Objective To investigate the experience of operative technique of donor organ harvesting and lung transplantation in some unusual circumstance, and to improve surgical success ratio of lung transplantation. Methods Lung transplants were preformed in 65 cases, including 47 singlelung transplants and 18 double single lung transplants. All the recipients were suffered from intensive respiratory failure,and nine patients were longterm ventilatordependented of the total. The recipients included emphysema (n=23), pulmonary fibrosis (n=24), pneumosilicosis(n=5), pulmonary tuberculosis(n=2), lymphangioleiomyomatosis(n=1) and ventricular septal defect(VSD) or VSD with Eisenmenger’s syndrome(n=4),bronchiectasis (n=4), diffuse panbronchiolitis (n=1) and primary pulmonary hypertension(n=1). Retrospectively summarize clinical experience of lung transplant operation especially experience of dealing with special circumstances encountered in operation. Results 64 donor organ harvesting were achieved successfully. Inhospital death was 11cases (16.9%) after operation. Early death was due to primary lung graft dysfunction (n=3), severe infection(n=6), acute rejection(n=1), pulmonary vein embolism(n=1). Complications took place after operation in 9 cases, to exploratory thoracotomy to stop bleeding after transplantation in 3 cases, pulmonary artery anastomosis again because of stenosis in 1 case, bronchus stoma stenosis in 3 cases, pulmonary infarction in 2 cases, of which one patient accepted pulmonary lobectomy. Follow-up period was from 1.0 year to 5.6 years of 54 cases. 1year survival rate was 72.3%（47/65）.The pulmonary function was improved and the quality of life is well in most patients of the group. Conclusion To improve the technique of donor organ harvesting and lung transplantation is important to decrease the early mortality after transplantation.
Objective To compare the clinical effect between high flow rate modified ultrafiltration （HMUF） and conventional modified ultrafiltration（CMUF）, and the effect on hemodynamic data and inflammatory mediators. Methods Forty children were divided into two groups with random number table, HMUF group and CMUF group, 20 cases each group. Hematocrit （HCT） and hemodynamic changes were recorded and the concentration of tumor necrosis factor （TNF） and interleukin 6 （IL-6） were measured. Results The operations were done uneventfully with moderate hypothermia cardiopulmonary bypass in 40 patients. Duration of ultrafiltration of HMUF group （7.83±0. 75 min） was less than that of CMUF group （13.86±1.95 min, P〈0.01）. The volumes ultrafiltrated of HMUF group （440.00±91.86ml） was more than that of CMUF group （372.22±56.52ml, P〈0.01）. There are no significant differences about the hemodynamic data, HCT, TNF and IL-6 between two groups. Conclusion The HMUF is safe and efficient,when it was used after pediatric cardiopulmonary bypass, the duration of ultrafiltration can be shortened significantly.
Objective To observe the effect of glutamine （Gln） on intestinal permeability after surgery of children, also its influence on the plama level of interleukin-2（IL-2）, endotoxin and synthesize of protein through a random nutrition trial. Methods Twenty children suffered from congenital heart disease were divided into Gln group and control group with random number table, 10 cases in each group. They were all given isonitrogenous and isocaloric total paraenteral nutrition after 24 h postoperatively. In Gln group the Dipeptiven [-N （2）-L-alanyl-Lglutamine] was used with 2 ml/kg · 24h additionly. Before operation, 24h and 96 h after operation, intestinal permeability, serum level of endotoxin, IL-2, C-reaction protein, prealbumine were measured. Results Intestinal permeability increased in 24 h after cardiac surgery in two groups, while the concentration of endotoxin also increased, 96 h after surgery the intestinal permeability recovered, but the endotoxin level did not decrease in control group （P〈0. 01）. Conclusion Utilization of Gln can improve immune suppression, elevate the IL-2 level, decrease the endotoxin concentration, alleviate the infection, but has no effect on the protein synthesis after congenital cardiac operation of children.
