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.

Objective:To examine the early and mid-term results of coronary endarterectomy (CE) combined with coronary artery bypass grafting (CABG) in the treatment of diffuse coronary artery stenosis.Methods:The clinical data and follow-up results of 248 patients who underwent CE+CABG surgery from January 2010 to January 2019 at Department of Cardiovascular Surgery, Nanjing Hospital Affiliated to Nanjing Medical University was analyzed retrospectively. There were 201 males and 47 females, aged (65.6±8.5) years (range: 43 to 79 years). The on-pump group included 156 patients and the off-pump group included 92 patients. CABG was performed after CE. CE was performed on 248 patients who represented 269 target coronary lesions, of which 108 were located on the left anterior descending artery and sub-branches, 140 were located on the right coronary artery and sub-branches, and 21 were located on the left circumflex artery and obtuse marginal artery. A total of 872 bypass grafts were performed, including 248 left internal thoracic arteries, 48 radial arteries, and 576 great saphenous veins, with (3.5±0.8) grafts (range:2 to 6 grafts) per patient.The grafts had satisfactory bridge blood flow after CE, with the graft flow rates of (26±8) ml/min (range: 13 to 59 ml/min) and the pulsatility index value of 3.1±0.8 (range: 2.0 to 6.7). The t test and χ 2 test was used to compare the surgical results and graft patency rate between patients in on-pump and off-pump group, respectively. Results:The number of graft vessels of on-pump group and off-pump group was 3.6±0.9 and 3.2±0.7, respectively( t=1.637, P=0.085). There were 3 deaths during the perioperative period, with a mortality rate of 1.2%. Two people died of renal failure, and one case was due to postoperative refractory low cardiac output. Perioperative myocardial infarction occurred in 9 cases. The follow-up time was (41.8±21.4) months (range:1 to 68 months). The all graft patency rate was 78.4%(812/232) in 1 year and 69.8%(162/232) in 3 years postoperatively. The left coronary graft patency rate was significantly higher than the right coronary graft patency rate(1-year: 87.4% vs.73.1%, χ2=6.533, P=0.011, 3-year: 78.2% vs. 64.8%, χ2=4.588, P=0.032). There was no significant difference in graft patency rates between the on-pump group and off-pump group (1-year: 80.0% vs. 76.9%, χ2=0.277, P=0.599, 3-year:71.5% vs. 67.9%, χ2=0.300, P=0.584). Conclusions:CE+CABG is a safe and feasible technique for patients with diffuse coronary artery disease to get more satisfied complete revascularization, with good early and medium-term results and graft patency rates. The outcomes of on-pump or off-pump CE+CABG are similar.

Objective:To examine the clinical experience and outcomes of coronary artery bypass grafting (CABG) using radial artery as the second arterial graft.Methods:Totally 585 patients in whom both left internal thoracic artery and radial artery as arterial conduits were used in CABG in Department of Cardiovascular Surgery, Nanjing Hospital Affiliated to Nanjing Medical University from April 2008 to August 2019 were consecutively enrolled. There were 436 males and 149 females, aging (63±10) years (range: 36 to 86 years). There were 40.7%(238/585) of patients had diabetes and 75.6%(442/585) of them had multivessel disease (two-vessel or three-vessel diseases). From January 2017, transit time flow measurement was performed on every patient. Demographic and perioperative data were retrospectively collected, as well as follow-up data for patients who underwent CABG from January 2014 to August 2019. Analysis were made on their early and late outcomes.Results:Most patients(81.9%(479/585)) in this cohort received on-pump CABG and 11 patients had intraoperative intro-aortic balloon counterpulsation (prior to CABG) support. Forty-three patients had concomitant valve procedures. The number of distal anastomosis was 3.6±0.9 (range: 2 to 6) and number of arterial distal anastomosis was 2.1±0.3(range:2 to 5). Radial artery was anastomosed to left obtuse marginal artery in 95.8%(560/585) patients. All target vessels for radial artery conduit had significant proximal stenosis (>70%) and 72.5%(424/585) patients′ target vessels had proximal stenosis which was >90%. Intraoperative transit-time flow measurement of 151 cases showed that radial artery conduits had a flow of (29.8±10.2) ml/minutes (range: 10 to 150 ml/minutes), and a pulsatility index of 2.5±1.4 (range: 0.7 to 5.0). There was no operative death. Two in-hospital deaths occurred more than 30 days after index surgery. There was no perioperative myocardial infarction. There were 188 patients who received CABG from January 2014 to August 2019 followed-up for a median duration of 3.2 years. There were 2 noncardiac deaths. No patient had myocardial infarction or myocardial revascularization.Conclusions:Radial artery as the second arterial conduit is a safe and effective strategy for CABG. Good selection of target vessel and intraoperative transit-time flow measurement may help achieve good patency, as well as the short and mid-term outcome.

