Objective To observe functional changes of the right ventricle (RV) during off-pump coronary bypass grafting (OPCABG) by using a continuous cardiac output (CCO) monitoring. Methods The study included 178 patients with 2~3 vessel disease requiring a coronary bypass grafting. Preoperative cardiac functions were classified as New York Heart Association (NYHA) class Ⅱ in 72 patients, class Ⅲ in 84 patients and class Ⅳ in 22. The ejection fraction of the left ventricle was 0.35~0.82. The mean number of bypassed vessel was 3.3. A Swan-Ganz catheter was inserted for continuous monitoring of cardiac output by thermodilution. Parameters measured were heart rate (HR), mean arterial pressure (MAP), central venous pressure (CVP), mean pulmonary artery pressure (MPAP), right atrial pressure (RAP), pulmonary capillary wedge pressure (PCWP), cardiac output (CO), cardiac index (CI), stroke volume index (SVI), systemic vascular resistance index (SVRI), pulmonary vascular resistance index (PVRI), mixed venous saturation value (SvO_2), right ventricular ejection fraction (RVEF), right ventricular end-systolic volume (RVESV), right ventricular end-diastolic volume (RVEDV), right ventricular end-systolic volume index (RVESVI), and right ventricular end-diastolic volume index (RVEDVI). The hemodynamic parameters were measured at time-points when a stable hemodynamics was obtained after the induction of general anesthesia and before the heart would be moved (T1), when the anterior descending branch would be anastomosed (T2), when the circumflex branch or the diagonal branch would be anastomosed (T3), when the right coronary artery or the posterior descending branch would be anastomosed (T4), and when the heart had been repositioned before the thoracic cavity would be closed (T5), respectively. Results There were 4 fatal cases: 2 patients received an emergency surgery for acute myocardial infarction and died with severe low cardiac output syndrome 3 days after the surgery, 1 patient ended with severe respiratory failure 7 days after the surgery, and 1 succumbed to acute pulmonary embolism 4 days after the surgery. As compared with the time-point of T1: the MPAP, PCWP, RAP and PVRI were significantly elevated and the SvO_2 was significantly reduced at the time-point of T2; the MPAP, PCWP, RAP, PVRI and SVRI were significantly elevated and the SvO_2, CI, SVI and RVEF were significantly depressed at the time-point of T3; the HR and RAP significantly went up and the SvO_2 significantly dropped at the time-point of T4; the parameters didn’t recover to normal levels at the time-point of T5. Conclusions When the obtuse marginal (OM) branch is anastomosed, right ventricular functions may decrease, particularly in CI and RVEF levels, while when the left anterior descending branch or right coronary artery is anastomosed, hemodynamics of the right ventricle vary within narrow limits. Therefore, a monitoring of right ventricular functions during OPCABG is of great significance, especially for those with right ventricular insufficiency.

Objective To assess and compare the the results of tricuspid annuloplasty performed with the Edwards MC3 and Kay methode.Methods From January 2010 to May 2014, 759 patients with function tricuspid regurgitation(FTR) secondary to left-sided valve disease received tricuspid annuloplasty.Cardiac ultrasound Heartbeat diagram were made to confirm the degree of tricuspid regurgitation, the diameter of tricuspid annulus, the pressure of pulmonary artery and the heart function both in the left and the right, and so on.Of them, 355 cases of male, female 404 cases, at the mean age of(54.1 ± 8.3) years old, with the heart function classical(NYHA) : Ⅰ 13, Ⅱ 177, Ⅲ 400, Ⅳ 169, the mean left ventricles ejection fraction(LVEF) was 0.53 ±0.04, the mean pulmonary artery pressure was(62.5 ± 17.6) mmHg(1 mmHg =0.133 kPa).The diagnosis include rheumatic heart disease 517 cases, degenerative disease 209 cases and infective endocarditis 33 cases.The operation include mitral annuloplasty 132 case, mitral replacement 295 cases, mitral annuloplasty and aortic replacement 20 cases, mitral and aortic replacement 388 cases, CABG 86 cases and Maze Ⅲ methode 23 cases.The degree of tricuspid regurgitation before the operation were class Ⅰ 88, Ⅱ 189, Ⅲ 352 and V 130.From January 2010 to May 2012, 447 cases received Kay' s methods and 312 cases received MC3 annuloplasty ring during May 2012 to May 2014.In the MC3, We use the rings in 28mm size were 79 cases, 30 mm 155 cases, 32 mm 66 cases and 34 mm 12 cases.Results There were no death, reoperation and adverse events in both groups.There were no diffent in the aorta block time, the circulation bypass time, the time of mechanical ventilation, stay in ICU and in the hospital(P ＞ 0.05).All the patient were followed up regularity.The rat of follow up was 90.4％ (686/759), and the mean time of follow up was(39.9 ± 7.7) month.The patients' s EF increased, inner diameter of the right ventricle decreased in both group.There were no severe TR in the patients in the Kay group within 3 months, and 1 case of severe TR 1 year later, as 5 cases at 2 years and 12 cases after 2 years.The regurgitation volume of tricuspid was (3.4 ± 1.4) ml at the moment of 3 month, (6.5 ± 2.1) ml at 1 year, (7.9 ± 2.5) ml at 2 years and (12.4 ± 4.7)ml 2 years later.In the MC3 group, there were no severe TR in the patients during all the stage of fellow-up.There were on regurgitation in the patient within 3 months, 1 case of Class Ⅲ of TR at 1 year and 3 cases of Class Ⅲ at 2 years, without worse TR happen.At the same stage as in MC3 group, the regurgitation volume was(2.9 ±0.9) ml,(3.5 ±1.3) ml and(3.4 ±2.1) ml.The result in MC3 group was similar with Kay group(P ＞0.05) in short term, but much better in the long-term(P ＜ 0.05).Conclusion The Kay methode has good early result, but not the same good in the long-term, which can be applied in the elder persons or the patient without long Life expectancy.And the MC3 ring can correct the FTR enduringly and effectually, specifically the size in small one which behaves perfectly.The MC3 ring should be used in the young patient or the patient wants more.