Objective To investigate the hospital outcomes and therapeutic strategy for multiple organ dysfunction syndrome （MODS） in children after cardiac surgery. Methods Seventy-seven consecutive pediatric patients （57 male/20 female, age 3.47±3.67 years, weight 13.08±7.52 kg） with MODS after cardiac surgery were enrolled in the study from 1999.7 to 2005.10. Corrective and palliative operation were performed in sixty-six patients and eleven patients, respectively. We evaluated the clinical score for all study patients according to the extent of organ injury. Results The overall mortality rate was 28. 6%（22/77）. （1） Cardiovascular, renal, hepatic, hematologic, neurologic and respiratory dysfunction was present in 100% （77/77）, 97.4% （75/77）, 84.4% （65/77）, 48.1%（37/77）, 45. 5%（35/77） and 44. 2%（34/77） of the patients, respectively. Cardiac injury appeared much earlier than other organs （P〈0. 05）. （2） Mortality rate with two, three, four, five and six dysfunctional organ systems was 0%, 12.5 %, 31.8 %, 42. 9 % and 87.5 %, respectively （r=0.487, P〈0. 001 in trend）. Furthermore, there was a positive correlation between the clinic score and mortality rate （r=0.603, P〈0. 001）. （3） Compared with survivors, non-survivors had longer cardiopulmonary bypass time, clamping time, higher incidence of accidental events and cardiopulmonary resuscitation during and after surgery （P〈0. 05）. Conclusion Mortality associated with MODS was highly correlated with the number of organ failing and clinical score. Cardiac dysfunction was the primary disease in MODS after cardiac surgery. Therefore, therapeutic strategy for MODS should be focused on management of primary disease, as well as providing consecutive evaluation and improvement for organ function.
Objective To summarize the clinical experiences of the application of posterior leaflet chordal transfer in the treatment of anterior mitral leaflet prolapse, and to investigate the best time for mitral valve repair. Methods From October 2004 to October 2008, 16 patients with anterior mitral leaflet prolapse underwent mitral valve repair. The echocardiography diagnosis revealed that 10 patients had chordal rupture, 4 had chordal elongation, 2 had both rupture and elongation. And there were 3 with A1 segment prolapse, 6 with A2 segment prolapse, 3 with A3 segment prolapse, 2 with both A1 and A2 segment prolapse, 2 with both A2 and A3 segment prolapse. All the patients underwent posterior leaflet chordal transfer, and one of them with coronary artery disease underwent coronary artery bypass grafting. Results There was no operative death. The echocardiography examination revealed that there were 2 patients with mild regurgitation, 6 with trivial regurgitation and 8 with no regurgitation before discharge. The patients received nticoagulation treatment of warfarin for 3 months after discharge. All the patients were followed up for 1-46 months(22.0±3.5 months). The echocardiography examination showed that there were 3 patients with mild regurgitation, 7 with trivial regurgitation and 6 with no regurgitation. There were 12 patients with New York Heart Association(NYHA) classⅠ, and 4 with class Ⅱ. The left ventricular ejection fraction(LVEF) was lower than that before operation(53.0%±3.4％ vs.65.0%±4.2％,P=0.013),and there was no statistical significance compared with that before operation(61.0%±2.1％vs.65.0%±4.2％, P=0.110). The left ventricular end diastolic diameter decreased significantly compared with that before operation(50.0±3.2 mm, 47.0%±2.8 mm vs.580±6.5 mm，P=0.031，0020). The postoperative cardiac function improved significantly (P=0.002). Conclusion Posterior leaflet chordal transfer is an effective method for anterior mitral leaflet prolapse. The best time for mitral valve repair is when LVEF＞60%, left ventricle enlarges a little, and NYHA class＞Ⅲ before operation.
