Jianping Xu

Surgical treatment of dissecting aneurysm of the interventricular septum.

OBJECTIVEnTo report a kind of extremely rare disease, dissecting aneurysm of the interventricular septum.nnnMETHODSnBetween May 1992 and January 1998, 4 patients underwent surgical treatment of dissecting aneurysm of the interventricular septum in Fuwai Hospital, Beijing. The cause of the disease was different in these four patients. Two patients may be attributable to the aneurysm of coronary sinus of valsava, 1 to the result of trauma, and the other to big perforation (diameter: 2 cm) in the bottom of the right coronary sinus of valsava, through which the blood rushed into the cavity of dissecting aneurysm of the interventricular septum. The aneurysm was resected or repaired in these patients. Three of them were subjected to aortic valve replacement and one received repair of the perforation of the right vaslava sinus.nnnRESULTSnTwo patients had successful reoperation and the other 2 suceeded in the first operation. All of them were uneventfully recovered.nnnCONCLUSIONSnThe development of dissecting aneurysm of the interventricular septum is rapid. Its prognosis is poor. Early diagnosis and operation are necessary. The pathogenic mechanism of dissecting aneurysm of the interventricular septum is unknown, but echocardiogram, electrocardiogram and nuclear magnetic resonance (NMR) are valuable for diagnosis. Surgical operation should involve the treatment of aortic valve disease. The wall of the aneurysm should be resected and the interventricular septum should be reconstructed. Good exposure can be obtained from the incision of the ascending aorta and right ventricular outflow tract. The A-V block should be treated simultaneously.

A new and simple classification for the non-coronary sinus of Valsalva aneurysm

OBJECTIVEnWe introduce a simple classification of the non-coronary sinus of Valsalva aneurysm, and suggest a different approach for the corresponding type of non-coronary sinus of Valsalva aneurysm.nnnMETHODSnBetween October 1996 and December 2009, 45 patients with non-coronary sinus of Valsalva aneurysm underwent surgical repair. Twenty-three were male and 22 female. The mean age was 32.80±11.77 years (range, 13-67 years). We divided them into two types, type I: rupture or protrusion into right atrium; and type II: rupture or protrusion into right atrium or right ventricle near or at the tricuspid annulus. For type I (n=32), the right atrium approach was chosen, using direct suture with patch repair. For type II (n=13), the transaortic approach with right atrium incision was chosen, with patch repair through an aortic incision and direct suture through a right atrium incision. Surgical results between types I and II were compared as regards cardiopulmonary bypass time, clamp aorta time, mechanical ventilation time, and intensive care unit time, and postoperative stay time.nnnRESULTSnThere was no early death after operation. There were no significant differences in cardiopulmonary bypass time, mechanical ventilation time, intensive care unit time, and postoperative stay time between two types (p>0.05). There was significant difference in clamp aorta time, with type II being longer than type I (p<0.05). Forty-three patients (93.33%) were followed up; one case of coronary artery disease using medication occurred, and there was no late death.nnnCONCLUSIONSnApproach through the right atrium or right atrium with aortotomy showed the same early surgical results. Our classification of non-coronary SVA is simple and practical for clinical usage.

Effect of Preoperatively Continued Aspirin Use on Early and Mid-Term Outcomes in Off-Pump Coronary Bypass Surgery: A Propensity Score-Matched Study of 1418 Patients

Background To date, effect of preoperatively continued aspirin administration in off-pump coronary artery bypass grafting (CABG) is less known. We aimed to assess the effect of preoperatively continued aspirin use on early and mid-term outcomes in patients receiving off-pump CABG. Methods From October 2009 to September 2013 at the Fuwai Hospital, 709 preoperative aspirin users were matched with unique 709 nonaspirin users using propensity score matching to obtain risk-adjusted outcome comparisons between the two groups. Early outcomes were in-hospital death, stroke, intra- and post-operative blood loss, reoperation for bleeding and blood product transfusion. Major adverse cardiac events (death, myocardial infarction or repeat revascularization), angina recurrence and cardiogenic readmission were considered as mid-term endpoints. Results There were no significant differences among the groups in baseline characteristics after propensity score matching. The median intraoperative blood loss (600 ml versus 450 ml, P = 0.56), median postoperative blood loss (800 ml versus 790 ml, P = 0.60), blood transfusion requirements (25.1% versus 24.4%, P = 0.76) and composite outcome of in-hospital death, stroke and reoperation for bleeding (2.8% versus 1.6%, P = 0.10) were similar in aspirin and nonaspirin use group. At about 4 years follow-up, no significant difference was observed among the aspirin and nonaspirin use group in major adverse cardiac events free survival estimates (95.7% versus 91.5%, P = 0.23) and freedom from cardiogenic readmission (88.5% versus 85.3%, P = 0.77) whereas the angina recurrence free survival rates was 83.7% and 73.9% in the aspirin and nonaspirin use group respectively (P = 0.02), with odd ratio for preoperative aspirin estimated at 0.71 (95% confidence interval, 0.49-1.04, P = 0.08). Conclusions Preoperatively continued aspirin use was not associated with increased risk of intra- and post-operative blood loss, blood transfusion requirements and composite outcome of in-hospital death, stroke and reoperation for bleeding in off-pump CABG. Preoperative aspirin use tended to decrease the hazard of mid-term angina recurrence.

