Gui-Can Zhang

Extensive Primary Repair of the Thoracic Aorta in Acute Type A Aortic Dissection by Means of Ascending Aorta Replacement Combined With Open Placement of Triple-Branched Stent Graft Early Results

Background— To simplify extensive primary repair of the thoracic aorta in acute type A aortic dissection, we developed the open triple-branched stent graft placement technique. The early results of this new technique are reported. Methods and Results— Between June 2008 and November 2009, 30 patients with acute Stanford type A aortic dissection underwent extensive primary repair of the thoracic aorta by means of ascending aorta replacement combined with open placement of triple-branched stent graft. Placement of the triple-branched stent graft into the true lumen of the descending aorta, arch, and 3 arch vessels was technically successful in all patients. The mean cardiopulmonary bypass time, aortic cross-clamp time, and lower body arrest time were 151.8±16.69, 84.1±6.97, and 31.17±5.34 minutes, respectively. The postoperative mechanical ventilation support period and duration of intensive care unit stay were 17.93±2.35 and 62.10±9.24 hours, respectively. All implanted stent grafts were fully opened and not kinked; there was no space or blood flow surrounding the triple-branched stent graft and no sidearm graft stenosis or occlusion. The false lumen of the descending aorta distal to the stent graft closed with thrombus in 25 of 30 patients at their first postoperative scans and in 26 of 30 at the 3-month postoperative scan. Conclusions— Open triple-branched stent graft placement is an effective technique with satisfactory early results. With this technique, extensive primary repair of the thoracic aorta may become easier and safer for acute type A aortic dissection.

Intraoperative Device Closure of Doubly Committed Subarterial Ventricular Septal Defects: Initial Experience

BACKGROUND The purpose of this study was to evaluate the safety and feasibility of intraoperative device closure of the doubly committed subarterial ventricular septal defect (VSD). METHODS From January 2009 to January 2010, we enrolled 15 patients with doubly committed subarterial VSD who underwent intraoperative device closure in our institution. Our method involved a minimal inferior median incision that was performed after full evaluation of the doubly committed subarterial VSD by real-time transesophageal echocardiographic guidance, and the insertion of the device through the delivery sheath to occlude the VSD. The proper size of the device was determined by means of transesophageal echocardiographic analysis. An asymmetric, domestically made device was chosen for closure (Shanghai Xingzhuangjiyi Alloy Material Co, Ltd). RESULTS Implantation was ultimately successful in 13 patients (86.7%). The complete closure rates at 24 hours and 3 months were 69.2% and 100%, respectively. In 5 of 13 patients, minor complications occurred: transient arrhythmia (n = 5) and blood transfusion (n = 3). In a follow-up period of 1 to 12 months there was no residual shunt, noticeable aortic regurgitation, significant arrhythmias, thrombosis, or device failure. CONCLUSIONS Minimally invasive transthoracic device closure of the doubly committed subarterial VSD with an asymmetric domestically made device without cardiopulmonary bypass is safe and feasible under transesophageal echocardiographic guidance. However, it is necessary to evaluate the long-term results.

Total Arch Repair for Acute Type A Aortic Dissection With 2 Modified Techniques: Open Single-Branched Stent Graft Placement and Reinforcement of the Dissected Arch Vessel Stump With Stent Graft

Background— In total arch replacement for patients with acute type A aortic dissection, anastomoses of the graft to the left subclavian artery and descending aorta are often difficult, and the arch vessel anastomosis is frequently performed at the site of dissection. To make this procedure easier and safer, we developed 2 modified techniques: open single-branched stent graft placement into the left subclavian artery and the descending aorta and reinforcement of the dissected arch vessel stump with a stent graft neointima. The feasibility and initial clinical results of these 2 new techniques are reported. Methods and Results— Total arch repair with the 2 new techniques was performed in 26 patients with acute Stanford type A aortic dissection. Most patients had an uneventful postoperative course, and there were no surgical deaths. All implanted stent grafts were fully opened and not kinked, and there was no space or blood flow surrounding any of the stent grafts. The false lumen of the descending thoracic aorta closed with thrombus formation in 22 of 26 patients. Disappearance of the false lumen and recovery of the true lumen was observed in all of the dissected arch vessels. Conclusions— Open single-branched stent graft placement into the left subclavian artery and the descending aorta and reinforcement of the dissected arch vessel stump with a stent graft neointima are 2 simple and effective techniques that should make total arch repair an easier and safer procedure for acute type A aortic dissection.

