femoral vein. The venous cannula was guided by transoesophageal echocardiography and reached the superior vena cava (SVC). The caval veins did not need to be snared with the heart beating during the operation, but applying the vacuum-assisted venous drainage (VAVD) controller was necessary. RESULTS: This cannulation makes it possible to achieve adequate drainage (3.48±0.44L/min) and accomplishes complete arterial perfusion. Most importantly, it guarantees a good visual field without blood and allows safe surgery. The average time of cardiopulmonary bypass (CPB) was 68.25±13.84min. The length of ICU and hospital stays were 4.13 ±3.52 days and 8.14±4.98 days, respectively. In eight patients, there was no early death in the hospital. One patient experienced acute renal dysfunction. CONCLUSION: Vacuum-assist venous drainage via a single femoral venous cannula in isolated redo tricuspid surgery is safe, effective, reliable, and significantly simplifies the procedure.

Effects of cardiopulmonary bypass on lung nuclear factor-kappa B activity, cytokine release, and pulmonary function in dogs.

OBJECTIVES: To study the effect of cardiopulmonary bypass (CPB) on nuclear factor-kappa B (NF-κB) and cytokine expression and pulmonary function in dogs. MATERIALS AND METHODS: Twelve male mongrel dogs were divided into a methylprednisolone group (group M) and a control group (group C). All animals underwent aortic and right atrial catheterization under general anesthesia. Changes in pulmonary function and hemodynamics were monitored and the injured site was histologically evaluated. RESULTS: The activity of NF-κB and myeloperoxidase (MPO), levels of tumor necrosis factor (TNF)-α, interleukin (IL)-1ß, IL-6, and IL-8, and the wet/dry (W/D) weight ratio were significantly higher after CPB than before CPB in both groups (P<0.01), with the lower values in group M than in group C, at different time points (P<0.01). Histological evaluation revealed neutrophilic infiltration and thickening of the alveolar interstitium in both groups; however, the degree of pathological changes was significantly lower in group M than in group C. The alveolar-arterial O2 tension difference (PA-aDO2) was significantly higher after CPB than before CBP (P<0.01), and lower in group M than in group C (P<0.01). The pulmonary compliance after removal of the aortic clamp obviously decreased in group C (P<0.05), with no significant change in group M. CONCLUSION: CPB can significantly enhance the activation of NF-κB in lung tissues and increase the expression of inflammatory cytokines, thus inducing lung injury. Methylprednisolone can inhibit the NF-κB activation, thus inhibiting the release of cytokines and protecting the lung function.

[Minimally invasive aortic valve replacement for isolated aortic valve disease: clinical analysis of 101 consecutive patients].

OBJECTIVE: To review the results for minimally invasive aortic valve replacement (AVR) through a 5 cm right anterolateral thoracotomy. METHODS: From July 2009 to September 2011, 101 consecutive patients with isolated aortic valve disease (degenerative in 37 patients, rheumatic in 21 patients, congenital in 37 patients, endocarditic in 3 patients and aorta-arteritis in 1 patients) underwent AVR through the right anterolateral thoracotomy approach in the third intercostal space with a groin incision for femoral connection of cardiopulmonary bypass. The mean age was 45.7 years (ranging from 17 to 71 years). Sixty patients were male. RESULTS: Operations were successfully performed in all but 1 patient (1.0%) who required intraoperative conversion to full sternotomy. Mean duration of cardiopulmonary bypass time and aortic cross-clamp time was (88 ± 24) minutes and (55 ± 18) minutes, respectively. Thirty-day mortality was 1.0% (1/101), this patient was found difficult in weaning off cardiopulmonary bypass and exhibited severe coronary artery plaque, although bypass graft was carried out immediately, the patient died of severe low cardiac output syndrome finally. No blood products were needed in 83.2% patients. Follow-up was performed in all patients at an average of (16 ± 7) months postoperatively. A good recovery was obtained in all patients except one who died of multiple organ failure caused by massive cerebral infarction 38 days after surgery. CONCLUSIONS: Minimally invasive aortic valve replacement though the right anterolateral thoracotomy approach is safe and feasible, with good cosmetic results and rapid postoperative recovery. It is worthy of clinical elective application.

