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Early and Mid-term Outcomes of Morphologic Tricuspid Valve Replacement with Preservation of Entire Valvular and Subvalvular Apparatus in Corrected Transposition of Great Arteries

Abstract： Objective To investigate the early and mid-term outcomes of morphologic tricuspid valve replacement by means of intravalvular implantation in corrected transposition of great arteries（cTGA）. Methods From January 2009 to January 2012，11 patients with cTGA were surgically treated in Fu Wai Hospital. There were 9 male patients and 2 female patients with their mean of age of（37.8±11.7）years and mean body weight of（73.0±11.3）kg. All the patients underwent morphologic tricuspid valve replacement with preservation of the entire valvular and subvalvular apparatus. Simultaneous surgical procedures included repair of ventricular septal defect in 2 patients，repair of atrial septal defect in 4 patients，pulmonary valvuloplasty in 1 patient，reconstruction of functional right ventricular outflow tract in 4 patients and repair of coronary-pulmonary artery fistula in 1 patient. Postoperative New York Heart Association （NYHA） classification, cardiothoracic ratio, morphological right ventricle ejection fraction, end-diastolic dimension of morphological right ventricle and left atrium were evaluated during follow-up. Results All the 11 patients were successfully surgically treated and followed up for an average duration of（13.0±10.6）months. There was no statistical difference between postoperative and preoperative average cardiothoracic ratio （0.54±0.06 vs. 0.57±0.09，t=1.581，P＞0.05），morphologic right ventricle ejection fraction （52.8%±9.0% vs. 54.9%±9.5%, t =0.712，P＞0.05），and end-diastolic dimension of . morphological right ventricle （54.3±7.5 mm vs. 56.9±9.2 mm，t =0.988，P＞0.05）. There was statistical difference between postoperative and preoperative average end-diastolic dimension of left atrium（42.1±8.9 mm vs. 53.4±11.1 mm，t =3.286，P＜0.05）and NYHA classification（Z = -2.640，P＜0.05）. Conclusion Intravalvular implantation of morphologic tricuspid prosthesis can protect the physiological structure of morphologic right ventricular and prevent furtherdamage to its function caused by morphologic tricuspid valve insufficiency. Postoperative dimension of morphologic left atrium and cardiac function are significantly improved. The early and mid-term outcomes are satisfactory．

影响冠状动脉旁路移植术加心瓣膜手术患者远期预后的危险因素分析

摘要： 目的 探讨影响行冠状动脉旁路移植术（CABG）加心瓣膜手术患者远期预后的危险因素。 方法 2003年1～10月北京阜外心血管病医院共收治冠状动脉粥样硬化性心脏病合并心瓣膜疾病患者68例，纳入研究66例(院内死亡2例)，男23例，女43例；年龄50～76岁(61.33±6.60岁)。行CABG+主动脉瓣手术19例，CABG+二尖瓣手术32例，CABG+双瓣膜手术15例；移植血管1.79±1.18支。先将各变量分别进行Cox风险模型单变量分析，再将所有有统计学意义的变量同时纳入Cox风险模型多变量分析。 结果 随访65例，随访时间50.65±17.98个月，随访期间死亡11例，其中死于胃癌2例，抗凝并发症脑出血1例，心源性猝死4例和心力衰竭4例。失访1例。Cox风险模型多变量分析结果显示：左心室射血分数（LVEF）≤40%（RR=5.960，P=0.010）、术前有糖尿病史（RR=7.170，P=0.004）是影响患者术后远期预后的独立危险因素。 结论 LVEF和术前有糖尿病史是影响CABG加心瓣膜手术患者远期预后的危险因素，术后严格控制血糖和提高心功能能改善患者的远期预后。

心瓣膜置换术后电机械分离五例

Validation of Four Different Risk Stratification Models in Predicting Early Death of Chinese Patients after Isolated Coronary Artery Bypass Grafting Surgery