Total arch repair with open triple-branched stent graft placement for acute type A aortic dissection: Experience with 122 patients

OBJECTIVE To summarize the clinical experiences and midterm follow-up results of total arch repair with open triple-branched stent graft placement for acute type A aortic dissection. METHODS From June 2008 to March 2013, 122 patients (95 men and 27 women; mean age, 50.9 ± 10.4 years) with acute type A aortic dissection underwent total arch repair with open placement of a triple-branched stent graft under hypothermic cardiopulmonary bypass and selective cerebral perfusion. During the follow-up period, enhanced computed tomography and echocardiography were performed at 3 months postoperatively and annually thereafter. RESULTS Placement of the triple-branched stent graft into the true lumen of the descending aorta, arch, and 3 arch vessels was technically successful in 121 patients. The cardiopulmonary bypass time was 186.50 ± 38.23 minutes, and the selective antegrade cerebral perfusion time was 31.97 ± 10.08 minutes. The in-hospital mortality was 4.93%. No permanent neurologic dysfunction or paraplegia was observed. Three patients were lost to follow-up. The mean follow-up period was 30.24 ± 12.35 months. After hospital discharge, 3 patients died. On the 3-month postoperative scans, complete thrombus formation around the triple-branched stent graft was observed in 89.38% of the patients. Endoleaks were detected in 12 patients; 8 patients refused any management for the endoleaks, but they maintained a good quality of life. The other 4 patients were successfully treated by additional surgery. CONCLUSIONS Total arch repair with open triple-branched stent graft placement is an effective technique with satisfactory early and midterm results. This technique could be an attractive alternative to conventional total arch replacement.

Intraoperative device closure of perimembranous ventricular septal defects: another safe and feasible alternative to surgical repair in infants

OBJECTIVES Conventional surgical closure has been considered the gold standard for the treatment of perimembranous ventricular septal defects (PVSDs) in infants for many years, but it requires a cardiopulmonary bypass and midline sternotomy which can lead to both physical and psychological trauma in the future. An intraoperative device closure can be performed with the advantages of reduced invasion, faster recovery and so on. We evaluate the safety and feasibility of intraoperative device closure of PVSDs in infants in comparison with surgical closure. METHODS One hundred eighty-six infants with a PVSD were enrolled in our study. Among them, 97 patients were treated by surgical closure and 89 were treated by intraoperative device closure. The success rates, complications, length of hospital stay and costs were measured. RESULTS The success rate was similar (P = 0.228) in the two groups: 87/89 patients (97.8%) in the device group versus 97/97 patients (100%) in the surgical group. Complication needs management was required in one patient of the device group (1.1%) and in two patients of the surgical group (2.0%) (P = 1.000). Minor complications were observed in 7/87 patients (8.0%) of the device group versus 15/99 patients (15.2%) of the surgical group (P < 0.001). Both groups were similarly effective in reducing the left ventricular end-diastolic dimension, pulmonary arterial pressure and cardiothoracic rate. The procedure time, inpatient stay and intensive care unit stay are shorter in the device group; the total cost was similar for both groups. CONCLUSIONS Intraoperative device closure of PVSDs under real-time transoesophageal echocardiography guidance is safe and feasible without CPB. Under the right conditions, intraoperative device closure can be a good alternative to surgical closure for the treatment of PVSDs in infants.

No association of functional variant in pri-miR-218 and risk of congenital heart disease in a Chinese population.

BACKGROUND MiR-218 plays an important role in heart development in zebrafish. pri-miR-218 rs11134527 variant is associated with cervical cancer carcinogenesis. Therefore, we hypothesized that single nucleotide polymorphism (SNPs) in pri-miR-218 might influence susceptibility to sporadic congenital heart disease (CHD). METHODS AND RESULTS We conducted a case-control study of CHD in a Chinese population to test our hypothesis by sequencing and genotyping pri-miR-218 in 1116 CHD cases and 1219 non-CHD controls. We identified one SNP rs11134527 located in pri-miR-218 sequence. Logistic regression analyses showed that there was no significant association in genotype and allele frequencies of pri-miR-218 rs11134527 A/G polymorphism between CHD cases in overall or various subtypes and the control group. However, real-time PCR analysis showed that rs11134527 allele G significantly increased mature miR-218 expression. In vitro binding assays further revealed that the rs11134527 variant affects miR-218-mediated regulation of Robo1. CONCLUSIONS This is the first study to investigate the relationship between miR-218 and CHD cases. Our results demonstrate that the functional variant rs11134527 in pri-miR-218 has no major role in genetic susceptibility to sporadic CHD, at least in the population studied here.

