Objective To summanrize the operative method and follow-up data of total aortic arch replacement combined with transaortic stented graft implantation into the descending aorta (Sun's procedure) for acute Stanford type A aortic dissection.Methods Between August 2004 and March 2012,73 patients with acute type A aortic dissection underwent this procedure.60 males and 13 females ranging in age from 26 to 79 years (mean age,49,6 years).Right axillary or femoral artery cannulation was routinely used for cardiopulmonary bypass.Cerebral protection was achieved by bilatero-antegrade or selected hrain perfusion.The stented elephant trunk was implanted throuugh the aortic arch under hypothermic circulatory arrest.The stented elephant trunk was a 10cmlong self expandable graft.Patent false lumina were evaluated using computed tomography 3 months and once each year after discharge to evaluate the postoperative time course of the residual false lumen.Results Mean cardiopulmonary bypass time was (248.1±69.8)min,and selected cerebral perfusion time was (38.2±10.5)min.Hospital morality was 6.85 ％ (5/73).Thrombus obliteration of the residual false lumen in the descending thoracic aorta was observed in 9 1.7％ of the aortic dissections 3 months postoperatively.The mean follow-up time was(36.4 ± 31.6)months (range,2 to91 months).Survival at 1,5,7 years was 97％,87％ and 81％,respectively.Conclusion Total aortic arch replacement combined with transaortic stented paft implantation into the descending aorta is an effective treatment and n more promising choice for acute type A aortic dissection.

Objective: To understand the clinical manifestation, imaging characteristics and outcomes of pulmonary malignant tumors in children. Method: We retrospectively collected information about seven cases of pulmonary malignant tumors in children in our hospital from Jan 2010 to Dec 2016. The information included clinical manifestation, imaging characteristics, pathologic results, and treatment. Result: (1) All the seven patients firstly visited pediatric internal medicine departments. Symptoms included cough (n=6), dyspnea (n=4), fever (n=2), anorexia (n=2), chest tightness (n=1), chest pain (n=1), lameness (n=1), abdominal distension and constipation (n=1). We did not find hemoptysis, wheezing or weight loss in those patients. Physical examinations revealed unilateral reduced breath sounds (n=5), moist rales and wheezes (n=1), and normal (n=1). Extrapulmonary signs included abdominal distension (n=2), left hip tenderness (n=1), and mass in left scrotum. We did not identify clubbing finger, anemic appearance, lymph node enlargement, or hepatosplenomegaly etc. (2) Laboratory examination results: complete blood count showed white blood cells in normal range except one case (17.44×10⁹/L). Neutrophil percentage ranged from 0.348 to 0.767. C reactive protein ranged between<1 and 162 mg/L. Hemoglobin was normal. Three out of four cases had abnormal blood tumor markers.(3) Imaging results showed multiple nodes (n=3), multiple cystic lesions in lungs (n=2) (both with pleuropulmonary blastoma), endobronchial soft tissue mass (n=1), pulmonary round-shaped mass (n=1), and mediastinal mass (n=1). Imaging results also found atelectasis (n=3), pneumonia (n=2), pneumothorax (n=2), longitudinal diaphragmatic hernia (n=2), pleural effusion (n=1), subcutaneous emphysema (n=1). (4) All the patients underwent tumor puncture biopsy or tumor resection. Pathology revealed the final diagnosis of pleuropulmonary blastoma (n=3), endodermal sinus tumors (n=2), squamous cell carcinoma of lung (n=1), and thyroid papillary carcinoma (n=1). All of them were malignant tumors. We followed up them. Two patients died (both with pleuropulmonary blastoma) after their parents refused any medical help. Two cases were lost to follow-up. Three patients survived (followed up for 19 months, 11 months and tow months, respectively). One case with thyroid papillary carcinoma pulmonary metastasis underwent right thyroid cancer radical plus left thyroid lobe resection plus modified selective central lymph node dissection, then iodine ¹³¹ treatment. One case with endodermal sinus tumor pulmonary metastasis underwent three times of chemotherapies, resection of left retroperitoneal tumor and left testicular tumor, and six additional chemotherapies. Another one case of endodermal sinus tumor pulmonary metastasis underwent three times of chemotherapies and was discharged. Conclusion Pulmonary malignant tumors are rare diseases in children. Clinical signs are often non-specific. For those with chest CT showing multiple cystic lesions, endobronchial soft tissue mass or multiple nodes, but no significant infection manifestation or no response to anti-infection therapy, pulmonary malignant tumors should be considered. Biopsy may be needed to confirm the final diagnosis.