Abstract: Objectives To evaluate the accuracy of four existing risk stratification models including the Society of Thoracic Surgeons(STS) 2008 Cardiac Surgery Risk Models for Coronary Artery Bypass Grafting (CABG), the European System for Cardiac Operative Risk Evaluation (EuroSCORE), the American College of Cardiology/American Heart Association (ACC/AHA) model, and the initial Parsonnet’s score in predicting early deaths of Chinese patients after CABG procedure. Methods We collected clinical records of 1 559 consecutive patients who had undergone isolated CABG in the Fu WaiHospital from November 2006 to December 2007. There were 264 females (16.93%) and 1 295 males (83.06%) with an average age of 60.87±9.06 years. Early death was defined as death inhospital or within 30 days after CABG. Calibration was assessed by the Hosmer-Lemeshow (H-L) test, and discrimination was assessed by the receiveroperatingcharacteristic (ROC) curve. The endpoint was early death. Results Sixteen patients(1.03%) died early after the operation. STS and ACC/AHA models had a good calibration in predicting the number of early deaths for the whole group(STS: 12.06 deaths, 95% confidence interval(CI) 5.28 to 18.85; ACC/[CM(159mm]AHA:20.67deaths, 95%CI 11.82 to 29.52 ), While EuroSCORE and Parsonnet models overestimated the number of early deaths for the whole group(EuroSCORE：36.44 deaths，95%CI 24.75 to 48.14；Parsonnet：43.87 deaths，95%CI 31.07 to 56.67). For the divided groups, STS model had a good calibration of prediction(χ2=11.46, Pgt;0.1)，while the other 3 models showed poor calibration（EuroSCORE：χ2=22.07，Plt;0.005；ACC/AHA：χ2=28.85，Plt;0.005；Parsonnet：χ2=26.74，Plt;0.005）.All the four models showed poor discrimination with area under the ROC curve lower than 0.8. Conclusion The STS model may be a potential appropriate choice for Chinese patients undergoing isolated CABG procedure.

心脏直视术后回输胸腔引流血30例

目的 探讨心脏直视术后回输未经洗涤的胸腔引流血的安全性和该技术对术后胸腔引流血量及库血需要量的影响. 方法 观察60例冠状动脉旁路移植术患者,并将其分为回输组和对照组,每组30例,分别测定两组血红蛋白、红细胞压积、红细胞计数和血小板计数. 结果 两组术后胸腔引流血差别无显著性意义,回输组患者引流血回输量为150～780 ml,平均280±155 ml ,节省库血40%.两组患者均未发生术后高热. 结论 心脏直视术后回输未经洗涤的胸腔引流血是安全、经济的,并可减少库血需要量.

Emergency surgery on severe myocardium ischemia of early post-coronary artery bypass grafting

Objective To summarize the experience of emergency coronary artery bypass grafting(CABG) on serious myocardium ischemia in early post CABG. Methods Between 1998 and 2002, emergency redo CABG was performed in 13 patients with serious early post operative myocardium ischemia. The causes included vein graft embolize(4 cases),uncompleted revascularize(3 cases), graft spasm(1 case) and anastomose stenosis or occlusion (5 cases). The grafts was 1 3(1.8±0.9) during redo CABG. Results There were 6 deaths, the mortality was 46%. The mean follow up was 31 months. There was no recurrence of angina. NYHA function was Ⅰ Ⅱ. Conclusion Emergency CABG is an important method in saving the patients with severe myocardium ischemia in early post CABG. The perioperative prevention and early treatment should be emphasized.

Surgical Treatment of Pulmonary Atresia with Ventricular Septal Defect in Elder Children and Adults