Intraoperative device closure of perimembranous ventricular septal defects in the young children under transthoracic echocardiographic guidance; initial experience

ObjectivesThis study aimed to assess the safety and feasibility of intraoperative device closure of perimembranous ventricular septal defects (VSD) in young children guided by transthoracic echocardiography (TTE).MethodsWe enrolled 18 patients from our hospital to participate in the study from June 2011 to September 2011. A minimal inferior median incision was performed after full evaluation of the perimembranous VSD by real-time TTE, and a domestically made device was inserted to occlude the perimembranous VSD. The proper size of the device was determined by means of transthoracic echocardiographic analysis.ResultsImplantation was ultimately successful in 16 patients using TTE guidance. In these cases, the complete closure rate immediately following the operation and on subsequent follow-up was 100%. Symmetric devices were used in 14 patients, and asymmetric devices were used in two patients. Two patient were transformed to surgical treatment, one for significant residual shunting, and the other for unsuccessful wire penetration of the VSD. The follow-up periods were less than nine months, and only one patient had mild aortic regurgitation. There were no instances of residual shunt, noticeable aortic regurgitation, significant arrhythmia, thrombosis, or device failure.ConclusionsMinimally invasive transthoracic device closure of perimembranous VSDs is safe and feasible, using a domestically made device under transthoracic echocardiographic guidance, without the need for cardiopulmonary bypass. This technique should be considered an acceptable alternative to surgery or device closure guided by transesophageal echocardiography in selected young children. However, a long-term evaluation of outcomes is necessary.

Closure of perimembranous ventricular septal defects with intraoperative device technique: another safe alternative to surgical repair.

OBJECTIVES This study aims at assessing the safety and feasibility of intraoperative device closure of the perimembranous ventricular septal defect (VSD). METHODS Total 89 patients in group I with intraoperative device closure and 58 in group II with surgical repair were enrolled in our hospital to participate in the study from January 2009 to December 2010. In group I, the approach involved a minimal inferior median incision that was performed after full evaluation of the perimembranous VSD by real-time transesophageal echocardiographic guidance, and the insertion of an asymmetric or a symmetric domestically made device was used to occlude the perimembranous VSD. RESULTS In group I, 83 patients were occluded successfully under this approach. The size of the occluder implanted ranged from 6 to 14 mm. Complete atrioventricular block occurred in one case and Mobitz type II atrioventricular block occurred in one case during the procedure. One patient presented complete atrioventricular block one week after the operation. Two patients converted to surgical repair because of severe intraoperative aortic valve regurgitation. One patient with significant residual shunt transformed to surgical treatment. In our comparative studies, patients in group II experienced significantly longer operative time, ICU stay, and hospital stay (p < 0.001). The cost of group I was less than that of group II (p < 0.001). CONCLUSIONS Minimally invasive transthoracic device closure of the perimembranous VSD with an asymmetric or a symmetric domestically made device without cardiopulmonary bypass is safe and feasible. It should be considered an acceptable alternative to surgery in selected subgroups. However, it is necessary to evaluate the long-term results.

Transthoracic echocardiographic guidance of minimally invasive perventricular device closure of perimembranous ventricular septal defect without cardiopulmonary bypass: initial experience

BACKGROUND Our purpose was to investigate the feasibility of transthoracic echocardiographic (TTE) guidance for minimally invasive periventricular device closure of perimembranous ventricular septal defects (VSDs). METHODS From June 2011 to September 2011, we enrolled 18 young children with perimembranous VSDs to receive minimally invasive device closure in our hospital. All of the patients were examined by TTE to determine the VSD morphology, diameter, and rims. During intra-operative device closure, real-time bedside TTE alone was used to guide device implantation. RESULTS Device implantation using TTE guidance was successful in 16 patients. Symmetric devices were used in 14 patients, and asymmetric devices were used in 2 patients. Only one patient experienced mild aortic regurgitation, and there were no instances of residual shunt, significant arrhythmias, thromboembolism, or device displacement. Two patients were transferred to surgical closure, one due to residual shunting and the other as a result of unsuccessful wire penetration of the VSD gap. CONCLUSIONS Our data indicate that TTE-guided VSD closure is feasible in young children, although a longer follow-up may be needed to document the long-term success.

Open-Branched Stent Graft Placement Makes Total Arch Replacement Easier for Acute Type A Aortic Dissection

In total arch replacement for acute type A aortic dissection, the left subclavian artery anastomosis and the distal anastomosis at the descending aorta are often remarkably difficult because of the deep surgical field. We developed a single-branched stent graft that was constructed by adding a side arm stent-graft to a conventional aortic stent graft. By its open placement into the origin of the left subclavian artery and the descending aorta, the left subclavian artery anastomosis could be avoided, and the distal aortic anastomosis was performed at the proximal arch between the brachiocephalic artery and the left common carotid artery.