Abstract： Objective To introduce the new procedure of endobronchial ultrasoundguided transbronchial needle aspiration (EBUSTBNA) for staging lung cancer and diagnosing thoracic diseases, in order to determine its value in the evaluation of thoracic diseases. Methods We retrospectively reviewed the data of all patients examined with EBUSTBNA our institution between September 2009 and May 2010. Among the patients, there were 75 males and 31 females with an average age of 62.3 years old. Based on their primary indication, we divided all the 106 patients into three categories. (1) There were 76 patients with known or bly suspected lung cancer. Enlarged mediastinal lymph nodes on radiographic examination of the chest (≥1.0 cm) were detected in all the patients. (2) There were 22 patients with enlarged mediastinal lymph nodes or mediastinal masses of unknown origin. (3) There were 8 patients with pulmonary mass located close to the central airways. Results (1) 76 patients underwent EBUSTBNA for known or bly suspected lung cancer. Among them, 58 patients were confirmed to have mediastinal lymph nodes metastasis on EBUSTBNA. Sixteen in the 18 patients with negative EBUSTBNA underwent thoracoscopy or thoracotomy for pulmonary resection and mediastinal lymph node dissection. Postoperative pathology confirmed that 12 patients did not have metastatic nodes, 2 patients had metastatic nodes and 2 other patients had benign lesions within the lung. The diagnostic sensitivity, specificity and accuracy of EBUSTBNA for the mediastinal staging of lung cancer were 96.66%(58/60), 100.00%(12/12) and 97.22%(70/72), respectively. (2) 22 patients underwent EBUSTBNA for the evaluation of mediastinal adenopathy or mass in the absence of any identifiable pulmonary lesion. Among them, 7 had malignancy, 13 had benign diseases on EBUSTBNA and the sensitivity of EBUSTBNA in distinguishing malignant mediastinal diseases was 87.50% (7/8). (3) 8 patients with pulmonary mass located close to the central airways were accessed by EBUSTBNA. Definite diagnosis was achieved in 7 patients, and lung cancer was detected in 6 patients. The sensitivity and the diagnostic accuracy of EBUSTBNA for the diagnosis of unknown pulmonary mass was 85.71%(6/7) and 87.50%(7/8), respectively. All the procedures were uneventful, and there were no complications. Conclusion EBUSTBNA is a highly effective and safe procedure. We believe that EBUSTBNA should be used routinely in the diagnosis and staging of thoracic diseases.
Abstract: Objective To introduce a new technique: transthoracic closure of perimembranous ventricular septal defect (VSD) without cardiopulmonary bypass (CPB) under transesophageal echocardiography (TEE）guidance, and summarize the clinical experiences and midterm followup results. Methods A total of 136 patients with perimembranous VSD, 3 months to 15 years averaging 1.8 years, underwent transthoracic device closure. The weight of these patients ranged from 4.0 to 26.0 kg with an average weight of 12.7 kg. The diameter of their VSD ranged from 3 to 12 mm averaging 5.1 mm. A small transthoracic incision (34 cm incision by inferior sternotomy or 23 cm transverse incision in the third intercostal space) was made and the best location for right ventricular puncture was chosen and the delivery pathway was established under TEE guidance. Proper devices were delivered and then deployed to close the defect. Patients were followed up closely with a standard protocol, arranged for echocardiography, electrocardiogram and chest Xray film. Results In all the cases, 131 cases of VSD (96.3%) were successfully closed. The procedure time was less than 90 minutes and the implanting time was 5.42 minutes (16.3±5.7 min). Symmetrical devices were implanted into 89(67.9%) of the 131 patients and the other 42 patients (32.1%) were closed with asymmetrical ones. The result of TEE soon after operation showed that 3 patients had tiny residual shunt, 4 had new trivial and mild tricuspid regurgitation (TR). However, no TR worsening, aortic regurgitation (AR), complete atrioventricular heart block, or left or right outflow tract obstruction was detected in all patients. One patient 〖CM(159mm〗with transient atrioventricular block restored to sinus rhythm after 3 days of medical treatment. Five cases (3.7%) were converted to conventional open heart repair during the operation. Followup was done to all the patients for a period ranged from 6 months to 30 months (18.3±6.6 months). Tiny residual shunt in the 3 cases mentioned above vanished during the followup period. No new TR, AR, hemolysis, thrombosis, dislocation of the devices, or outflow stenosis was detected postoperatively. The tiny incision caused less psychologic depression. Conclusion Minimally invasive transthoracic device closure of VSD without CPB is a simple, effective and safe intervention under guidance of TEE for most of perimembranous VSD patients. The short and midterm clinical outcomes are promising. Longterm followup is indispensable.
