Pulmonary oligemia maneuver can alleviate pulmonary artery injury during pulmonary thromboendarterectomy procedure / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>Pulmonary thromboendarterectomy (PTE) has evolved as a treatment of choice for chronic thromboembolic pulmonary hypertension (CTEPH). This study aimed to characterize if pulmonary oligemia maneuver (POM) can alleviate pulmonary artery injury during PTE procedure.</p><p><b>METHODS</b>A total of 112 cases of CTEPH admitted to Beijing Anzhen Hospital from March 2002 to August 2011 received PTE procedure. They were retrospectively classified as non-POM group (group A, n = 55) or POM group (group B, n = 57). Members from group B received POM during rewarming period, whereas members from group A did not.</p><p><b>RESULTS</b>There were three (5.45%) early deaths in group A, no death in group B (0) (Fisher's exact test, P = 0.118). Six patients in group A needed extracorporeal membrane oxygenation (ECMO) as life support after the PTE procedure, no patients in group B needed ECMO (Fisher's exact test, P = 0.013). The patients in group B had a shorter intubation and ICU stay, lower mean pulmonary arterial pressure (mPAP) and pulmonary vascular resistance (PVR), higher partial pressure of oxygen in artery (PaO2) and arterial oxygen saturation (SaO2) and less medical expenditure than patients in group A. With a mean follow-up time of (58.3 ± 30.6) months, two patients in group A and one patient in group B died. The difference of the actuarial survival after the procedure between the two groups did not reach statistical significance. Three months post the PTE procedure, the difference of residual occluded pulmonary segment between the two groups did not reach statistical significance (P = 0.393).</p><p><b>CONCLUSION</b>POM can alleviate pulmonary artery injury, shorten ICU stay and intubation time, and lower down the rate of ECMO after PTE procedure.</p>

High volume practice proved the safety of off-pump coronary artery bypass surgery in left main coronary artery lesions: a two-year single center experience / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>Left main coronary artery (LMCA) stenosis has been recognized as a risk factor for early death among patients undergoing coronary artery bypass grafting (CABG). This study aimed to assess if LMCA lesions pose an additional risk of early or mid-term mortality and/or a major adverse cardiac and cerebrovascular event (MACCE) after off-pump coronary artery bypass grafting (OPCABG), compared with non-left main coronary artery stenosis (non-mainstem disease).</p><p><b>METHODS</b>From January 1, 2009 to December 31, 2010, 4869 patients had a primary isolated OPCABG procedure at Beijing Anzhen Hospital. According to the pathology of LMCA lesions, they were retrospectively classified as a non-mainstem disease group (n = 3933) or a LMCA group (n = 936). Propensity scores were used to match the two groups, patients from the non-mainstem disease group (n = 831) were also randomly selected to match patients from the LMCA group (n = 831). Freedom from MACCE in the two groups was calculated using the Kaplan-Meier method.</p><p><b>RESULTS</b>The difference in the mortality and the rate of MACCE during the first 30 days between the non-mainstem disease group and the LMCA group did not reach statistical significance (P = 0.429, P = 0.127 respectively). With a mean follow-up of (12.8 ± 7.5) months and a cumulative follow-up of 1769.6 patient-years, the difference in the freedom from MACCEs between the two groups, calculated through Kaplan-Meier method, did not reach statistical significance (P = 0.831).</p><p><b>CONCLUSION</b>Analysis of a high volume of OPCABG procedures proved that LMCA lesions do not pose additional early and mid-term risk to OPCABG. Therefore, a LMCA lesion is as safe as non-mainstem disease lesion during the OPCABG procedure.</p>

The management of acute pulmonary arterial hypertension.

Acute pulmonary arterial hypertension (PAH), which may complicate the course of many complex disorders, is always underdiagnosed and its treatment frequently begins only after serious complications have developed. Acute PAH is distinctive because they differ in their clinical presentation, diagnostic findings, and response to treatment from chronic PAH. The acute PAH may take either the form of acute onset of chronic PAH or acute PAH or surgery-related PAH. Significant pathophysiologic differences existed between acute and chronic PAH. Therapy of acute PAH should generally be aimed at acutely relieving right ventricular (RV) pressure overload and preventing RV dysfunction. There are three classes of drugs targeting the correction of abnormalities in endothelial dysfunction, which have been approved recently for the treatment of PAH: (1) prostanoids; (2) endothelin receptor antagonists; and (3) phosphodiesterase-5 inhibitors. The efficacy and safety of these compounds have been confirmed in uncontrolled studies in patients with PAH. Intravenous epoprostenol is suggested to serve as the first-line treatment for the most severe patients. In the other situations, the first-line therapy may include bosentan, sildenafil, or a prostacyclin analogue. Recent advances in the management of PAH have markedly improved prognosis.

