Xi-Jie Wu

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.

A self-adaptive triple-branched stent graft for arch repair during open type A dissection surgery

OBJECTIVE To make the open placement of the triple-branched stent graft technique suitable for most patients with acute type A aortic dissection to achieve effective individual total arch repair, we developed a self-adaptive triple-branched stent graft and arch open technique. In this study, we report the clinical experience and outcomes of total arch repair using implantation of this self-adaptive triple-branched stent graft with the aid of the arch open technique. METHODS Between December 2012 and July 2014, 105 consecutive patients with acute type A aortic dissection with indications of total arch repair underwent total arch repair using implantation of a self-adaptive triple-branched stent graft with the aid of the arch open technique under hypothermic cardiopulmonary bypass and selective cerebral perfusion. Survivors were followed up prospectively by means of computed tomography angiography. RESULTS The cardiopulmonary bypass time was 169.37 ± 27.17 minutes, aortic crossclamp time was 60.48 ± 16.72 minutes, and selective cerebral perfusion and lower body arrest time was 28.95 ± 7.23 minutes. The in-hospital mortality was 4.76%. One patient was lost to follow-up. One sudden death of unknown cause occurred 10 months after surgery. On the 3-month postoperative scans, the false lumen closed with complete thrombus formation around the self-adaptive triple-branched stent graft was found in all survivors and at the diaphragmatic level in 71.72% of patients. CONCLUSIONS The simple implantation of a self-adaptive triple-branched stent graft with the aid of the arch open technique can be used safely in most patients with acute type A aortic dissection for effective individual total arch repair.

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.

A modified valve-sparing aortic root replacement technique for acute type A aortic dissection: the patch neointima technique

We describe a modified valve-sparing aortic root replacement technique for acute type A aortic dissection. After the normal root geometry was restored by removing blood and clots in the proximal false lumen and the valve insufficiency was corrected by simple resuspension of the aortic commissures, three teardrop-shaped patches were sutured inside the sinuses as neointima and then in situ coronary buttons were connected to the small holes created in the corresponding patches. Our initial application showed that this modified valve-sparing aortic root replacement technique is an easy and effective way to restore the geometry of the aortic root and avoid bleeding during surgery for acute type A dissection.

Total arch repair for acute type A aortic dissection with open placement of a modified triple-branched stent graft and the arch open technique

BackgroundIn total arch repair with open placement of a triple-branched stent graft for acute type A aortic dissection, the diameters of the native arch vessels and the distances between 2 neighboring arch vessels did not always match the available sizes of the triple-branched stent grafts, and insertion of the triple-branched stent graft through the distal ascending aortic incision was not easy in some cases. To reduce those two problems, we modified the triple-branched stent graft and developed the arch open technique.Methods and resultsTotal arch repair with open placement of a modified triple-branched stent graft and the arch open technique was performed in 25 consecutive patients with acute type A aortic dissection. There was 1 surgical death. Most survivors had an uneventful postoperative course. All implanted stents were in a good position and wide expansion, there was no space or blood flow surrounding the stent graft. Complete thrombus obliteration of the false lumen was found around the modified triple-branched stent graft in all survivors and at the diaphragmatic level in 20 of 24 patients.ConclusionsThe modified triple-branched stent graft could provide a good match with the different diameters of the native arch vessels and the various distances between 2 neighboring arch vessels, and it’s placement could become much easier by the arch open technique. Consequently, placement of a modified triple-branched stent graft could be easily used in most patients with acute type A aortic dissection for effective total arch repair.

A modified technique of anastomosis between dissected aortic stump and a Dacron tube graft: the suture line inclusion technique.

We describe a modified technique of anastomosis between dissected aortic stump and a Dacron tube graft (Sulzer Vascutek, Renfrewshire, Scotland) with the aim of minimizing suture line complications. After a stented graft was implanted into the stump or a Teflon felt strip (C.R. Bard, Inc, Tempe, AZ) was circumferentially placed on the intima of the stump, a series of nonpledgeted 2-0 horizontal mattress sutures were placed from inside to outside. Certain tension on those sutures should be created to keep the intraluminal Teflon felt strip in place. The end of the Dacron tube graft was everted outward, and its double-folded end was anastomosed to the aortic stump with incorporation of the proximal end of the stented graft or the intraluminal Teflon felt strip. The everted Dacron portion was then returned to its original position, and the previously placed horizontal mattress sutures were appropriately passed through the corresponding site, and all sutures were securely tied in place. Our initial application showed that this simple technique provides a more hemostatic anastomosis.