Objective To compare early outcomes of the minimally invasive aortic valve surgery (MIAVS) through right parasternal mini-thoracotomy with conventional mitral valve surgery (AVS),and evaluate feasibility and safety of MIAVS.Methods From January 2017 to December 2017,60 patients undergoing elective AVS in Nanjing First Hospital were prospectively enrolled in this study.There were 32 male and 28 female patients with their age of 28-72 (46.5 ± 10.2)years.Using a random number table,all the patients were randomly divided into a port-access MIAVS group (MIAVS group,n =20) and a conventional AVS group (conventional group,n =60).MIAVS group patients received port-access cardiopulmonary bypass (CPB) establishment via femoral artery,femoral vein and right internal jugular vein cannulation through right the 3rd in tercostal space with 5-6 cm right parasternal incision in length.Special MIAVS operative instruments were used for mitral valve repair or replacement.Conventional group patients received mitral valve repair or replacement under conventional CPB through median sternotomy.Perioperative clinical data,morbidity and mortality were compared between the 2 groups.Results There was no death in-hospital or shortly after discharge in this study.CPB time [(106.0 ± 21.0) minutes vs (73.0 ± 15.0) minutes] and aortic cross-clamping time [(78.0 ± 10.0) minutes vs (47.0 ± 7.0) minutes] of MIAVS group were significantly longer than those of conventional group (P ≤ 0.05).Postoperative mechanical ventilation time [(7.0 ±4.2) hours vs (10.2 ±5.3)hours],length of intensive care unit (ICU) stay [(19.0 ± 4.0) hours vs (27.5 ± 8.0) hours] and postoperative hospital stay [(8.5 ± 2.5) days vs (13.0 ± 3.0) days] of MIAVS group were significantly shorter than those of conventional group (P ≤ 0.05).Chest drainage volume within postoperative 12 hours [(100.0 ±40.0)ml vs (410.0 ±80.0)ml] and the percentage of patients receiving blood transfusion (15.0％ vs 55.0％) of MIAVS group were significantly lower than those of conventional group (P ≤0.05).Patients were followed up for 1-12 months,and the follow-up rate was 96.7％.There was no statistical difference in postoperative morbidity or mortality between the 2 groups (P ＞ 0.05).Conclusions Minimally invasive aortic valve surgery through right right parasternal mini-thoracotomy is a safe and feasible procedure for surgical treatment of mitral valve diseases.MIAVS can achieve similar clinical outcomes as conventional AVS,with more quickly recovery and less blood transfusion,and is a good alternative to conventional AVS.

Objective: To summarize the experience of reoperations on patients who had late complications related to previous aortic surgery for Stanford type A dissection. Methods: From August 2008 to October 2016, 14 patients (10 male and 4 female patients) who underwent previous cardiac surgery for Stanford type A aortic dissection accepted reoperations on the late complications at Department of Thoracic and Cardiovascular Surgery, Nanjing Hospital Affiliated to Nanjing Medical University. The range of age was from 41 to 76 years, the mean age was (57±12) years. In these patients, first time operations were ascending aorta replacement procedure in 3 patients, ascending aorta combined with partial aortic arch replacement in 4 patients, aortic root replacement (Bentall) associated with Marfan syndrome in 3 patients, aortic valve combined with ascending aorta replacement (Wheat) in 1 patient, ascending aorta combined with Sun′s procedure in 1 patient, Wheat combined with Sun′s procedure in 1 patient, Bentall combined with Sun′s procedure in 1 patient. The interval between two operations averaged 0.3 to 10.0 years with a mean of (4.8±3.1) years. The reasons for reoperations included part anastomotic split, aortic valve insufficiency, false aneurysm formation, enlargement of remant aortal and false cavity. The selection of reoperation included anastomotic repair, aortic valve replacement, total arch replacement and Sun′s procedure. Results: Of the 14 patients, the cardiopulmonary bypass times were 107 to 409 minutes with a mean of (204±51) minutes, cross clamp times were 60 to 212 minutes with a mean of (108±35) minutes, selective cerebral perfusion times were 16 to 38 minutes with a mean of (21±11) minutes. All patients survived from the operation, one patient died from severe pulmonary infection 50 days after operation. Three patients had postoperative complications, including acute renal failure of 2 patients and pulmonary infection of 1 patient, and these patients were recovered after treatment. Thirteen patients were finally recovered from hospital. The patients were followed up for 16 to 45 months, and no aortic rupture, paraplegia and death were observed in the follow-up. Conclusions Patients for residual aortic dissection after initial operations on Stanford type A aortic dissection should be attached great importance and always need emergency surgery, but the technique is demanding and risk is great for surgeons and patients, which need enough specification and accurate on aortic operation. More importantly, the Sun′s procedure also should be performed on the treatment of residual aortic dissection or distal arch expansion, and obtains the short- and long-term results in the future.

