Eryong Zhang

Treatment strategies for left subclavian artery during total arch replacement combined with stented elephant trunk implantation

OBJECTIVE One of the technical challenges in total arch replacement for type A aortic dissection is the left subclavian anastomosis and the descending aortic anastomosis. We present a technique that simplifies this surgery. METHODS A total of 33 consecutive patients (mean age, 48.0 ± 11.6 years) with acute Stanford type A aortic dissection who underwent a total arch replacement were included in this study. Instead of anastomosing the graft to the descending aorta distal to the left subclavian artery, we ligated the left subclavian artery and performed the distal aortic anastomosis between the left carotid artery and the left subclavian artery. The left subclavian artery is then revascularized with a side arm from our aortic graft through the first intercostal space to the left axillary artery. The descending aorta also is stented in an antegrade fashion under direct visualization. Both intraoperative and postoperative complications were then noted. RESULTS All enrolled patients underwent total arch replacement performed using this newly introduced technique with a mortality rate of 18.2% (6/33). The causes of mortality were multiorgan failure (4 patients), renal failure (1 patient), and postoperative sepsis (1 patient). There was no intraoperative death and no anastomotic leak in our study cohort. Limb ischemia was observed in 4 patients, with all occurring in the lower limb. Postoperative delirium also was observed in 5 patients. CONCLUSIONS The left subclavian artery bypass technique during total arch replacement for type A dissection is reliable and simplifies the surgery by bringing the descending aortic anastomosis more proximal and eliminating the difficult left subclavian artery anastomosis.

Intestinal Barrier Dysfunction: A Novel Therapeutic Target for Inflammatory Response in Acute Stanford Type A Aortic Dissection

Background: Intestinal barrier dysfunction would lead to a rigorous inflammatory reaction due to the translocation of intestinal lumen-derived bacteria and endotoxins. The aim of the present study was to investigate whether intestinal barrier dysfunction occurs in patients with acute Stanford type A aortic dissection (ATAAD) and to determine its potential relationship with the plasma levels of several inflammatory biomarkers in the progression of ATAAD. Design and Methods: Serum samples from a total of 46 patients with ATAAD and 36 healthy volunteers were prospectively collected and analyzed. The serum levels of diamine oxidase (DAO), lactate dehydrogenase (LDH), interleukin 6 (IL-6), tumor necrosis factor α (TNF-α), and C-reactive protein (CRP) were measured using colorimetric assay, enzyme-linked immunosorbent assay, and immunoturbidimetric assay. Results: Serum levels of DAO, LDH, IL-6, TNF-α, and CRP in patients with ATAAD were significantly higher than those in healthy participants. A significantly positive correlation between DAO activity and IL-6 (r = .56, P < .001), TNF-α (r = .63, P < .001), and CRP (r = .53, P < .001) was observed. Moreover, the activity of DAO correlated negatively with the Pao 2/fraction of inspired oxygen (Fio 2) ratio (r = −.39, P = .007). Conclusions: Intestinal barrier dysfunction, reflected by an increased level of serum DAO, may play an important role in the development of systemic inflammatory responses in patients with ATAAD. Therefore, strategies of preserving a normal intestinal barrier function may open new horizons in the treatment of inflammation-related adverse events in the setting of ATAAD.

Quadricuspid aortic valve by using intraoperative transesophageal echocardiography.

Quadricuspid aortic valve is a rare congenital malformation of the aortic valve. Its diagnosis is often missed even with the use of transthoracic echocardiogram. Many of these patients progress to aortic incompetence later in life, hence requiring surgical intervention.In the case described in this report, a 61-year-old woman is presented with the features of congestive heart failure. The preoperative transthoracic echocardiogram disclosed a moderate to severe aortic valve insufficiency but failed to reveal the quadricuspid aortic value anomaly. This case underscores the important role of three-dimensional transesophageal echocardiography for the diagnosis of quadricuspid aortic valve.

Sternal fractures and delayed cardiac tamponade due to a severe blunt chest trauma

Sternal fractures caused by blunt chest trauma are associated with an increased incidence of cardiac injury. Reports of the incidence of cardiac injury associated with sternal fracture range from 18% to 62%. Delayed cardiac tamponade is a rare phenomenon that appears days or weeks after injury. Moreover, after nonpenetrating chest trauma, cardiac tamponade is very rare and occurs in less than 1 of 1000. This case describes a patient who had delayed cardiac tamponade 17 days after a severe blunt chest trauma.

Intramuscular Lipoma as an Unusual Cause of Right Ventricular Outflow Tract Obstruction.