Objective To investigate the surgical treatment methods and effects for pulmonary atresia with ventricular septal defect (PAVSD) in elder children and adults in order to promote the treatment effects. Methods From October 1996 to October 2008, we performed stage1 or staged biventricular repair on 39 PAVSD patients including 21 males and 18 females, ranging from 8 to 27 years old with an average age of 13.43 years. There were 14 cases of type A, 11 cases of type B, and 14 cases of type C. Among them, 23 patients underwent stage1 radical repair in which either human blood vessel with valves or bovine jugular vein with valves were used to connect the pulmonary artery and the right ventricular outflow tract. In these 23 patients, 3 patients complicated with major aortopulmonary collaterals(MAPCAs) underwent unifocalization (UF) operation. The other 16 patients received staged repair, including 9 cases of systemic to pulmonary artery shunt and 7 of staged radical cure. Results There were 6 perioperative deaths with a total mortality of 15.38%(6/39), including 4 (17.39%) stage1 radical repair cases and 2 (12.50%) staged radical repair cases. The former 4 were all type C patients, dying from low cardiac output due to increased pulmonary arterial pressure. In the latter 2 deaths, 1 was a type B secondary shunt patient, and the other was a type C staged radical repair case, both of whom died of bleeding caused by aortic injury in the succeeding operations. Followup was done on 28 cases with a followup rate of 84.85%. The followup time ranged from 14.0 months to 9.2 years with 5 cases missing. No patient died during the followup, and 9 patients maintained their cardiac function at class Ⅰ, 13 at class Ⅱ, 5 at class Ⅲ and 1 at class Ⅳ. Three patients had aortic valve regurgitation of small to medium volume, the treatment of which included an administration of oral potassium diuretic medication and regular follow-up. Conclusion Pulmonary vessels of elder children and adults with PAVSD are usually injured severely and oftentimes it is complicated with MAPCAs. Standard for stage1 radical repair should be defined more strictly based on the present one.

《瓣膜病术后抗凝个体化和低抗凝标准研究》 阶段研究进展

先天性心脏病三尖瓣关闭不全的外科治疗

目的　为提高先天性心脏病三尖瓣关闭不全外科治疗的疗效 ,总结其外科治疗经验。　方法　 1995～2 0 0 1年 ,共收治 16例先天性心脏病三尖瓣关闭不全患者 ,三尖瓣中度反流 3例 ,重度反流 13例。行单纯 De Vega环缩术 7例 ,De Vega环缩加前叶腱束缩短、隔叶腱束转移、裂修补和前叶自体心包扩大术各 1例 ,应用三尖瓣人工瓣环 3例 ,三尖瓣置换术 2例。　结果　全组无手术死亡。随访所有患者 ,平均随访 38个月 ,1例单纯 De Vega环缩术患者于术后 4年出现中至重度三尖瓣关闭不全。　结论　先天性心脏病三尖瓣关闭不全患者的外科治疗首选三尖瓣成形术 ,De Vega成形术环缩瓣环方法简便、有效。

Modified De Vega Annuloplasty Is Superior to Traditional De Vega Technique

Objective To compare the efficacy of one kind of modified De Vega technique and traditional De Vega technique. Methods From January 2002 to August 2005, 70 patients were treated with tricuspid valve plasty. These patients were divided into modified De Vega annuloplasty group and traditional De Vega annuloplasty group randomly before operation. The tricuspid regurgitation （TR） were functional and secondary in all patients. The grade of TR and New York Heart Association（NYHA） functional class of two groups were analyzed by Ridit analysis. The changes of right ventricular end-diastolic dimension of two groups were analyzed by paired-sample t test. Results There was no statistically difference between two groups about preoperative characteristics. The follow-up time of modified De Vega annuloplasty group was 12.91±8.84 months and that of traditional De Vega annuloplasty group was 13.61±11.21 months. There was no significant difference between two groups. The outcome of follow-up was satisfactory. In modified De Vega annuloplasty group, there were 12 patient with no TR, 17 patient with mild TR, and 6 patients with moderate TR. There was no patient with severe TR. In traditional De Vega annuloplasty group, 7 patients were observed with no TR, 19 patients mild TR, 7 patients moderate TR and 2 patients severe TR. In modified De Vega annuloplasty group, 32 patients were in NYHA class Ⅰ, 2 patients in NYHA class Ⅱ and only 1 patient in NYHA class Ⅲ. As for traditional De Vega annuloplasty group, 31 patients were in NYHA class Ⅰ, 2 patients in NYHA class Ⅱ and 2 patients in NYHA class Ⅲ. The Ridit analysis showed that there was no significant difference about NYHA class between two groups. However, the difference of TR between two groups was statistically significant （P〈0.05）. The outcome of modified De Vega annuloplasty was superior to that of traditional De Vega technique. Paired-sample t test demonstrated that the modified De Vega annuloplasty could reduce the right ventricular end-diastolic dimension significantly （P〈0.05）. However, the right ventricular end-diastolic dimension of traditional De Vega annuloplasty groups did not change significantly （P 〉 0.05）. Conclusion The efficacy of modified tricuspid De Vega technique is superior to that of traditional De Vega technique in patients with secondary TR.