A teaching clinic is an outpatient clinic specialized for teaching, where trainees are responsible for medical activities such as medical history taking, physical examination, and diagnosis and treatment, under the assistance and guidance of teachers. Only a few hospitals in China have built up teaching clinics for standardized training of pediatric residents. This paper summarizes the experience in the operation management of the standardized residency training teaching clinic in Children's Hospital, Zhejiang University School of Medicine. The teaching clinic takes teaching as its core task, adheres to humanistic care, and follows the principle of hierarchical progression. Its operation involves organizational approval, preliminary arrangements, outpatient appointments, the implementation of teaching activities, and other processes, which are carried out under organizational management and quality management. We have explored a preliminary strategy for evaluating the teaching effects of teaching clinics, and proposed some suggestions for the future development of pediatric residency training teaching clinics such as increasing objective evaluation methods and increasing pediatric subspecialty teaching clinics.

OBJECTIVETo compare the effect aortic valve replacement(AVR) combined with aortic root enlargement and simple St.Jude Regent AVR in small aortic annulus patients.

METHODSFrom June 2008 to June 2012, 62 severe aortic valvular stenosis patients with small aortic annulus (annulus diameter of 15-21 mm) entered the study. Twenty-seven cases received AVR combined with aortic root enlargement (enlargement group) and 35 cases received simple St.Jude Regent AVR(non-enlargement group), 17 mm St.Jude Regent in 15 cases(17 mm group) and 19 mm in 20 cases (19 mm group). Aortic root enlargement techniques included Nicks in 2, modified Nicks in 6 cases, modified Manouguian in 19 cases. Patients were followed up and received ultrasonic cardiogram (UCG) 3, 12 months postoperatively and t-test was used for statistical comparison.

RESULTSIn enlargement group, 1 Nicks patient received reoperation due to aortic root hemorrhage, and died of mediastinal infection, 1 Manouguian patient received permanent pacemaker. In non-enlargement group, low cardiac output syndrome in 1 case. Three months and 12 months postoperative UCG showed, comparing to preoperation, effective orifice area (EOAI) increased significantly, postoperative transvalular pressure gradient and flow rate decreased significantly in each group (P = 0.000). Left ventricular diastolic diameter (LVDd) decreased significantly in both enlargement group and 19 mm group(P = 0.000), but no significant change in 17 mm group (P > 0.05). In non-enlargement group, 19 mm compared to 17 mm group, 3 months and 12 months postoperative EOAI increased significantly, pressure gradient, flow rate and LVDd decreased significantly(t = 2.449-12.291, P = 0.000-0.029). Comparing to enlargement group, there were significant differences in EOAI, pressure gradient, flow rate and LVDd in 17 mm group (t = 2.278-17.860, P = 0.000-0.028), but no significant differences in 19 mm group(t = 0.118-1.630, P = 0.110-0.907).

CONCLUSIONSFor small aortic annulus AVR patient, 19 mm and larger St.Jude Regent prosthetic valves may produce satisfied hemodynamic, otherwise, aortic root enlargement is recommended.