A 49-year-old woman was referred to our institution for the evaluation of new-onset atypical chest pain and exertional dyspnea. Transesophageal echocardiography detected a homogeneous, ill-defined mass (dimension of 61 mm 9 31 mm) adherent to the right ventricular wall (Fig. 1A). The mass had no stalk and protruded into the right ventricular outflow tract (RVOT) during systole, resulting in a peak pressure gradient of 45 mmHg across the RVOT (Fig. 1B, movie clip S1). Cardiac magnetic resonance imaging (MRI) showed high-signal-intensity mass on T1-weighted image (Fig. 1C, movie clip S2). On T2-weighted bright blood image

Epigallocatechin gallate attenuates mitochondrial DNA-induced inflammatory damage in the development of ventilator-induced lung injury

OBJECTIVE We aim to investigate the role of mitochondrial DNA (mtDNA), a novel endogenous pro-inflammatory cytokine, in the development of ventilator-induced lung injury (VILI). Moreover, the protective effect of epigallocatechin gallate (EGCG) on VILI through inhibiting local mtDNA release was examined. METHODS From March 2015 to March 2016, bronchoalveolar lavage fluid (BALF) from 36 patients with VILI and well-matched 36 patients without VILI after major surgery were consecutively collected. The expression levels of mtDNA and inflammatory cytokines in BALF were tested. SD rats were divided into five groups: control, low tidal volume (7 ml/kg) group, high tidal volume (HTV, 40 ml/kg) group, HTV+low dose EGCG and HTV+high dose EGCG groups. BALF were collected to examine the expression levels of mtDNA and several inflammatory cytokines and the lung tissue was harvested for pathological examinations. In addition, cyclic stretch cell culture was used and culture media was collected to analyze expressions of inflammatory cytokines. Administration of mtDNA in a rat model and in vitro cell culturing were used to confirm its pro-inflammatory properties in the development of inflammatory lung injury. RESULTS A Significant elevation of mtDNA was detected in BALF from patients with VILI (581 ± 193 vs. 311 ± 137, p < 0.05) and also in rats ventilated with HTV. EGCG could significantly inhibit HTV-induced local mtDNA release and attenuate the level of inflammatory lung injuries (reduced infiltration of local inflammatory cells, lower lung wet/dry ratio and expression levels of inflammatory cytokines). The beneficial effects of EGCG on preventing inflammatory lung injuries were in a concentration-dependent manner. Meanwhile, higher expression levels of mtDNA and inflammatory cytokines were observed in the media of cyclic stretched cell culture compared to those in the control group (p < 0.05). Furthermore, intra-tracheal administration of mtDNA in rats could lead to a marked increase of local inflammatory cytokines and subsequent inflammatory lung injuries (p < 0.05). And by adding mtDNA into the cell culture, higher level of inflammatory cytokines in the media was detected (p < 0.05). EGCG also showed preventive effects on inflammatory responses on a concentration-dependent manner (p < 0.05). CONCLUSION The increased expression level of mtDNA and subsequent inflammatory cytokines overproduction may play an important role in the development of VILI. EGCG may be a potential novel therapeutic candidate for protection against VILI by inhibiting the local release of mtDNA.

Bullet incarcerated in aortic root

A 47-year-old man was admitted to our emergency department with thoracic gunshot after 11 h. He complained no dizzy, headache, or short of breath. Physical examinations showed an …

Multiple images of pacemaker-related endocarditis and superior vena cava syndrome

A 32-year-old male was referred to our institution after developing a persistent fever and symptomatic superior vena cava (SVC) obstruction following implantation of a dual-chamber cardiac pacemaker 4 years earlier due to sick sinus syndrome (Fig. 1a). The physical examination was remarkable for swelling of the face, neck, and right arm and varicosities at the surface of the skin around the upper body. Three-dimensional volume-rendered images demonstrated numerous dilated superficial veins over the right chest (Fig. 1b). Contrast enhanced computed tomography (Fig. 1c) and venography (Fig. 1d, Video 1) revealed occlusion of SVC and brachiocephalic vein. Transesophageal echocardiography (TEE) further confirmed the obstruction of SVC due to a solid mass (Fig. 1e, Video 2), part of which was located at the right atrium and prolapsed into the right ventricle during diastole (Fig. 1f, Video 3). The patient underwent surgical intervention with the aid of cardiopulmonary bypass. After opening the right atrium, a 40x40x60 mm grey-yellowish mass attached to the pacing leads was identified (Fig. 1g). The mass within the atrial chamber was then completely excised (Fig. 1h-j, Video 4), and no vegetation or thrombus was observed at the tip of the ventricular lead. A new dual-chamber pacemaker with permanent epicardial pacing leads was implanted after the removal of the infected previous pacemaker and intracardiac wires (Fig. 1k). Histopathological examinations of the mass showed a mixture of thrombotic and fibrotic tissues, and cultures yielded no growth (Fig. 1l). Multiple images of pacemaker-related endocarditis and superior vena cava syndrome

Intraoperative Evaluation of Right Ventricular Outflow Tract Myxoma by Real Time Three-Dimensional Transesophageal Echocardiography

Cardiac myxoma arising form right ventricular outflow tract (RVOT) is extremely rare, but could cause major clinical sequelae and pose considerable diagnostic and therapeutic challenges. Here, we report the intraoperative application of real time three‐dimensional transesophageal echocardiography (RT3DTEE) in the assessment of a patient with a RVOT myxoma. RT3DTEE clearly assess the characteristics of the mass, such as the size, shape, attachment points, and composition. With the intraoperative guidance of RT3DTEE, the patient underwent successful removal of the mass.