Li-Zhong Sun

Primary Cardiac Tumors: Early and Late Results of Surgical Treatment in 91 Patients

Abstract Background Our goal was to study the clinical characteristics of primary valve tumors and the late surgical results of their resection. Methods We reviewed our clinical experience with the surgical treatment of ten primary valve tumors at Fu Wai Hospital over the past 19 years. During that time, cardiac valve tumors accounted for 2.65% of all primary cardiac tumors at our hospital, and the incidence of primary valve tumors was roughly one in 4,000 cardiac operations. There were 5 male and 5 female patients aged 2 to 66 years (mean age, 30.1 years). The clinical presentation included exertional dyspnea in 7 patients, neurological symptoms in 2, and cyanosis at rest in 1 patient. The diagnosis was established by preoperative echocardiography in 8 patients, and in the other 2, it was confirmed by the findings at operation. All of the tumors were resected. Eight of the ten tumors were benign, and two were malignant. Results All patients survived the operation and recovered uneventfully. Late outcomes were known for all patients. There were three late deaths. One patient with a benign tricuspid valve tumor died 2 months postoperatively of an electrolyte disorder. The other 2 patients with a malignant mitral valve tumor died within 1 year postoperatively. The 7 survivors, all with a benign valve tumor, were followed for an average of 5.7 years (range, 8 months to 19 years), and all were in functional class I. Exercise tolerance improved to normal levels. The latest follow-up echocardiograms showed no evidence of local recurrence in any patient. Conclusions Excellent early and late surgical results can be obtained in patients with benign valve tumors. The prognosis for patients with a malignant valve tumor is poor.

VKORC1 Haplotypes Are Associated With Arterial Vascular Diseases (Stroke, Coronary Heart Disease, and Aortic Dissection)

Background— The haplotypes in the gene vitamin K epoxide reductase complex subunit 1 (VKORC1) have been found to affect warfarin dose response through effects on the formation of reduced-form vitamin K, a cofactor for &ggr;-carboxylation of vitamin K–dependent proteins, which is involved in the coagulation cascade and has a potential impact on atherosclerosis. We hypothesized that VKORC1-dependent effects on the coagulation cascade and atherosclerosis would contribute to susceptibility for vascular diseases. Methods and Results— To test the hypothesis, we studied the association of polymorphisms of VKORC1 with stroke (1811 patients), coronary heart disease (740 patients), and aortic dissection (253 patients) compared with matched controls (n=1811, 740, and 416, respectively). Five common noncoding single-nucleotide polymorphisms of VKORC1 were identified in a natural haplotype block with strong linkage disequilibrium (D′>0.9, r2>0.9), then single-nucleotide polymorphism (SNP) +2255 in the block was selected for the association study. We found that the presence of the C allele of the +2255 locus conferred almost twice the risk of vascular disease (odds ratio [OR] 1.95, 95% confidence interval [CI] .58 to 2.41, P<0.001 for stroke; OR 1.72, 95% CI 1.24 to 2.38, P<0.01 for coronary heart disease; and OR 1.90, 95% CI 1.04 to 3.48, P<0.05 for aortic dissection). We also observed that subjects with the CC and CT genotypes had lower levels of undercarboxylated osteocalcin (a regulator for the bone), probably vascular calcification, and lower levels of protein induced in vitamin K absence or antagonism II (PIVKA-II, a des-&ggr;-carboxy prothrombin) than those with TT genotypes. Conclusions— The haplotype of VKORC1 may serve as a novel genetic marker for the risk of stroke, coronary heart disease, and aortic dissection.

Total Arch Replacement Combined With Stented Elephant Trunk Implantation A New “Standard” Therapy for Type A Dissection Involving Repair of the Aortic Arch?