Adult ; Aged ; Aortic Valve ; surgery ; Female ; Follow-Up Studies ; Heart Valve Prosthesis ; Heart Valve Prosthesis Implantation ; methods ; Humans ; Male ; Middle Aged

Objective    To analyze the cause of death in low-risk cardiac surgery patients during postoperative period and discuss the prevention and treatment methods to increase the survival rate. Methods    We retrospectively analyzed the clinical data of 132 patients dead after cardiac surgery from January 2014 to December 2018, among whom 35 patients had a EuroSCORE Ⅱ score <4% (low-risk cardiac surgery patients), including 20 males and 15 females aged 62.7±13.4 years. The cause of death in these low-risk patients was analyzed. Results    The main causes of death were cardiogenic and brain-derived causes (60.0%), and infections and ogran failure (45.7%). Pulmonary infection and low cardiac output after surgery were the main causes of death. Cerebral infarction, malignant arrhythmia and multiple organ failure were the common causes of death. There were 4 deaths (11.4%) caused by accidents, including gastrointestinal bleeding caused by esophageal ultrasound probe, cough and asphyxia caused by drinking water, postoperative paralytic ileus and multiple perioperative allergic reactions caused by allergic constitution. Conclusion    Postoperative treatment and prevention for low-risk cardiac surgery patients should be focused on postoperative infection, and cardiac and brain function protection. Changes in various organ functions need to be closely monitored for preventing organ failure, accidents should be strictly controlled, and more details of intraoperative and postoperative treatment still need to be further improved.

Objective    To explore the operability of concomitant ablation for the patients with valvular heart diseases with left atrium bigger than 60 mm. Methods    We prospectively included 306 patients with concomitant ablation in our hospital between 2013 and 2015 year. Based on diameter of left atrium measured by intra-operative transesophageal echocardiography (TEE), we separated these patients into two groups including a group L (left atrium >60 mm, 93 patients, 55 males and 38 females at age of 57.0±10.1 years) and a group S (left atrium <60 mm, 213 patients, 120 males and 93 females at age of 55.2±9.9 years) and followed them on 4 time points (time on discharge, three months, six months, and one year after surgery). Then, we analyzed the impact of left atrial size on cardioversion outcome of surgical ablation based on the following data. Results    The successful rate of the group S and the group L in the 4 time points was 72.8% vs. 75.3%, 74.2% vs. 75.3%, 78.9% vs. 77.4%, and 77.0% vs. 77.4%, respectively . The result of both univariate logistic regression analysis and receiver operation characteristic(ROC) curve analysis showed that there was no statistical difference in cardioversion rates between the group S and the group L. And there was no evident correlation between size of left atrium and ablation failure. Conclusion    Patients with left atrium enlarged from 60 mm to 70 mm can achieve the same satisfactory results in cardioversion, and should not be the contraindication of concomitant surgical ablation.

Objective    To analyze the clinical effect of partial aortic root remodeling for root reconstruction on Stanford type A aortic dissection. Methods    From January 2010 to December 2015, 30 patients (25 males, 5 females) underwent partial aortic root remodeling for root reconstruction on Stanford type A aortic dissection with involvement of aortic root. The range of age was from 27 to 72 years, and the mean age was 51.2±8.0 years. The proximal aortic dissection received partial aortic root remodeling, and the operation procedures included partial aortic root remodeling+ascending aortic replacement in 9 patients, partial aortic root remodeling+ascending aortic replacement+hemi-arch replacement in 6 patients, partial aortic root remodeling+ascending aortic replacement+Sun's procedure in 15 patients. The patients were followed up for 10 to 60 months with a mean of 37.9±3.2 months. Preoperative and postoperative degrees of aortic regurgitation were compared. Results    All patients survived from the operation, and one patient died from severe pulmonary infection 15 days after operation. The overall survival rate was 96.7% (29/30). One patient died during the follow-up. Two patients underwent aortic valve replacement in the 12th and 15th postoperative month respectively because of severe aortic regurgitation (AI). Up to the last follow-up, trivial or no aortic regurgitation was demonstrated in 24 patients, but mild aortic regurgitation occurred in 2 patients. Conclusion    The surgical treatment for aortic root pathology due to Stanford type A aortic dissection is challenging, and partial aortic root remodeling operations could restore valve durability and function, and obtains the early- and mid-term results.