ObjectiveTo study the pulmonary arterial development over five years in patients underwent extracardiac total cavopulmonary connection (ETCPC).Methods43 survived patients,who had undergone ETCPC were examined with pulmonary perfusion at one month and five year following the operation.Central venous pressure (CVP) and arterial oxygenation saturation (SatO2 ％ ) were measured by right cardiac catheter,pulmonary arterial index (PAI) and pulmonary vascular resistance (PVR) were calculated.Pulmonary blood distribution were measured and calculated by 99m Tc-MAA perfusion imaging.ResultsThe PAI and PVR of the follow-up group reduced significantly ( t =2.41,P ＜ 0.05 ; t =2.08,P ＜ 0.05 ),CVP also reduced significantly ( t =2.69,P ＜ 0.05 ),but SatO2 ％ did not changed significantly.Total radionuclide counts and the ratio of rightorleft pulmonary perfusion did not change significantly.( t =0.38,P ＞ 0.05 ;t =1.12,P ＞ 0.05 ),but the ratio of the superior and inferior lobe decreased significantly( t =2.54,P ＜ 0.05 ).ConclusionThe weak pulsation and low dynamic of Fontan circulation also can promote pulmonary vascular development.However,the improvement of hemodynamic in pulmonary circulation at mid-term follow will not lead to an increased amount of pulmonary perfusion or oxygen supply,which is probably due to the massive opening of the arteriovenous shunt and increased futile circulation.

Objective To evaluate the causes,treatment,and prevention of left ventricular rupture after mitral valvereplacement.Methods From May 1981 to November 2010,11 cases occurred in 4 male and 7 female patients aged 28 - 71 years old.There were 2 cases of New York Heart Association (NYHA) functional class Ⅱ and 9 cases of class Ⅲ.Echocardiography showed that the left ventricular end diastolic internal diameter (LVEDI) was 32 -62 mm.Results Rupture probably occurs after endocardial damage to a thin myocardium that has lost the internal buttress of the subvalvar apparatus.With the rise in intraventricular pressure at the end of bypass blood dissects into the myocardium,resulting in a large haematoma and eventual rupture.According to the onset of ruptures,there were 4 cases of delayed rupture which occured at several hours till days post operation after the patients had been back in the ICU,and 7 cases of early ruptur,which occured at the early stage of surgery,while the patient was still in the operation room.There were no cases of ruptures.The types of the ruptures were identified by operation or necropsy as 5 cases of type Ⅰ,4 cases of type Ⅱ,and 2 cases of type Ⅲ.Four patients were saved after emergency treatment,and 7 died.Conclusion It is difficult to repair left ventricle rupture,but effective prevention for onset can decrease its occurrence.The risk factors for left ventricular ruptures are female,advanced age,pathological changes characterized by mitral stenosis,small left ventricle (LVEDD ＜ 35 mm),and low weight( ＜50 kg ).The following actions raise the risk of let ventricular rupture.Isolated replacement of the mitral valve than after double valve replacement or mitral valve replacement and coronary artery bypass graft; aggressive removal of calcification at the mitral valve; undue selection and replacement of mitral valve prostheses; large size of prosthetic valve with a high bioprosthetic angle in particular; deep sutures at the valve ring; aggressive traction or removal of papillary muscle,hematoma,and heart move.Also we should continue correcting unstable hemodynamic especially with very high blood pressure.Once left ventricular rupture occurs,extracorporeal circulation should be established as soon as possible,and direet suture or intracardiac and extracardiac repair suited to actual conditions are reliable ways to save the patient's life.