Abstract: Objective To study the pathophysiological mechanism of the morphological change of immature pulmonary vessels in the piglet model of congenital heart defect with decreased pulmonary blood flow established with balloon atrial septostomy and pulmonary artery banding. Methods Twenty piglets at an age of one to two months were divided into three groups with random number table. For the control group (group C,n=6), small incisions were carried out on the right chest to produce a transient reduction in the pulmonary blood; for the lowmedium pulmonary artery stenosis group (group T1, n=7), the balloon dilator was delivered through the surface of the right atrium and septostomy and pulmonary artery banding were performed, and the systolic transpulmonary artery banding pressure (Trans-PABP) was controlled to be 20.30 mm Hg; For the severe pulmonary artery stenosis group (group T2, n=7), the same surgical procedures with group T1 were performed while TransPABP was controlled to be more [CM(159mm]than 3050 mm Hg.At 2 months after surgery respectively,a lung tissue of 1.0 cm×0.8 cm×0.8 cm from the lateral segment of the right middle lobe was taken out to be observed under optic microscope. The morphological change of the distal arterioles was detected. Furthermore, the content of vascular endothelial growth factor (VEGF) and matrix metalloproteinase2( MMP2) were also examined by the method of enzymelinked immunosorbent assay (ELISA). Results The model was successfully established in all the survival piglets of the group T1 and group T2. Two months after operation, the inner diameter of the pulmonary arterioles in group T1 was significantly higher than that in group C (82.89±10.72 μm vs.74.12±9.28 μm;t=－5.892, Plt;0.05), so as group T2 (85.47±5.25 μm vs.74.12±9.28 μm;t=-6.325, Plt;0.05); the number of arterioles per square centimeter (NAPSC) of group T1 was significantly lower than that of the group C (229.70±88.00 entries/cm 2 vs. 431.50±40.60 entries/cm2; t=39.526, Plt;0.05), so as group T2 (210.00±40.30 entries/cm2 vs. 431.50±40.60 entries/cm2; t=67.858, Plt;0.05). Two months after operation, the lung expression of MMP -2 and VEGF in group T1 was significantly lower than that in group C (58.30±19.60 ng/ml vs. 81.20±16.70 ng/ml, t=14.261, Plt;0.05; 17.80±3.00 pg/ml vs. 21.40±3.80 pg/ml, t=8.482, P＜0.05), so does group T2 (42.10±15.20 ng/ml vs. 81.20±16.70 ng/ml, t=27.318, P＜0.05; 12.30±3.20 pg/ml vs. 21.40±3.80 pg/ml, t=15.139, P＜0.05). Conclusion Structural remodeling of pulmonary extracellular matrix is an important feature of the piglet model of congenital heart defect with decreased pulmonary blood flow. The arterioles show significant hypoplasia or degradation. Change in the structural proteins and cytokines during the reduction of blood in the lung is the key to structural remodeling.
Abstract： Objective To analyze risk factors for perioperative mortality in the arterial switch operation (ASO), in order to provide better operation and decrease the mortality rate. Methods We enrolled 208 ASO patients including 157 males and 51 females at Fu Wai Hospital between January 1, 2001 and December 31, 2007. The age ranged from 6 h to 17 years with the median age of 90 d and the weight ranged from 3 kg to 43 kg with the median weight of 5 kg. Among the patients, 127 had transposition of great artery (TGA) with ventricular septal defect (VSD), and 81 patients had TGA with intact ventricular septum (IVS) or with the diameter of VSD smaller than 5 mm. Coronary anatomy was normal (1LCX2R) in 151 patients and abnormal in the rest including 15 patients with single coronary artery, 6 with intramural and 36 with inverse coronary artery. Preoperative, perioperative and postoperative clinical data of all patients were collected to establish a database which was then analyzed by univariate analysis and multivariate logistic regression analysis to find out the risk factors formortality in ASO. Results There were 24 perioperative deaths (11.54%) in which 12 died of postoperative infection with multiple organ failure (MOF), 10 died of low cardiac output syndrome, 1 died of pulmonary hypertension, and 1 died of cerebral complications. Among them, 20 patients (18.30%) died in early years from 2001 to 2005, while only 4 (4.00%) died in the time period from 2006 to 2007, which was a significant decrease compared with the former period (Plt;0.05). The univariate analysis revealed that cardiopulmonary bypass (CPB) time was significantly longer in the death group than in the survival group（236±93 min vs. 198±50 min, P=0.002）, and occurrence of major coronary events (33.3% vs. 2.2%, P=0.000) and unusual coronary artery patterns（33.3% vs. 6.5%,P=0.000） were much more in the death group than in the survival group. Multivariate logistic regression analysis showed that early year of [CM(159mm]operation (OR=7.463, P=0.003), unusual coronary artery patterns (OR=6.303,P=0.005) and occurrence of majorcoronary events (OR=17.312, P=0.000) were independent predictors for perioperative mortality. Conclusion The ASO can be performed with low perioperative mortality in our hospital currently. Occurrence of major coronary events, unusual coronary artery patterns and year of surgery before 2006 are independent predictors for perioperative mortality.