The early and middle-long term clinical results of surgical treatment for ventricular septal rupture / 中华外科杂志

<p><b>OBJECTIVE</b>To explore the way of promoting the efficacy of surgical treatment for ventricular septal rupture (VSR) after acute myocardium infarction in terms of perioperative and long term survival.</p><p><b>METHODS</b>The clinic data of 37 VSR cases underwent surgical treatment from October 1994 to October 2007 were analyzed retrospectively. There were 24 male and 13 female, and the age was (63.4 +/- 7.6) years old. The whole group was divided into the VSR repair plus revascularization group (group A, 26 cases) and simple VSR repair group (group B, 11 cases).</p><p><b>RESULTS</b>There were 4 operative deaths in group A (15.4%), 7 deaths in group B (63.6%), P = 0.006. With the follow-up of (34.0 +/- 29.8) months ranged from 2 to 103 months of the 26 operational survivors, there were 5 late deaths, of which 2 deaths in group A and 3 deaths in group B. According to the Kaplan-Meier survival curve, the actuarial survival rate at 6 to 8 year was (64.3 +/- 21.0)% for group A and the actuarial survival rate at 4 year was (25.0 +/- 21.7)% for group B, P = 0.011. Of the 21 mid-long term survivors, 17 cases were in NYHA class I to II and 4 cases in NYHA class III to IV. There were 4 cases suffered from VSR recurrence. According to Logistic regression, the risk factors for the early death were not adoptive of revascularization, cardiogenic shock and emergency surgical procedure, while the risk factors for late death were not adoptive of revascularization and low cardiac output after the procedures.</p><p><b>CONCLUSIONS</b>VSR repair plus revascularization could improve the perioperative and mid-long term survival for the surgical treatment of VSR. The appropriate timing and procedures of the surgical operation are very important to promote perioperative survival and to prevent VSR recurrence.</p>

Prognosis of patients with chronic thromboembolic pulmonary hypertension receiving conservative or operative treatments according to a new clinical classification scheme / 中华心血管病杂志

<p><b>OBJECTIVE</b>To compare the efficacy of conservative or pulmonary thromboendarterectomy (PTE) therapy for chronic thromboembolic pulmonary hypertension (CTEPH) patients according to a new clinical classification scheme.</p><p><b>METHODS</b>This retrospective study analyzed 63 cases of CTEPH admitted to our hospital from February 1995 to October 2007 and 45 cases were treated surgically (Group A) and 18 cases received conservative therapy (Group B). Results were analyzed using Fisher exact test and t test according to San Diego medical center quartering classification scheme and Anzhen Hospital modified bifurcate classification scheme.</p><p><b>RESULTS</b>There were 6 operational deaths in Group A and 2 deaths during hospital stay in Group B. During follow-ups (mean 3.6 +/- 2.5 years), there were 4 deaths in Group A and 9 deaths in Group B. the totality survival rate is significantly higher in Group A than that in Group B (P < 0.05). For patients with San Diego Type I CTEPH, survival rate was significantly higher in Group A compared with Group B (P = 0.009) and was similar for patients with type II and III and IV CTEPH between the two groups (P = 0.338, 0.455, 0.800). Survival rate was significantly higher in Group A than that in Group B for patients with Anzhen central type CTEPH (P = 0.009), but was similar between the two groups for patients with Anzhen peripheral type CTEPH (P = 0.125). The Kaplan-Meier survival curve 5 years survival rate in the Group A was (91.7 +/- 8.0)% for Anzhen central type and (76.0 +/- 8.5)% for Anzhen peripheral type (P = 0.04), and the 5 years Kaplan-Meier survival rate in the Group B was (42.9 +/- 18.7)% for Anzhen central type and (56.2 +/- 10.8)% for Anzhen peripheral type (P = 0.851).</p><p><b>CONCLUSION</b>Anzhen Hospital modified bifurcate classification scheme is a simple and effective classification to predict the prognosis and choose treatment method of CTEPH.</p>

The clinical analysis of 54 cases for the surgical treatment of pulmonary embolism / 中华外科杂志