Background— Appropriate surgical management of type A dissection is a critical factor for achieving satisfactory outcome, but the choice of optimal procedure is controversial. We retrospectively reviewed our experience with aortic arch replacement for type A dissection involving the arch. Methods and Results— Excluding 14 cases of subtotal or total aortic replacement, 411 of 544 patients with type A dissection (stented elephant trunk=291, conventional surgical repair=120) underwent aortic arch replacement between January 2003 and September 2008. In-hospital mortality was 3.09% (9 of 291) for stented (acute=4.73%, 7 of 148; chronic=1.40%, 2 of 143) and 5.00% (6 of 120) for conventional repairs (acute=6.06%, 4 of 66; chronic=3.70%, 2 of 54). Spinal cord injury was 2.41% (7 of 291) in the stented and 0.83% (1 of 120) in the conventional group. The overall prevalence of stroke was 1.95% (8 of 411) (stented=2.41%, 7 of 291; conventional=0.83, 1 of 120). Secondary intervention was 2.34% (5 of 214) for acute dissection (stented=1 and conventional=4; P=0.031) and 3.05% (6 of 197) for chronic dissection (stented=4 and conventional=2; P=0.661) during follow-up. Obliteration of the false lumen around the stented elephant trunk occurred in 94.2% (130 of 138) of patients with acute dissection and in 92.0% (126 of 137) of patients with chronic dissection. Conclusions— Total arch replacement combined with stented elephant trunk implantation demonstrated the superiority of the combination of the surgical and interventional approaches while avoiding the weaknesses associated with the individual methods. The encouraging surgical results could enable this procedure to become the new “standard” therapy for type A dissection involving repair of the aortic arch.Background— Appropriate surgical management of type A dissection is a critical factor for achieving satisfactory outcome, but the choice of optimal procedure is controversial. We retrospectively reviewed our experience with aortic arch replacement for type A dissection involving the arch. Methods and Results— Excluding 14 cases of subtotal or total aortic replacement, 411 of 544 patients with type A dissection (stented elephant trunk=291, conventional surgical repair=120) underwent aortic arch replacement between January 2003 and September 2008. In-hospital mortality was 3.09% (9 of 291) for stented (acute=4.73%, 7 of 148; chronic=1.40%, 2 of 143) and 5.00% (6 of 120) for conventional repairs (acute=6.06%, 4 of 66; chronic=3.70%, 2 of 54). Spinal cord injury was 2.41% (7 of 291) in the stented and 0.83% (1 of 120) in the conventional group. The overall prevalence of stroke was 1.95% (8 of 411) (stented=2.41%, 7 of 291; conventional=0.83, 1 of 120). Secondary intervention was 2.34% (5 of 214) for acute dissection (stented=1 and conventional=4; P =0.031) and 3.05% (6 of 197) for chronic dissection (stented=4 and conventional=2; P =0.661) during follow-up. Obliteration of the false lumen around the stented elephant trunk occurred in 94.2% (130 of 138) of patients with acute dissection and in 92.0% (126 of 137) of patients with chronic dissection. Conclusions— Total arch replacement combined with stented elephant trunk implantation demonstrated the superiority of the combination of the surgical and interventional approaches while avoiding the weaknesses associated with the individual methods. The encouraging surgical results could enable this procedure to become the new “standard” therapy for type A dissection involving repair of the aortic arch. # Clinical Perspective {#article-title-30}

Surgery for acute type A dissection using total arch replacement combined with stented elephant trunk implantation: Experience with 107 patients

OBJECTIVE In patients with acute type A dissection, it is controversial whether to use a more aggressive strategy with extended aortic replacement to improve long-term outcome or to use a conventional strategy with limited ascending aortic or hemiarch replacement to circumvent a life-threatening situation. METHODS Between April 2003 and June 2007, 107 patients (17 women, 90 men; mean age, 45 +/- 11 years; range, 17-78 years) with acute type A dissection underwent total arch replacement combined with stented elephant trunk implantation under hypothermic cardiopulmonary bypass and selective cerebral perfusion. Computed tomography was performed to evaluate the residual false lumen in the descending aorta during follow-up. RESULTS Thirty-day mortality was 3.74% (4/107 patients), and in-hospital mortality was 4.67% (5/107 patients). Spinal cord injury was observed in 3 patients (1 patient with left lower-extremity paraparesis and 2 patients with paraplegia). Cerebral infarction was observed in 3 patients, ventilator support exceeding 5 days was required in 9 patients, and rebleeding was observed in 4 patients. During a mean follow-up of 35 +/- 14 months, 3 patients died and 3 patients were lost to follow-up. On postoperative computed tomography, complete thrombus formation was observed around the stented elephant trunk in 95% of patients (95/100) and at the diaphragmatic level in 69% of patients (69/100). CONCLUSION Low morbidity and mortality were achieved using total arch replacement combined with stented elephant trunk implantation. These encouraging surgical results and postoperative outcomes favor this more aggressive procedure for acute type A dissection.

Surgery for marfan patients with acute type a dissection using a stented elephant trunk procedure.