The surgical management of hypertrophic obstructive cardiomyopathy with the concomitant mitral valve abnormalities

OBJECTIVESnThe purpose of this retrospective study was to analyse the pathogenesis and the treatment strategies of hypertrophic obstructive cardiomyopathy (HOCM) with the concomitant mitral valve abnormalities.nnnMETHODSnBetween October 1996 and December 2009, 76 patients with the HOCM underwent the ventricular septal myotomy-myectomy in Fuwai hospital. There were 51 males and 25 females aged between 6 and 68 years (mean: 37.18 ± 15.85 years) old. All the patients had left ventricular outflow tract (LVOT) obstruction with a resting or physically provoked gradient of ≥50 mmHg and the systolic anterior movement (SAM) of the mitral leaflets, and 64 patients had mitral regurgitation (MR). These patients underwent the ventricular septal myotomy-myectomy under general anaesthesia and cardiopulmonary bypass. The concomitant surgical procedures included mitral valve replacement (MVR, n = 14) and mitral valve plasty (MVP, n = 12).nnnRESULTSnAll the surgical procedures were technically successful. In comparison with the preoperative conditions, the resting LVOT gradient had marked reduction (99.73 ± 38.61-23.55 ± 16.53 mmHg, P < 0.001), the mean septal thickness was decreased from 26.23 ± 5.24 to 17.33 ± 4.74 mm. MR had significant improvement, SAM was resolved completely or only mild. Four patients (5.3%, 4/76) died during the hospital stay. The causes of death included severe ventricular arrhythmias with low cardiac output, severe acute renal failure, septic shock with acute renal dysfunction and the complete AV block with low cardiac output. The others were followed up for 5-18 years: there were no deaths. Moderate MR was noted in two patients at 2 months or 2 years after operation respectively, who had undergone MVP with the edge-to-edge technique stitch procedure, and only had mild or trivial MR at hospital discharge, of whom one received repeat operation with MVR and the other is still in follow-up. All surviving patients were evaluated as New York Heart Association Functional class I or II, and had a significant increase in physical capacity and a significant reduction in disabling symptoms.nnnCONCLUSIONSnThe ventricular septal myotomy-myectomy can be performed successfully for the severe obstructive HOCM and MR with the low morbidity and mortality and excellent survival in the great majority of patients. But for the few patients with the intrinsic mitral valve disease, the concomitant MVP or MVR may be required, and MVR should be performed only as a priority choice for the inherent risks of prosthetic valves and anticoagulation therapy.

A new and simple classification for sinus of Valsalva aneurysms and the corresponding surgical procedure

OBJECTIVESnThe classification system of Sakakibara and Konno for sinus of Valsalva aneurysm (SVA) is highly complex and seldom utilized in clinical practice. In this study, we propose a new and simple classification system; we suggest a novel approach that utilizes four distinct types of SVAs.nnnMETHODSnWe retrospectively studied 257 cases of SVAs in which surgical repair was performed between October 1996 and December 2009 and divided these cases into four types: I, rupture or protrusion into the right atrium; II, rupture or protrusion into the right atrium or right ventricle near or at the tricuspid annulus; III, rupture or protrusion into the right ventricular outflow tract under pulmonary valve and IV, others. The surgical results of the different approaches in each respective type were compared as follows: cardiopulmonary bypass time, clamp aorta time, mechanical ventilation time, intensive care unit time and postoperative stay time.nnnRESULTSnIn all the patients, there was no early postoperative death; all the patients recovered and were discharged as expected. There were no significant differences in intensive care unit time and postoperative stay time among different approaches in each type (P > 0.05). Two hundred and thirty-eight (92.61%) patients were followed up.nnnCONCLUSIONSnSurgical repair of SVAs exhibited good long-term results. Our classification of SVA could be potentially helpful for surgical practice. For Type I, the right atrium approach is advised; for Type II, the transaortic approach with a right atrium incision is advised; for Type III, the transaortic approach with pulmonary incision is advised while for Type IV, repair according to the respective situation is advisable.

Case studies of two related Chinese patients with Carney complex presenting with extensive cardiac myxomas and PRKAR1A gene mutation of c.491_492delTG

Carney complex is an autosomal dominant disease that is clinically characterized by cardiac myxomas, spotty skin pigmentation, and endocrine overactivity. Carney complex is most commonly caused by mutations in the PRKAR1A gene on chromosome 17q22-24. Currently, there are at least 117 pathogenic mutations in PRKAR1A that have been identified. Herein, we report on two cases of Carney complex in related Chinese patients with a c.491_492delTG mutation that presented with multiple and extensive cardiac myxomas and skin pigmentation.

Mid-term results after correction of type I and type II persistent truncus arteriosus in older patients.

