Objective:To summarize the feasibility and clinical experience of various types of aortic surgery through upper hemisternotomy.Methods:From June 2016 to October 2019, 63 patients underwent various types of aortic operations through upper hemisternotomy in our department. Among them, there were 51 males and 12 females with an average age of(49.7±12.7) years. All kinds of major vascular operations include: 33 cases of aortic dissection procedure; 9 cases of Bentall procedure; 7 cases of wheat procedure; 2 cases of Ross procedure; 2 cases of David procedure; 2 cases of simple ascending aorta replacement procedure; 3 cases of redo thoracic Bentall procedure; 2 cases of redo thoracic wheat operation; 1 case of redo thoracic aortic root leakage repair procedure; 2 cases of redo thoracic ascending aorta procedure, innominate artery, left common carotid artery replacement and removal of intravalvular vegetation procedure; 1 case of Bentall plus pulmonary valve and pulmonary artery replacement procedure. Among them, aortic dissection included 11 cases of ascending and total arch replacement plus descending aortic stent implantation procedure; 2 cases of AVR plus ascending and total arch replacement procedure; 5 cases of ascending and semi-arch replacement procedure; 4 cases of David plus ascending and total arch replacement plus descending aortic stent implantation procedure; 1 case of redo thoracotomy David plus ascending and total arch replacement with descending aortic stent implantation procedure; 1 case of David plus ascending and total arch replacement procedure; 6 case of AVP/AVR/Bentall plus ascending and total arch replacement and descending aortic stent implantation procedure; 2 cases of redo total arch replacement and descending aortic stent implantation procedure and aortic root vascular graft wrapping plus ascending aorta and 1 case of total arch replacement with descending aortic stent implantation procedure.Results:All 63 cases of operation were successfully completed without transforming to middle sternotomy; 1 case with acute renal failure was treated by dialysis, and then complicated with septic shock and intracranial hemorrhage, and died of ineffective rescue; 2 cases were treated by thoracotomy exploration and hemostasis; 9 cases with pericardial effusion needed pericardiocentesis; 2 cases with lower extremity muscle weakness after operation: one treated by drainage of spinal fluid and the muscle strength of the lower extremities was restored, another one complicated with infection, acute renal failure and hypoxemia was treated by anti-infection, continuous CRRT, gamma globulin infusion and rehabilitation exercise, the muscle strength of the lower extremities was eventually restored. Except for one death in hospital, all the other patients were cured and discharged.Conclusion:Well exposure of aortic root, ascending aorta and descending part of arch can be obtained through upper hemisternotomy and various types of aortic proceduer can be done with satisfactory results through this approach.

ObjectiveTo evaluate the outcomes for elderly( ＞70 years) patients undergoing valvular heart surgery and determine the early mortality and major morbidity associated with cardiac valve surgery in the elderly.MethodsBetween 2005and 2011,1366 patients underwent cardiac valve surgery in our department.115 patients(65 males,50 females) were 70 or older [aged (74.3 ± 3.1 ) years].Rheumatic valvular disease presented in 68 ( 59.1％ ),degenerative valvular disease in 33(28.7 ％),congenital heart disease in 6 (5.2 ％) and the others in 8 (7.0％).20 cases( 17.4％ ) had hypertention,17 cases( 15.8 ％ ) had diabetes mellitus,18 (15.7％) had coronary heart disease.Chronic obstructive pulmonary disease was found in 25 cases(21.7 ％ ),and renal insufficiency was found in 9(7.8 ％ ).6 patients(5.2％ ) had the history of cerebrovascular disease.72 (62.6 ％) had atral fibrillation and 11 cases(9.6％ ) had the history of cardiac valve surgery previously.75(65.2 ％ ) cases were in New York Heart Association(NYHA) functional class Ⅲ-Ⅳ.Left ventricular ejection fraction (LVEF) was 0.28-0.72 (0.53 ± 0.01 ).All the patients receieved coronary angiography preoperatively.All the operations were performed on cardiac-pulmonary bypass (CPB) with moderate hypothermia.During CPB,the perfusional pressure was maintained between 60-70 mm Hg and the oxygen saturation for mixed venous blood was kept above 0.70.Artificial ultrafilitration was performed for all the patients during the time of CPB.55 ( 47.8 ％ ) patients had mitral valve replacement ( MVR),3 (2.6％) had mitral valve repair( MVP),33 (28.7 ％) had aortic valve replacement (AVR),16 ( 13.9 ％ ) had AVR +MVR,5(4.3％ ) had AVR + MVP,and 3 had tricuspid replacement.The concomitant procedures included left atrial thrombus scavenging in 18( 15.7％ ),tricuspid valvularplasty in 71 (61.7 ％ ),bental procedure in 6 (5.2 ％ ),and coronary artery bypass grafting(CABG) in 15 ( 13.0 ％).ResultsThe early mortality was 0.87 ％.The major complications included sever low cardiac output syndrome in 6 patients,transient atrial fibrillation in 17,acute renal failure requiring dialysis in 3,delayed ventilation assistance in 12,and stroke in 3.112 (97.4％) patients survived during 6 months period of follow-up,in whom only 8(7.14％) were in NYHA functional class Ⅲ-Ⅳ which was lower significantly compared with that preoperatively.ConclusionHeart valve surgery for elderly patients can get satisfactory result and early mortality and major mortality is low for them.Concerns over the risk of cardiac valve surgery in the elderly should not prevent referral,and elderly patients can do well.

