Objective To declare the unique anatomy,surgical management and prognosis of tetralogy of Fallot with subarterial ventricular septal defect (VSD). Methods From November 2002 to April 2009, 150 cases of typical tetralogy of Fallot were performed operations, 13 of which had subarterial VSD. Results Morphology and sites of right ventricular outflow obstruction in 13 cases: 2 cases isolated infundibular stenosis, 3 cases infundibular + pulmonary stenosis and 8 cases infundibular + pulmonary stenosis + valve ring stenosis. The diameter of subarterial VSD ranged from 1.5 to 3.0 cm. The proportion of aorta lying above the right ventricle varied from 30% to 50%. Twelve cases cured, one died of low cardiac output syndrome. Early postoperative mortality was 7.7% ( 1/13 ). The follow-up duration ranged from 1 month to 6 years. All cases had no cyanosis and the active ability were improved. Echo showed residual stenosis in 4 cases,residual VSD in 1 case and aortic regurgitation in 1 case. Conclusions Tetralogy of Fallot with subarterial VSD is associated with worse functional outcome. To prevent adverse outcomes, precise suturing of the distal ventricular septal patch, extensive infundibulectomy,lower threshold for transannular incision, and smaller-sized ventricular septal patch placement are warranted.

BACKGROUND: Neurological complications after coronary artery bypass grafting still have a high incidence rate, and the etiology is multiple.OBJECTIVE: To retrospectively investigate the occurrence and relevant factors of severe neurological complications after coronary artery bypass grafting (CABG).METHODS: A total of 761 consecutive patients with undergoing CABG were included in this study from September 2002 to August 2009 at the Nanjing Drumtower Hospital, including 443 males and 318 females, aged from 32-89 years. All patients were grouped according to age(more than or less than 70-year-old) and on pump or off pump coronary surgery. Disclose the relationship between the risk factors and the neurological complications by statistics analysis.RESULTS AND CONCLUSION: Totally 41 patients had serious neurological complications in this study. There was a higher complication incidence in 570-year-old group patients (n=22) than < 70-year-old group (n=19)(14.9% vs. 3.1%, P< 0.001). The neurological complications incidence was similar in on-Pump CABG group (n =7) and off-Pump CABG group (n = 34) (5.3% vs.5.4%, P=0.39). The incidence rate of severe neurological complications was high in carotid artery stenosis > 50% patients. A total of 8 cases died, 2 for massive hemorrhage of gastrointestinal tract; 1 for severe sepsis; 4 for multiple organ dysfunction syndrome;1 for epilepsia gravior postoperatively. Finally, 33 cases survived. The average time of follow up was 3 years, 3 cases died, 3 cases recovery from limitation of limb or hand movement partly, and 1 case had severe mental retardation. Results displayed that elderly patients(= 70 years) undergoing CABG are at higher risk of neurological dysfunction. Carotid artery stenosis is the most risk factor. There are no significant effects on postoperative complications between on-pump CABG and off-pump CABG.

Objective The prosthesis used for aortic valve replacement (AVR) can be too small in relation to body size,thus causing valve prosthesis-patient mismatch (PPM).The aim of this article was to summarize the preventive strategy of PPM during AVR.Methods A total of 357 patients [203 males,154 females; mean age (54.9 ± 18.7 ) years ] underwent AVR between February.2010 and December 2011.The weight and body surface area (BSA) of the group is( 60.1 ± 11.4 )kg and (1.67 ± 0.21 )m2 respectively.The aortic valve prosthesis effective orifice area (EOA) was divided by body surface area (BSA) to obtain the EOA index (EOAI).PPM was then defined as none or mild if EOAI was ＞ 0.85 cm2/m2,as moderate for (0.65 - 0.85 ) cm2/m2 and as severe for ＜ 0.65 cm2/m2.To avoid PPM,a simple three-step algorithm was applied:Step 1,Calculate the patient's BSA from weight and height;Step 2,Calculate the minimal valve EOA required based on the BSA to ensure an EOAI ＞0.85 cm2/m2 ; Step 3,Select the type and size of prosthesis that has reference values for EOA greater or equal to the minimal EOA value obtained in step 2.For patients with a small aortic root,the following three methods was used:( 1 ) Replace aortic valve with simple interrupted suture technique ; (2) Apply new type and high-performance prosthetic valves such as St.Jude Medical Regent mechanical valve ; (3) Enlarge the narrowed aortic root when necessary.Results Of all 357 patients,272 patients received mechanical AVR and 85 bioprosthetic AVR.Among the 49 patients who received AVR with simple interrupted suture technique.St.Jude Medical Regent mechanical valve was implanted in 38 patients and the aortic root enlargement was performed in 11 patients.The total prevalence of PPM was 6.4％ and there was no severe PPM.The prevalence of PPM with mechanical AVR and bioprosthetic AVR was 1.8％ and 21.2％ respectively.There were 4 deaths during early period of operation,and the operative mortality was 1.1％.Conclusion Prosthesis-patient mismatch can be effectively prevented at the time of AVR with appropriate measurement.