Ascending Aorta and Hemiarch Replacement Combined With Modified Triple-Branched Stent Graft Implantation for Repair of Acute DeBakey Type I Aortic Dissection

BACKGROUND To simplify extensive repair of acute DeBakey type I aortic dissection, ascending aorta and hemiarch replacement combined with modified triple-branched stent graft implantation was developed. The descriptions and early results of this technique are reported. METHODS From August 2014 to September 2015, 116 patients with acute DeBakey type I aortic dissection underwent ascending aorta and hemiarch replacement combined with modified triple-branched stent graft implantation. Clinical data of all patients were retrospectively reviewed. Survivors were followed up prospectively by computed tomography angiography. RESULTS The cardiopulmonary bypass time was 131.5 ± 10.7 minutes, the aortic cross-clamp time was 50.0 ± 9.9 minutes, and the selective cerebral perfusion and lower body arrest time was 17.2 ± 2.2 minutes. The in-hospital mortality rate was 3.4%. Two patients were lost during follow-up. One patient died of a cerebrovascular accident 2 months after discharge, and another died of chronic renal failure 5 months after discharge. At the 3-month postoperative scans, complete thrombus formation of the false lumen around the implanted modified triple-branched stent graft occurred in all survivors, at the diaphragmatic level in 69.7% patients, and at the superior mesenteric arterial level in 8.3% patients. CONCLUSIONS Extensive thoracic aorta repair of acute type I aortic dissection can be performed simply by combining ascending aorta and hemiarch replacement with modified triple-branched stent graft implantation. This technique can reduce the risk and technical difficulty of extensive thoracic aorta repair to levels close to those seen with ascending aorta and hemiarch graft replacement with open distal anastomosis.

An Alternative Approach for Repair of Supracardiac and Infracardiac Total Anomalous Pulmonary Venous Drainage in Neonates and Infants: Superior Approach with Caval Transection

Recently, the superior approach with transaction of the superior vena cava was introduced for the repair of supracardiac anomalies in adults. We developed a bidirectional right‐angle venous cannula and placed it within the innominate vein to make the modified superior approach with the superior caval transection suitable for neonates and tiny infants. We applied this modified superior approach for the repair of infracardiac forms of total anomalous pulmonary venous drainage. doi: 10.1111/jocs.12472 (J Card Surg 2015;30:278–280)

Valve-Sparing Root Replacement With Root Reduction Plasty and Patch Neointima Placement

We describe an alternative valve-sparing aortic root replacement technique for patients with root aneurysms accompanied by aortic valve insufficiency. Aortic root reduction plasty was accomplished by plication and exclusion of parts of the sinus walls. Subsequently, 3 teardrop-shaped patches compatible with the sizes and shapes of the corresponding plicated sinuses were sutured inside the sinuses as neointima, and in situ coronary buttons were connected to the small holes created in the corresponding patches. A Dacron tube graft was then anastomosed to the reconstructed aortic root with incorporation of the distal margin of the implanted patches. Our initial application showed that this combined root reduction plasty and patch neointima placement is a feasible valve-sparing aortic root replacement technique. This combined technique easily restores the aortic root geometry and effectively prevents bleeding.

A Modified Atrial Volume Reduction Technique for a Giant Left Atrium

We describe a modified volume reduction technique for a giant left atrium that consists of circumferential resection of a strip of left atrial wall with the appendage, plicated pericardium replacing the posterior atrial wall, and anastomoses of the remaining right side free wall to the interatrial septum instead of the interatrial groove. Our initial application showed that this technique can safely reduce a giant left atrium to the desired volume and obtain a high rate of sinus rhythm restoration after a maze operation.