Objective Analyzing risk factors for gastrointestinal bleeding(GIB) after coronary artery bypass grafting(CABG). Methods 582 cases undergoing CABG from August 2001 to May 2005 were divided into two groups (GIB group ,n=6 ;control group,n=576) . Preoperative , operative and postoperative clinic data were com-pared. Results The ratio of over-aging(age greater than 70), hypertension, cerebrovascular disease, myocardial in-fraction,heart function (NYHA) over Ⅲ and postoperative low output syndrome (LOS) in GIB group were signifi-cantly higher than that in control group;age, blood transfusion and hospitalized time were significantly higher and left ventricular ejective fraction was significantly lower in GIB group than that in control group. Age over 70,history of myocardial infraction and heart function (NYHA) over Ⅲ were selected as risk factors of GIB after CABG by step-wise logistic regression analysis. Conclusions It is very useful for precaution, early diagnosis and early therapy of GIB after CABG to evaluate if patients have the risk factors of GIB after CABG before operations.

Objective To evaluate the indication and surgical technique for treating tetralogy of F allot with pulmonary atresia (TOF-PA).Methods From June 1984 to June 2009,66 patients with TOF-PA underwent 69 operations.Among them,34 were males and 32 females.Their age ranged from 6 months to 29 years.The anatomic characteristics of TOF-PA included 31 cases of Type Ⅰ,14 Type Ⅱ,12 Type Ⅲ and 9 Type Ⅳ.The operations included palliative aorto-pulmonary shunts in 11 cases,one-stage unifocalization with unpatched VSD in 2 cases,one stage complete repair in 40 cases,one-stage unifocalization with VSD repair in 13 cases,and delayed intracardiac repair after shunt procedures in 3 cases.Results There were 6 early deaths,including 1 death happened after aorta-pulmonary shunt and 5 after complete repair.The causes of death were severe low cardiac output in 3 cases,respiratory failure in 1,multiorgan function failure in 1 and severe wound infection with endocarditis in 1 after aorta-pulmonary shunt.The postoperative oxygen saturation of the patients undergone shunt and one stage unifocalization with unpatched VSD increased to 82％ ～ 91％.The postoperative ratio of right ventricular pressure/left ventricular pressure after complete repair was ＜ 0.5 in 31 cases,18 cases were between 0.5 and 7 cases ＞ 0.75.47 patients were followed up from 3 months to 15.5 years.The heart function(NYHA) of 44 patients were in class Ⅰ or Ⅱ and 3 in class Ⅲ or Ⅳafter operation.Conclusion The surgical strategy for TOF-PA mainly depends on the anatomic characteristics of the pulmonary and aortopulmonary collateral arteries.An individualized approach based on the anatomy of the pulmonary circuits permits a better result in the patients with TOF-PA.Patients with well developed pulmonary arteries should undergo one stage complete repair as early as possible.

Objective To assess the results of the Fontan procedure in patients with visceroatrial heterotaxy syndrome and complex cardiac anomalies.Methods From April 2002 through December 2010,25 patients (male 10,female 15) had undergone the Fontan procedure for heterotaxy syndrome or atrial isomerism and complex congenital heart disease 28 times.Median age at operation was (9.1 ± 5.5) years (2 to 18 years).Heterotaxy syndrome were associated with right atrial isomerism (n =18) or left atrial isomerism (n =7),asplenia (n =13) or polysplenia (n =7),double inlet of left ventricle (n =15),double inlet and outlet of left ventricle (n =5),double outlet right ventricle with pulmonary atresia (n =2) and with pulmonary stenosis (n =1),tricuspid or mitral atresia (n =2).A bidirectional cavopulmonary shunt was performed in 8 patients (bilateral in 3 patients).A cavopulmonary shunt placement,so-called Kawashima operation,was performed in 4 patients.An extracardiac conduit Fontan connection was pefformed in 15 patients and intracardiac lateral tunnel Fontan connection in one patient.Results 2 patients died in hospital caused by ventricular failure.Five patients developed early postoperative atrial arrhythmias and 2 patients had sinus node dysfunction.Mean arterial oxygen saturation at discharge was 0.86 ± 0.07 (range,0.78 to 1.00).Follow-up (range,0.5 to 7 years) was available on 15 patients.Mean arterial oxygen saturation was 0.82 ±0.08 (range,0.68 to 0.97).Ventricular function was normal in 13 patients (EF range,0.50 to 0.66) and depressed in 2 patients.Four patients had a junctional rhythm.Conclusion The Fontan procedure was still the main procedure for patients with visceroatrial heterotaxy syndrome and complex cardiac anomalies,which can reach satisfactory early and medium-term results.The choice of Fontan procedure,extracardiac conduit Fontan connection,aggressive treatment of concomitant malformations were essential to improve the outcomes.