Objective:To examine the early and mid-term results of coronary endarterectomy (CE) combined with coronary artery bypass grafting (CABG) in the treatment of diffuse coronary artery stenosis.Methods:The clinical data and follow-up results of 248 patients who underwent CE+CABG surgery from January 2010 to January 2019 at Department of Cardiovascular Surgery, Nanjing Hospital Affiliated to Nanjing Medical University was analyzed retrospectively. There were 201 males and 47 females, aged (65.6±8.5) years (range: 43 to 79 years). The on-pump group included 156 patients and the off-pump group included 92 patients. CABG was performed after CE. CE was performed on 248 patients who represented 269 target coronary lesions, of which 108 were located on the left anterior descending artery and sub-branches, 140 were located on the right coronary artery and sub-branches, and 21 were located on the left circumflex artery and obtuse marginal artery. A total of 872 bypass grafts were performed, including 248 left internal thoracic arteries, 48 radial arteries, and 576 great saphenous veins, with (3.5±0.8) grafts (range:2 to 6 grafts) per patient.The grafts had satisfactory bridge blood flow after CE, with the graft flow rates of (26±8) ml/min (range: 13 to 59 ml/min) and the pulsatility index value of 3.1±0.8 (range: 2.0 to 6.7). The t test and χ 2 test was used to compare the surgical results and graft patency rate between patients in on-pump and off-pump group, respectively. Results:The number of graft vessels of on-pump group and off-pump group was 3.6±0.9 and 3.2±0.7, respectively( t=1.637, P=0.085). There were 3 deaths during the perioperative period, with a mortality rate of 1.2%. Two people died of renal failure, and one case was due to postoperative refractory low cardiac output. Perioperative myocardial infarction occurred in 9 cases. The follow-up time was (41.8±21.4) months (range:1 to 68 months). The all graft patency rate was 78.4%(812/232) in 1 year and 69.8%(162/232) in 3 years postoperatively. The left coronary graft patency rate was significantly higher than the right coronary graft patency rate(1-year: 87.4% vs.73.1%, χ2=6.533, P=0.011, 3-year: 78.2% vs. 64.8%, χ2=4.588, P=0.032). There was no significant difference in graft patency rates between the on-pump group and off-pump group (1-year: 80.0% vs. 76.9%, χ2=0.277, P=0.599, 3-year:71.5% vs. 67.9%, χ2=0.300, P=0.584). Conclusions:CE+CABG is a safe and feasible technique for patients with diffuse coronary artery disease to get more satisfied complete revascularization, with good early and medium-term results and graft patency rates. The outcomes of on-pump or off-pump CE+CABG are similar.