<p><b>OBJECTIVE</b>To evaluate the results of surgical procedures for pulmonary embolism.</p><p><b>METHODS</b>Fifty-four patients of pulmonary embolism received surgical treatment from October 1994 to June 2007, of which 9 were acute pulmonary embolism underwent pulmonary embolectomy and 45 patients were chronic thromboembolic pulmonary hypertension (CTEPH) underwent pulmonary thromboendarterectomy.</p><p><b>RESULTS</b>The mortality rate was 44.4% in acute pulmonary embolism group and 13.3% in CTEPH group (P < 0. 05). Thirteen patients had residual pulmonary hypertension and 23 patients had severe pulmonary reperfusion injury postoperatively. The pulmonary artery systolic pressure changed from (89.4 +/- 36.3) mm Hg (1 mm Hg =0.133 kPa) preoperative to (55.6 +/- 22.4) mm Hg postoperative. The pulmonary vascular resistance changed from (89. 7 +/- 56.7) kPa L(-1) S(-1) preoperative to (38.9 +/- 31.1) kPa L(-1) S(-1) postoperative. The arterial partial pressure of oxygen changed from (52. 3 +/- 6.7 ) mm Hg preoperative to (87.6 +/- 6.5) mm Hg postoperative. The arterial oxygen saturation changed from (88.9 +/- 4.5)% preoperative to (95.3 +/- 2.8 )% postoperative (P < 0.05). With the follow-up of (41.8 +/- 36.4) months, there were 4 patients died. According to NYHA, there were 28 patients for class I , 10 patients for class II and 2 patients for class III. According to Kaplan-Meier survival curve, the 3-year, 4-year, 5-year and 8-year survival rate were (97.1 +/- 2.8 )%, (94.0 +/- 4.1)%, (90.8 +/- 5.2)% and (85.0 +/- 7.3)% respectively. Linear rate of bleeding and thromboembolic related to anticoagulation were 0. 63% patient-years and 0. 62% patient-years respectively.</p><p><b>CONCLUSIONS</b>The operational mortality of acute pulmonary embolism is significantly higher than CTEPH, and the mid-long term survival rate is agreeable and the complication rate related to anticoagulation is relatively low.</p>

Repair of anterior leaflet mitral valve prolapse: the comparison between chordal replacement and chordal shortening / 中华外科杂志

<p><b>OBJECTIVE</b>To compare the relative merits between chordal shortening and artificial chordae to repair the anterior leaflet prolapses (ALP).</p><p><b>METHODS</b>The clinic data of 50 cases underwent repair of ALP from March 1990 to March 2008 were analyzed retrospectively. There were 29 male and 21 female patients with a mean age of (42.6 +/- 11.3) years old. There were 23 patients in chordal shortening group and 27 patients in artificial chordae group.</p><p><b>RESULTS</b>There were 3 operative deaths in chordal shortening group (13.0%), and 1 death in artificial chordae group (3.7%, P = 0.199). With a mean follow-up of (5.8 +/- 4.8) years and a total follow-up of 278 patient-years, there were 3 late deaths respectively in each group. According the Kaplan-Meier survival curve, the actuarial survival rate at 5-8 years was 70.0% +/- 18.2% for chordal shortening group and 86.8% +/- 9.2% for artificial chordae group (chi(2) = 8.17, P = 0.046). There were 5 reoperations, of which 4 in chordal shortening group and 1 in artificial chordae group. According to the Kaplan-Meier freedom from reoperation curve, the freedom from reoperation at 5 years was 83.3% +/- 15.2% for chordal shortening group and 100% for artificial chordae group (chi(2) = 12.06, P = 0.007). The COX proportional hazard regressions revealed that chordal-shortening technique was the independent risk predictor for the late cardiac event after ALP surgical repair.</p><p><b>CONCLUSION</b>Artificial chordae techniques has a relative superiority to chordal shortening for repair of mitral valve ALP.</p>

Experience on transplantation of auto-pulmonary graft treating with congenital aortic disease / 中华外科杂志

<p><b>OBJECTIVE</b>To summarize the experience on auto-pulmonary transplantation (Ross procedure) treating with congenital aortic disease.</p><p><b>METHODS</b>From October 1994 to November 2003, 20 cases of Ross procedure were performed to treat with congenital aortic disease, Male: 15 cases; Female: 5 cases; age: 25 years;</p><p><b>DIAGNOSIS</b>congenital heart disease (CHD), aortic abnormalities: 12 cases; aortic valve prolapse: 5 cases; aortic valve hypogenesis: 3 cases; combined with subacute bacterial endocarditis (SBE): 4 cases, and ventricle septal defect (VSD): 2 cases; UCG showed aortic stenosis(AS) and/or aortic insufficience (AI) (moderate to severe), Left ventricle diastole diameter (LVDD): (60.51 +/- 11.87) mm, the grade pressure across aortic valve: (27.04 +/- 6.80) mmHg, heart function (NYHA): Class II: 13 cases; Class III: 3 cases; all cases were performed under CPB and moderate hypothermia, the operation procedure was following: (1) taking off auto-pulmonary artery valve; (2) removing dysfunctional aortic valve and auto-transplantation of pulmonary valve on aortic root; (3) putting a pulmonary homograft to rebuild right ventricular outflow tract.</p><p><b>RESULTS</b>The mortality was 0 during stay at hospital, aortic valve function were all normal, LVDD decreased significantly (t = 3.4007, P = 0.0008), the grade pressure across aortic valve was in normal limitation, (6.8 +/- 0.19) mmHg. Follow-up showed heart function was in Class I (NYHA), aortic and pulmonary valve function was very well.</p><p><b>CONCLUSION</b>Ross procedure is a kind of effective alterative operation for treating with congenital aortic valve disease, with good short and middle term results.</p>