[Repair of posterior mitral valve prolapsed: comparative study of three different approaches].

OBJECTIVE: To compared outcomes of robotic mitral valve repair with those of standard sternotomy, and right anterolateral thoracotomy. METHOD: From August 2010 to July 2011, 70 patients with degenerative mitral valve disease and posterior leaflet prolapsed scheduled for elective isolated mitral valve repair were prospectively nonrandomized to undergo mitral valve operation by standard sternotomy (n = 30), right anterolateral thoracotomy (n = 30), or a robotic approach (n = 10). There were 49 male and 21 female patients, aging from 16 to 70 years with a mean of 53.4 years. Outcomes of the three groups were compared. RESULTS: Mitral valve repair was achieved in all patients except 1 patient in the standard group. There were no in-hospital deaths. The median operation time [(300 ± 41) min, (184 ± 20) min and (169 ± 22) min, F = 112.5, P < 0.01], cardiopulmonary bypass time [(139 ± 26) min, (82 ± 20) min and (69 ± 23) min, F = 36.8, P < 0.01], aortic cross-clamping time [(93 ± 23) min, (47 ± 10) min and (38 ± 8) min, F = 75.0, P < 0.01] were longer for robotic than standard sternotomy and right anterolateral thoracotomy. The robotic group had shortest time of mechanical ventilation time [(4.9 ± 2.1) h, (5.3 ± 4.5) h and (14.1 ± 10.2) h, F = 13.2, P < 0.01], ICU time [(15.1 ± 2.1) h, (16.4 ± 5.4) h and (28.7 ± 16.1) h, F = 11.6, P < 0.01], postoperative hospital stay time [(4.6 ± 1.0) d, (5.7 ± 1.7) d and (8.8 ± 5.1) d, F = 8.0, P < 0.01] with the lowest of drainage [(192 ± 200) ml, (215 ± 163) ml and (405 ± 239) ml, F = 7.1, P < 0.01] and ratio of the patients needed blood transfusion (0, 20.0% and 66.7%, χ(2) = 22.7, P < 0.01). Patients were followed up 6 to 17 months, with 100% completed. No patients died during follow-ups, and no moderate or more mitral regurgitation was observed. The robotic group had the shortest time of return to normal activities compared with the other two groups [(2.4 ± 0.7) weeks, (4.2 ± 1.2) weeks and (8.2 ± 1.8) weeks, F = 83.0, P < 0.01]. CONCLUSION: This study shows mitral valve repair via the right anterolateral thoracotomy and a robotic approach is safe and feasible, with good cosmetic results and rapid postoperative recovery, and is worthy of clinical selective application.

Bilateral versus unilateral antegrade cerebral perfusion in arch reconstruction for aortic dissection.

BACKGROUND: The superiority of bilateral versus unilateral antegrade cerebral perfusion (ACP) has been the subject of much debate. This study aimed to compare the two methods of cerebral perfusion. METHODS: Between September 2005 and June 2011, 263 patients (median age 51.4±10.1 years, range, 26 to 75; 200 men) underwent open aortic arch reconstruction with hypothermic circulatory arrest and bilateral or unilateral ACP. Among them, 231 patients had acute aortic dissection, 12 had subacute aortic dissection, 20 had chronic aortic dissection, 7 had Marfan syndrome, 8 had reconstruction secondary to endovascular stent graft placement for type B dissection, and 9 had bicuspid aortic valve. Our patient cohort is divided into those protected with hypothermic circulatory arrest and bilateral ACP (group A, n=128) and those with hypothermic circulatory arrest and unilateral ACP (group B, n=135). RESULTS: There was no significant difference between groups A and B in cardiopulmonary bypass time, cross-clamp time, or cerebral perfusion time. Overall in-hospital mortality was 11.7% for group A and 11.1% for group B (p=0.877). Postoperative temporary and permanent neurologic dysfunction was 5.5% versus 6.7% and 12.5% versus 10.4%, respectively (group A versus group B: p=0.685, p=0.587). Intensive care unit time was 9.4±9.8 days for group A and 8.4±14.0 days for group B (p=0.972). Hospitalization was 24.3±14.6 days for group A and 23.1±21.1 days for group B (p=0.172). CONCLUSIONS: Unilateral ACP with hypothermic circulatory arrest is a safe cerebral protection technique for open aortic arch reconstruction, and is not inferior to bilateral ACP with hypothermic circulatory arrest.