Abstract: Objective To compare the multiple organ dysfunction score (MODS), the sequential organ failure assessment (SOFA), the acute physiology, age, and chronic health evaluation system Ⅱ(APACHE Ⅱ), the acute physiology, age, and chronic health evaluation system Ⅲ(APACHE Ⅲ) in evaluating risks for patients after cardiac surgery, in order to provide better treatment and prediction of prognosis after cardiac operation. Methods A prospective study was carried out on 1 935 cardiac postoperative patients, including 1 050 males and 885 females, enrolled in cardiac postoperative intensive care unitof Anzhen hospital between October 2007 and April 2008. The age of the patients ranged from 18 to 86 years with the mean age of 53.96 years. The patients underwent the surgery because of various cardiac diseases including coronary heart disease, valve disease, congenital heart disease, aortic aneurysm, pericardial disease, atrial fibrillation, and pulmonary embolism. We used MODS, SOFA, APACHE Ⅱ, and APACHE Ⅲ respectively to calculate the value of the first day after operation, the maximum value during the first three days, the maximum value, and the change of the value between the third day and the first day for every patient, and then we compared the calibration and discrimination of these different systems using HosmerLemeshow goodnessoffit analysis and Receiver Operating Characteristic (ROC) curve. Results There were 47 perioperative deaths because of circulating system failure, respiration failure, kidney failure, liver failure or nervous system diseases. The death rate was 2.43%. In discrimination analysis, the area under the curve (AUC) in ROC of the first day value after operation, the maximum value, the maximum value during the first three days, and the change of value between the third day and the first day for MODS were respectively 0.747, 0.901, 0.892, and 0.786; for SOFA were respectively 0.736, 0.891, 0.880, and 0.798; for APACHE Ⅱ were respectively 0.699, 0.848, 0,827, and 0.562; for APACHE Ⅲ were respectively 0.721, 0.872, 0.869, and 0.587. In calibration analysis, we compared the χ2 value of the first day value, the maximum value, the maximum value during the first 3 days, and the change of value between the third day and the first day of these systems. χ2 value of MODS was 4.712, 5.905, 5.384, and 13.215; χ2 value of SOFA was 8.673, 3.189, 3.111, and 14.225; χ2 value of APACHE Ⅱ was 15.688, 10.132, 8.061, and 42.253; χ2 value of APACHE Ⅲ was 13.608, 11.196, 19.310, and 47.576. AUC value of MODS and SOFA were all larger than those of APACHE Ⅱ and APACHE Ⅲ (Plt;0.05); AUC value of APACHE Ⅱ was smaller than that of APACHE Ⅲ (Plt;0.05). Conclusion MODS, SOFA, APACHE Ⅱ and APACHE Ⅲ are all applicable in evaluating risks for patients after cardiac surgery. However, MODS and SOFA are better than APACHE Ⅱ、APACHE Ⅲ in predicting mortality after cardiac surgery. In cardiac surgery, the complicated APACHE Ⅱ and APACHE Ⅲ systems can be replaced by MODS and SOFA systems which are simpler for use.