Abstractu2002 Objective: This study aims to analyze long‐term results after correction of type I and type II truncus arteriosus in older patients operated in one institution over five years. Methods: Between 2006 and 2010, 12 patients, median age 4 years, underwent repair of truncus arteriosus. Repair with reconstruction of the right ventricular to pulmonary artery continuity was performed using a valved conduit in 12 patients. Results: There was no early mortality. All patients are alive with their original conduit 0.6 to 5 years after correction. No patients required reoperations for conduit dysfunction. Recent clinical examination was undertaken in all patients and they are in good condition. Conclusions: Though mean age at operation was higher in this study than published results, the operation should be performed if the pulmonary vascular resistance is under 8 units.m2 before operation.

Surgical Correction for Sinus of Valsalva Aneurysm with Right Ventricular Outflow Tract Stenosis

Abstractu2002 Background: Sinus of Valsalva aneurysm (SVA) is a rare cardiac anomaly, and SVA combined with right ventricular outflow tract stenosis is even rarer. We retrospectively analyzed 222 patients receiving surgical repair of SVA in our center over nine years, and report the incidence of right ventricular outflow tract stenosis in SVAs and the surgical results of 13 cases of SVA with right ventricular outflow tract stenosis. Methods: Between January 2000 and December 2009, 13 patients with SVA combined with right ventricular outflow tract stenosis underwent surgical repair of SVA and correction of right ventricular outflow tract stenosis. There were nine males and four females. The mean age was 29.69 ± 9.98 years (range 13 to 45 years). Associated cardiovascular lesions were ventricular septal defect (n = 12), aortic regurgitation (n = 9), mitral regurgitation (n = 2), and tricuspid regurgitation (n = 1). All 13 patients were followed from 35 to 126 months (mean 80.15 ± 32,14 months). Results: There was neither early death after operation nor late death. All the patients recovered well uneventfully. The incidence of right ventricular outflow tract stenosis among 222 SVA patients was 5.86%. Conclusions: Surgical correction of SVA with right ventricular outflow tract stenosis results in good mid‐term results. Longer follow‐up is needed to determine the efficacy of this procedure as this cohort of patients ages. (J Card Surg 2012;27:99–102)

Surgical Outcome in Adolescents and Adults with Anomalous Left Coronary Artery from Pulmonary Artery

BACKGROUNDnThe outcomes of different repair strategies of an anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) in adolescent and adult patients are uncertain. The long-term outcomes of reimplantation and Takeuchi repair were compared in this study.nnnMETHODSnWe conducted a retrospective review of data collected from patients receiving ALCAPA repair at our institute from January 2005 to December 2016. Short- and long-term outcomes of reimplantation and Takeuchi repair were compared.nnnRESULTSnA total of 50 consecutive patients underwent ALCAPA repair, with an average age of 31.6 ± 15.6 years and 66% women. No significant differences were found in short-term outcomes between the 2 groups. However, at a median of 65.7 months follow-up, the major adverse cardiovascular event (MACE) (including all-cause death, admission due to heart failure, new-onset acute myocardial infarction, and repeated revascularization) rate of the Takeuchi repair group was significantly lower than that of the reimplantation group (hazard ratio, 0.21; 95% confidence interval, 0.04 to 0.97). Furthermore, the preoperative glucose level was significantly associated with increased MACE rate (hazard ratio, 10.82; 95% confidence interval, 1.20 to 97.54). Left ventricular end-diastolic diameter and ejection fraction significantly improved in both groups. However, mitral valvuloplasty did not predict long-term recovery of left ventricular function.nnnCONCLUSIONSnAlthough short-term outcomes were satisfactory in both groups, a higher MACE rate was observed in reimplantation group than Takeuchi repair group; mitral valvuloplasty was not significantly associated with improved prognosis and left ventricular reverse remodeling. Elevation of preoperative blood glucose level was significantly associated with increasing long-term MACE rate.

Mitral valve annuloplasty versus replacement for severe ischemic mitral regurgitation

Although practice guidelines recommend surgery for patients with severe chronic ischemic mitral regurgitation (CIMR), they do not specify whether to repair or replace the mitral valve. 436 consecutive patients with severe CIMR were eligible for inclusion in the study, of which 316 (72.5%) underwent mitral valve annuloplasty (MVA) whereas 120 (27.5%) received mitral valve replacement (MVR). At 59 months (interquartile range, 37–85 months) follow-up, though the left ventricle end-diastolic diameter was markedly larger (Pu2009=u20090.019) in the MVA group than in the MVR group, no significant difference was observed in overall survival, freedom from cardiac death, or avoidance of major adverse cardiac or cerebrovascular events (MACCE). MVA provides better results in freedom from cardiac death in subgroups of age ≥65years and left ventricular ejection fraction (EF) ≥50% (Pu2009=u20090.014 and Pu2009=u20090.016, respectively), whereas MVR was associated with a lower risk of MACCE in subgroups of age <65years, EF <50% and left ventricular inferior basal wall motion abnormality (BWMA) (all Pu2009<u20090.05). In conclusion, MVR is a suitable management of patients with severe CIMR, and it is more favorable to ventricular remodeling. The choice of MVA or MVR should depend on major high-risk clinical factors.