Analysis of the risk factors of postoperative respiratory dysfunction of type A aortic dissection and lung protection.

AIM: Retrospectively to analyze the risk factors of postoperative respiratory dysfunction (RD) in 196 patients with type A dissection operated on with cerebral perfusion and a lower body hypothermia circulatory arrest (HCA) and to investigate the method of the lung protection. METHODS: From January 2005 to April 2008, 196 patients with type A dissection underwent surgical repair with cerebral perfusion and HCA. There were 142 male patients and 54 female patients, with ages from 17 to 78 years. Antegrade selective cerebral perfusion (SCP) through the axillary artery was performed for 168 patients and retrograde cerebral perfusion (RCP) from the superior vena cava for 28 patients. All the factors underwent univariate and multivariate analysis. RESULTS: Mean cardiopulmonary bypass (CPB) duration was (186+/-56) minutes and mean cerebral perfusion time was (35+/-15) minutes; mean HCA time was (39+/-14) minutes. Postoperative RD was detected in 26 patients (13.3%). Multivariate analysis showed that the longer duration of circulatory arrest (CA), P=0.008, OR=1.048, and the higher temperature in the bladder during CA, P=0.002, OR=1.614, were independent risk factors of postoperative RD. There was a higher mortality (23.1%, P=0.025) in patients with postoperative RD when compared with the other patients. CONCLUSION: The longer duration of CA and the higher temperature in the bladder during CA were found to be the independent risk factors of postoperative RD after type A aortic dissection surgery. Attention should be paid to lung protection for these patients and the adjunct of continuing descending aortic perfusion and cerebral perfusion should be a safe and feasible procedure and it would be valuable to perform a prospective trial.

[Analysis of the risk factors of postoperative renal failure of type A aortic dissection].

OBJECTIVE: To evaluate the risk factors of postoperative renal failure (RF) in the patients with type A dissection of aorta operated on with cerebral perfusion and deep hypothermia circulatory arrest (DHCA). METHODS: From January 2004 to October 2007, 157 patients with type A dissection of aorta underwent surgical procedures with cerebral perfusion and DHCA. There were 115 male patients and 42 female patients with the age from 17 to 76 years old. Antegrade selective cerebral perfusion through axillary artery was performed for 129 patients and retrograde cerebral perfusion from superior cava vein was performed for 28 patients. All the factors underwent univariate and multivariate analysis. RESULTS: Mean cardiopulmonary bypass duration was (188.0 +/- 10.8) min and mean cerebral perfusion time was (36.0 +/- 3.1) min. Fifteen patients died in hospital and the hospital mortality was 9.6%. Permanent neurological dysfunction (PND) occurred in 8 patients (5.1%). Postoperative RF was observed in 20 patients (12.8%). Multivariate analysis showed the preoperative renal dysfunction (P = 0.042, OR = 4.41) and over seventy-year-old patients (P = 0.049, OR = 4.94) were found to be the risk factors of postoperative RF. There was a higher incidence of death (45%, P = 0.001) and PND (25%, P = 0.009) in the patients of postoperative RF when compared with the other patients. CONCLUSION: The preoperative renal dysfunction and elderly patients were found to be the risk factors of postoperative RF after type A dissection of aorta surgery.