BACKGROUND The purpose of the study was to assess the efficacy of total arch replacement combined with stented elephant trunk implantation for Marfan patients with acute Stanford type A aortic dissection involving the aortic arch. METHODS Between January 2004 and April 2006, 13 consecutive Marfan patients (4 female, 9 male) with acute type A aortic dissection involving the aortic arch underwent total arch replacement combined with implantation of a stented elephant trunk. Aortic dissection extending to the iliac artery was seen in 10 patients, and to the abdominal aorta in 3 patients. Ages ranged from 17 to 65 years (mean, 39 +/- 13). Computed tomography was done to evaluate the residual false lumen in the descending aorta. RESULTS All patients survived and were discharged from hospital. One patient with thrombosis of the innominate artery suffered cerebral infarction and recovered during follow-up. One patient had ischemia of the left upper limb postoperatively, but recovered after axillary to axillary artery bypass. There was 1 death during the mean follow-up period of 27 +/- 10 months. Complete thrombus formation was observed in 84.6% of patients (11 of 13) around the stented elephant trunk, and in 69.2% of patients (9 of 13) at the diaphragmatic level. CONCLUSIONS Total arch replacement combined with stented elephant trunk implantation for Marfan patients with acute type A aortic dissection involving the aortic arch results in less late dilatation of the dissected descending aorta. That prolongs the reoperation interval or reduces the number of late thoracoabdominal aortic replacements, unless there is a patent false lumen around the stented elephant trunk.

Surgery for Acute Type A Dissection With the Tear in the Descending Aorta Using a Stented Elephant Trunk Procedure

BACKGROUND Surgical management of acute type A dissection with the tear in the descending aorta is challenging because of the technical difficulty in managing proximal and distal aortic lesions through a median sternotomy or lateral thoracotomy using a single-stage procedure. METHODS Thirty-three patients with acute type A dissection with the tear in the descending aorta underwent total arch replacement combined with stented elephant trunk implantation through a median sternotomy from April 2003 to June 2007. Preoperative complications included acute cardiac tamponade (n = 1), acute left heart failure (n = 1), acute myocardial infarction (n = 1), cerebral ischemia (n = 1), acute renal failure (n = 2), chronic renal dysfunction (n = 2), and acute mesenteric ischemia (n = 1) and lower extremity ischemia (n = 3). The residual false lumen was evaluated using postoperative computed tomography. RESULTS Death at 30 days was 6.06% (2 of 33 patients). One patient with preoperative mesenteric ischemia died of postoperative multiple-organ failure. One patient with preoperative acute renal failure ceased treatment after three reoperations owing to uncontrollable bleeding. Left lower-extremity paraparesis occurred in 1 patient, and transient neurologic dysfunction occurred in 1 patient. Severe complications were not observed at a mean follow-up of 25 +/- 11 months. Thrombus obliteration of the false lumen was observed at the distal end of the stented graft in 29 patients (96.7%) and at the diaphragmatic level in 20 patients (66.7%) during follow-up. CONCLUSIONS Encouraging outcomes favor this technique in patients with acute type A dissection with the tear in the descending aorta. Simultaneous repair of proximal aortic lesions and thrombosis of the false lumen in the descending aorta could be obtained.

Sun's procedure of total arch replacement using a tetrafurcated graft with stented elephant trunk implantation: analysis of early outcome in 398 patients with acute type A aortic dissection.

BACKGROUND Acute type A aortic dissection (AAAD) remains one of the most lethal conditions requiring surgical repair, and is associated with a high rate of postoperative mortality and morbidity. Despite the satisfactory clinical outcomes achieved with the frozen elephant trunk technique so far, controversies still exist regarding the use of this aggressive approach in patients with AAAD. In this study, we seek to analyze the early outcomes of the Suns procedure, which is an approach integrating total arch replacement using a 4-branched graft with implantation of a special stented graft in the descending aorta, and identify the risk factors for postoperative mortality and morbidity of the Suns procedure in patients with AAAD. METHODS Clinical data of 398 consecutive AAAD patients undergoing the Suns procedure were analyzed. The associations between 20 preoperative and intraoperative variables and early mortality were assessed by univariate and multivariate analysis. RESULTS Early mortality occurred in 31 patients (7.8%, 31/398), with leading causes including multi-organ failure in 16 patients (51.6%), permanent neurologic deficit in 6 (19.4%), and low cardiac output syndrome in 4 (12.9%). Permanent neurologic deficit and spinal cord injury occurred, each in 10 patients (2.5%, 10/398). Five significant risk factors for early mortality were identified with multivariate analysis: preexisting cerebrovascular disease [relative risk (RR) 14.76; P<0.001], acute heart failure (RR 18.18; P=0.001), spinal cord malperfusion (RR 60.13; P<0.002), visceral malperfusion (RR 30.25; P<0.001) and cardiopulmonary bypass time >190 minutes (RR 3.62; P=0.007). CONCLUSIONS The Suns procedure has generated a relatively lower mortality rate in 398 patients with AAAD. Patients with preexisting cerebrovascular disease, acute heart failure, spinal cord malperfusion, visceral malperfusion and long cardiopulmonary bypass time are at a higher risk of early mortality.