Objective To prove that valve sparing aortic root reconstruction may have an impact on the outcome and longevity of the repair for patients with acute type A aortic dissection.Methods Clinical data of 98 consecutive AAAD patients undergoing the valve sparing aortic root reconstruction were analyzed.The postoperative follow-up and the clinical effect of the procedure were retrospectively analyzed.Results Pre-operative grade of aortic insufficiency was(2.3 ± 0.5), CPB-time was (217.8 ± 43.1)min, aortic cross clamp time was(142.7 ± 37.4)min and stay on ICU (11.1 ± 5.7) days, while hospitalisation was(14.3 ± 3.2) days.8 patients(8.2％) died peri-operatively.None of the early deaths were valve-related.Rethoracotomy rate was 3.1％.All patients followed up(19.3 ± 7.6) (6-68) months.Survival at 1 year was 90.8％.Freedom from valvular reoperation was 97.9％ at 3 years.At last investigation, mean grade of aortic insufficiency for AADA was 0.5 ± 0.3 (0-3).Conclusion Regardless of the underlying indication, the aortic valve preserving reimplantation technique can be performed with favourable functional results.

Objective To explore the plasma expressions of monocyte chemotaxis proteins(MCPs) in patients with type A aortic dissection and their clinical significance.Methods 51 patients with type A aortic dissection were enrolled,in which 29 combined with hypertension.Fourteen hypertension patients and 1 1 hcalthy subjects were enrolled as control.Plasma samples were collected and we examined the levels of MCP-1,MCP-2 and MCP-4 by enzyme linked immunosorbent assay (ELISA).Results Plasma levels of MCP-1 and MCP-2 significantly decreased in patients with type A aortic dissection compared to healthy subjects(P ＜0.001),while MCP-4 had no change.Type A aortic dissection patients with or without hypertension both showed significant decreased plasma MCP-1 and MCP-2 levels compared to hypertension patients(P ＜0.001).There was no change of MCP-4 among different groups.Furthermore,Spearman correlation analysis showed that there was no correlation between serum CRP levels and plasma MCP-1,MCP-2 concentrations.Conclusion Plasma MCP-1 and MCP-2 may participate in the pathogenesis of type A aortic dissection,and their concentrations were not correlated with hypertension or serum CRP levels.The detailed mechanism needs further observations.

Cardiac surgery carried out on cardiopulmonary bypass(CPB) in a pregnant woman is associated with poor neonatal outcomes although maternal outcomes are similar to cardiac surgery in non-pregnant women.Most adverse maternal and fetal outcomes from cardiac surgery during pregnancy are attributed to effects of CPB.The CPB is associated with utero-placental hypoperfusion due to a number of factors,which may translate into low fetal cardiac output,hypoxia and even death.Better maternal and fetal outcomes may be achieved by early pre-operative optimization of maternal cardiovascular status,use of perioperative fetal monitoring,optimization of CPB,delivery of a viable fetus before the operation and scheduling cardiac surgery on an elective basis during the second trimester.