Objective Study the management and outcomes of one-stage repair of aortic coarctation or interrupted aortic arch associated with cardiac anomalies through median sternotomy.Methods From July 2002 to June 2009,43 patients with aortic coarctation(34 cases)or interrupted aortic arch(9 cases)and associated with cardiac anomalies underwent one-stage repair.There were 27 males and 16 females.The age ranged from 5 months to 9 years and the body weight from 3.5 kg to 29.0 kg.The associated cardiac anomalies included ventricular septal defect in 42 patients,patent ductus arterious in 34,secundum atrial septal defect in 12,subaortic stenesis in 5,mitral valve regurgitation in 2 and double outlet of right vantricule in 1.All patients underwent one-stage repair through median sternotomy.The aortic continuity was reestablished by direct anastomosis between the descending aortic segment and aortic arch.Results There was one postoperative death.The causs was pulmonary hypertension and severe low cardiac output syndrome.The postoperative complications included severe low cardiac output syndrome in 3 patients,hypoxemia in 6,pneumonia in 11,atelectasis in 14,injury of recurrent laryngeal nerve in 19,and supra ventricular tachycardia in 23.34 patients were followed up from 3 months to 5 years and were in good condition without recoarctation.Conclusion The outcomes of early and medium term for one-stage repair of aortic coarctation or interrupted aortic arch and associated cardiac anomalies through median sternotomy is excellent.Technique of extended anastomosis between the descending aortic segment and aortic arch may reduce the incidence of recoarctation

Objective The aim was to evaluate the development of pulmonary arteries(PA) in patients with pulmonary atresia,ventricular septal defect and diminutive pulmonary arteries by using a central end-to-side shunt between the ascending aorta and pulmonary arteries and to identify the associated factors for the results.Methods 51 consecutive patients(37 male,14 female) with pulmonary atresia,ventricular septal defect and diminutive pulmonary arteries received a central end-to-side shunt between PA and the ascending aorta from May 2004 to June 2013.Ages and weight ranged between 2-86 months and 2.5-21.5 kg,respectively.39 patients with main PA diameters less than 4 mm received the central end-to-side shunt between the ascending aorta and PA,and 14 patients with main pulmonary arteries absence received a modified shunt.Results There were no deaths during operation and follow-up.Compared with preoperative measures,total pulmonary artery index increased from a mean value of(68.8 ± 11.4) mm2/m2 to(129.1 ± 24.9) mm2/m2 (P ＜ 0.001) at the time of six months or the final repair after shunt.The increased pulmonary artery index change was(87.7 ± 27.4) ％ (27.0％ to 150.0％).By multivariate regression analysis,age at shunt,shunt procedure and number of major aortopulmonary collateral arteries were correlated with increasing pulmonary artery index change.Conclusion The central end-to-side shunt between the ascending aorta and pulmonary arteries promoted sufficient growth of the diminutive central pulmonary arteries.Due to the risk of a distortion of pulmonary branches,we interposed a modified procedure for patients with main pulmonary arteries absence.It is technically easy to perform,warrants low risk of shunt thrombosis in the early postoperative period.

Objective To summarize the clinical features and treatment experience of subpulmonic ventricular septal defect (SPVSD). Method The clinical data of 241 cases of SPVSD were analyzed retrospectively. Results Two hundred and fifteen cases were confirmed by echocardiography before operation, while other 26 cases were misdiagnosed (10.79%, 26/241), 42 cases with aortic valve prolapsed,ECG showed left ventricular hypertrophy. All patients underwent surgical repair of VSD. Other procedures had been done in the same stage including aortic valve replacement (AVR) in 8 cases, aortic valvuloplasty (AVP) in 6 cases and other operations. The size of VSD was larger than the value echocardiography measured before operation. There were no perioperative death and no complete atrioventricular block. Two hundred and thirty cases (95.44%, 230/241) were followed up for 3 months to 5 years. The cardiac function (NYHA) in 189 cases were grade Ⅰ and 41 cases were grade Ⅱ. There was no residual shunt of VSD. Among patients who underwent AVP or AVR, 1 case developed mild insufficiency, others developed well. Others underwent another operations all developed well. Conclusion To achieve satisfactory results, it should enhance the overall understanding of SPVSD, improve the diagnostic accuracy of SPVSD, take positive surgical repair of VSD and reasonable treatment with aortic valve disease, and other malformation or disease.