Is total arch replacement combined with stented elephant trunk implantation justified for patients with chronic Stanford type A aortic dissection

OBJECTIVE Surgical treatment of chronic Stanford type A aortic dissection using total arch replacement combined with stented elephant trunk implantation is controversial owing to the visceral arteries and intercostal arteries originating from the false lumen. METHODS Eighty-nine patients (mean age, 45.67 +/- 10.18 years; range, 21-68 years) with chronic type A dissection underwent total arch replacement combined with stented elephant trunk implantation between April 2003 and March 2007. Careful assessment of the visceral arteries and location of entry and re-entry was done before surgery. Postoperative patency of the visceral arteries and diameter of the aortic artery and the residual false lumen were evaluated by computed tomography. RESULTS One (1.12%) hospital death and 2 (2.25%) late deaths occurred at a mean follow-up of 28.5 months (range, 8-52 months). Visceral malperfusion was not observed. Two patients had spinal cord injury and recovered during follow-up. One patient had a transient neurologic deficit and recovered completely before discharge. One patient underwent thoracoabdominal aortic replacement for aneurysmal dilatation of the residual descending aorta 3 months after the operation. Thrombus obliteration of the false lumen at the distal edge of the stented elephant trunk and at the diaphragmatic level was 94.2% (81/86) and 61.6% (53/86), respectively. CONCLUSIONS Satisfactory results with low morbidity and mortality were obtained. No visceral malperfusion and a low risk of postoperative spinal cord injury favor this technique in patients with chronic type A dissection.

The chimney technique for preserving the left subclavian artery in thoracic endovascular aortic repair.

OBJECTIVES The objective of the present study was to evaluate short- and mid-term outcomes of the left subclavian artery (LSA) chimney stent implantation (LSACSI) during thoracic endovascular aortic repair (TEVAR), and to summarize our experience with this technique. METHODS From June 2010 to September 2012, 59 patients (49 men; mean age of 57.4 ± 13.3 years, range from 26 to 83 years) who underwent TEVAR and LSACSI were enrolled. Patients suffered from Stanford type B aortic dissection (n = 27), penetrating aortic ulcer (n = 18), aortic arch aneurysm (n = 9), pseudoaneurysm of the aortic arch (n = 4) and proximal type I endoleak after TEVAR of aortic dissection (n = 1). Elective settings were performed in 72% and emergent in 38% of all patients. Follow-up was performed at postoperative 3 months, 6 months and yearly thereafter. RESULTS The technical success rate was 98.3% (58/59), and 69 thoracic stent grafts were used. Sixty-two chimney stents, including 55 uncovered and 7 covered stents, were implanted in 59 LSAs. The overall immediate endoleak rate was 15.3% (9/59); type I endoleak was observed in 5 patients and type II in 4 patients. The difference in the immediate endoleak rate related to the anatomy between the outer and the inner curvature was statistically significant (35 vs 4%, P = 0.018). Chimney stent compression was observed in 3 patients and another stent was deployed inside the first one. Perioperative complications included stroke (3.4%, 2/59) and left upper limb ischaemia (1.7%, 1/59). The median follow-up period was 16.5 (range 1-39 months). The mortality rate during follow-up was 5.4% (3/56). Complications during follow-up included endoleak [overall, n = 8 (14.3%, 8/56); type I, n = 5; type II, n = 3], retrograde type A aortic dissection (n = 1), collapse (n = 3, 5.4%) or occlusion (n = 2, 3.6%) of the chimney stent. CONCLUSIONS Short- and mid-term results showed that it is feasible to preserve the patency of the LSA in TEVAR with the chimney technique for thoracic aortic pathologies close to the LSA. However, TEVAR combined with LSACSI was not advocated for lesions located at the outer curve of the aortic arch due to a high possibility of endoleak.

Ultra-flexible Piezoelectric Devices Integrated with Heart to Harvest the Biomechanical Energy.

Power supply for medical implantable devices (i.e. pacemaker) always challenges not only the surgery but also the battery technology. Here, we report a strategy for energy harvesting from the heart motion by using ultra-flexible piezoelectric device based on lead zirconate titanate (PZT) ceramics that has most excellent piezoelectricity in commercial materials, without any burden or damage to hearts. Experimental swine are selected for in vivo test with different settings, i.e. opened chest, close chest and awake from anesthesia, to simulate the scenario of application in body due to their hearts similar to human. The results show the peak-to-peak voltage can reach as high as 3 V when the ultra-flexible piezoelectric device is fixed from left ventricular apex to right ventricle. This demonstrates the possibility and feasibility of fully using the biomechanical energy from heart motion in human body for sustainably driving implantable devices.