The reform of medical service prices in China has been launched, and the reasonable pricing and management of medical technology services are of great significance for improving patient well-being and advancing the reform of our medical system. The author provided a detailed review of the policy evolution, current management status, and main issues of medical service price management in China since 2000. The medical service price management policies in China since 2000 were divided into four evolutionary stages: initial exploration of decentralization, substantial development, continuous advancement, and deep promotion. The author also described the formation mechanism and pricing methods of international medical service prices, and compared the similarities and differences in medical service price management at home and abroad. Some suggestions were put forward for improving the macro reform of medical service price management in China.

Objective:In comparison with full sternotomy, we explore the safety and clinical efficacy of upper hemisternotomy for Stanford A acute aortic dissection.Methods:Retrospective analysis of 78 patients with Stanford type A acute aortic dissection from January 2014 to December 2018(20 patients underwent UHS invasive, 58 patients underwent FS invasive). Based on variables including gender、age、BMI、LVEF、Euro SCORE Ⅱ and type of surgery, two matched cohorts including 18 patients respectively were constructed: group UHS and group FS, the baseline data and perioperative indicators were analyzed.Results:Operative mortality was 3.9%(3 of 78). The patients＇baseline data were nearly balanced between the two groups after matching( P>0.05), only 1 case died of infectious cerebral hemorrhage in the FS group. The UHS group had a shorter cardiopulmonary bypass time than the FS group[(202±41)min vs.(235±39)min, P=0.041]. There was no significant difference in aorta clamping time[(159±38)min vs.(158±59)min, P=0.918] and hypothermic circulatory arrest time[(40±10)min vs.(50±20)min, P=0.081] between the two groups. The bladder temperature in the UHS group was significantly higher than that in the FS group[(24.0±3.1)℃ vs.(28.2±2.3)℃, P=0.001]. Compared with the FS group, the UHS group had less red blood cell transfusion[(4.8±2.8)U vs.(7.2±3.9)U, P=0.038], less postoperative drainage[(855±657)ml vs.(1510±703)ml, P=0.007], shorter ventilation support time(22 h vs. 58 h, P=0.037), shorter intensive care unit retention time[(4.6±2.7) days vs.(7.2±2.8) days, P=0.009], and shorter postoperative hospital stay time[(8.2±3.8) days vs.(18.4±3.8) days, P=0.001], but the incidence of pericardial puncture was higher in the UHS group[7(33%) vs. 1(6%), P=0.041]. 3 cases had postoperative renal insufficiency(requires dialysis), 5 cases(13.9%)had neurological complications, 1 case received re-exploration in the two groups respectively. Conclusion:The upper hemisternotomy approach is safe and feasible for Stanford A acute aortic dissection, with excellent early outcomes.