Objective To analyze the effect of the false lumenstatus of different methods in a single center.Methods From January 2010 to December 2015,391 cases of acute Stanford A aortic dissection were treated in our center.139 cases(of which 108 malesand 31 females) were finally selected after excluding the cases who died during hospitalization,whose perioperative clinical data were incomplete,follow-up information were incomplete,and DeBakey type Ⅱ aortic dissection and the cases with descending aorta dilatation.The average age was(50.3 ± 11.6) years(22-76 years).According to the methods for aortic arch and descending aorta,139 cases were divided into 5 groups:24 cases in AR(including ascending aorta replacement,ascending aorta + hemi-arch replacement and ascending aorta + island-arch replacement),9 cases in AR + SET (including ascending aorta + hemi-arch replacement + stent elephant trunk and ascending aorta + island-arch replacement + stent elephant trunk),42 cases in Arch + SET(ascending aorta + arch replacement + stent elephant trunk),22 cases in AR + TBS (ascending aorta + triple branched stent) and 42 cases in AR + FS(ascending aorta + arch fenestrated stent).Statistical analysis the size of true lemen and the status of false lumen among these five groups in the level of aortic arch,the distal end of stent,diaphragm,celiac artery,renal artery and iliacartery postoperatively.Results Different levels of descending aorta in each group have showed arying degrees of true lumen open and thrombosisof false lumen during follow-up period.Among them,cases with aortic arch treatment and stent implantation have showed higher ratio of thrombosis of false lumen.Effects of different stents were similar,which all promoted the process of thrombosis of false lumen.Conclusion Three methods for aortrc arch and desc ending aorta repair including Cronus (R),triple branched stent and arch fenstrafed stent had similar clinical aortic false lumen closure rate.Three methods had similar long term effect.

Objective Acute Stanford type A aortic dissection(aTAAD) is often misdiagnosed as acute coronary syndrome(ACS), anti-platelet therapy for ACS will influence the timing and outcome of aTAAD.We reviewed the surgical outcome of these misdiagnosed aTAAD patients.Methods From January 2011 to October 2015, 309 aTAAD patients have received surgical therapy in our department, among them 15 patients had misdiagnosed as ACS and taken oral anti-platelet therapy, 9 male and 6 female, the average age was(60.6±8.7) years.Retrospectively reviewed the data of perioperative and follow-up period.Results 5 patients took orally aspirin, 10 took aspirin and clopidogrel.2 patients had received operation 7 days after stopping the agents, 3 days for 3 patients, 1 day for 1 patient, and the other 5 patients received emergency operation without stopping the agents.The cardiopulmonary bypass time was(259.7±64.8) minutes, aortic cross-clamp time was(181.0±51.7) minutes, and selective cerebral perfusion and lower body arrest time was(34.9±8.1) minutes.There were 2 in-hospital deaths due to circulation failure(mortality 13.3%).The average drainage volume in the first 24 hours after operation was(800.7±598.8)ml.During a mean follow-up period of(20.6±17.4) months, one patient had suddenly death.Conclusion aTAAD misdiagnosed as ACS was not rare, anti-platelet therapy will increase the risk of bleeding.The decision of operation time rely on considering balance between the rupture risk of aortic dissection and the hemorrhage risk of anti-platelet therapy.Emergency operation for these patients will increase the bleeding and transfusion.

Objective To investigate the clinical applications of coronary CT angiography in patients with suspected coronary artery disease and identify factors that affect CT findings. Methods Medical records of patients suspected of coronary artery disease over a period of 12 months from a tertiary teaching hospital were retrospectively reviewed. Patient age, sex (male/female), duration of symptoms and abnormal rates of coronary CT angiography scans were analysed to investigate the relationship among these parameters. The patients by age were duration of symptoms was also classified into five groups: less than one week, one week to one month, one to three months, three to six months and more than six months. Results Of the 880 patient records reviewed, 800 met the above study criteria. Five hundred and forty nine patients demonstrated abnormal CT findings (68.6%). There was no significant difference in the percentage of abnormal CT findings based on patient sex and the duration of symptoms (P = 0.14). The abnormal rates of coronary CT angiography, however, increased significantly with increasing age (P < 0.001); with patients over 65 years of age 2.5 times more likely to have an abnormal CT scan relative to a patient under 45 years. A significant difference was found between abnormal coronary CT angiography and the duration of symptoms (P = 0.012). Conclusions Our results indicate coronary CT angiography findings are significantly related to the patient age group and duration of symptoms. Clinical referral for coronary CT angiography of patients with suspected coronary artery disease needs to be justified with regard to the judicious use of this imaging modality.