Objective:To examine the clinical experience and outcomes of coronary artery bypass grafting (CABG) using radial artery as the second arterial graft.Methods:Totally 585 patients in whom both left internal thoracic artery and radial artery as arterial conduits were used in CABG in Department of Cardiovascular Surgery, Nanjing Hospital Affiliated to Nanjing Medical University from April 2008 to August 2019 were consecutively enrolled. There were 436 males and 149 females, aging (63±10) years (range: 36 to 86 years). There were 40.7%(238/585) of patients had diabetes and 75.6%(442/585) of them had multivessel disease (two-vessel or three-vessel diseases). From January 2017, transit time flow measurement was performed on every patient. Demographic and perioperative data were retrospectively collected, as well as follow-up data for patients who underwent CABG from January 2014 to August 2019. Analysis were made on their early and late outcomes.Results:Most patients(81.9%(479/585)) in this cohort received on-pump CABG and 11 patients had intraoperative intro-aortic balloon counterpulsation (prior to CABG) support. Forty-three patients had concomitant valve procedures. The number of distal anastomosis was 3.6±0.9 (range: 2 to 6) and number of arterial distal anastomosis was 2.1±0.3(range:2 to 5). Radial artery was anastomosed to left obtuse marginal artery in 95.8%(560/585) patients. All target vessels for radial artery conduit had significant proximal stenosis (>70%) and 72.5%(424/585) patients′ target vessels had proximal stenosis which was >90%. Intraoperative transit-time flow measurement of 151 cases showed that radial artery conduits had a flow of (29.8±10.2) ml/minutes (range: 10 to 150 ml/minutes), and a pulsatility index of 2.5±1.4 (range: 0.7 to 5.0). There was no operative death. Two in-hospital deaths occurred more than 30 days after index surgery. There was no perioperative myocardial infarction. There were 188 patients who received CABG from January 2014 to August 2019 followed-up for a median duration of 3.2 years. There were 2 noncardiac deaths. No patient had myocardial infarction or myocardial revascularization.Conclusions:Radial artery as the second arterial conduit is a safe and effective strategy for CABG. Good selection of target vessel and intraoperative transit-time flow measurement may help achieve good patency, as well as the short and mid-term outcome.

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 examine the efficacy of two surgical procedures on post-infarction left ventricular aneurysm.Methods:The clinic data of 254 patients with post-infarction left ventricular aneurysm, who underwent surgical ventricular reconstruction between January 1997 and December 2019 in Department of Cardiovascular Surgery, Nanjing Hospital Affiliated to Nanjing Medical University was analyzed retrospectively. There were 183 males and 71 females aged from 31 to 81 years, with a median age of 64.6 years. Based on the size of the ventricular aneurysm, there were 73 patient received linear reconstruction (linear group) and 181 patients received endoventricular patch plasty technique (patch plasty group). Ejection fraction, left ventricular systolic and end diastolic volume and left ventricular systolic and end diastolic volume index were recorded preoperatively, 2-week, 3-month, 1-year and 5-year after operation. The survival curves were plotted with Kaplan-Meier method and the survival rates were compared by Log-rank test.Results:All patients underwent surgery with a mean cardiopulmonay bypass duration of (92±32) minutes (44 to 196 minutes) and aortic cross clamp duration of (67±22) minutes (33 to 152 minutes).There were 9 perioperative deaths with a mortality rate of 3.5%. Angina pectoris of other cases are relief and heart function improved greatly. Five years after operation, the percentage of cardiac function (New Yord Heart Association) class Ⅲ to Ⅳ patients decreased from 96.1%(244/254) to 9.9%(16/161). There was no significant difference in survival rate between linear group and patch plasty group at 1-, 3-, 5-years postoperatively (96%, 91%, 77% vs. 96%, 90%, 79%, P=0.562). Ejection fraction increased from (39±10)% (range: 22% to 50%) preoperatively to (46±6)% (range: 39% to 54%) 1-year postoperatively in the linear group, while increased from (38±13)% (range: 26% to 51%) preoperatively to (50±6)% (range: 39% to 55%) in the patch plasty group. Conclusions:Left ventricular reconstruction is quite effective for patients with post-infarction left ventricular aneurysm. The choice of operative approaches is determined by the size and range of ventricular aneurysm. Both linear reconstruction and endoventricular patch plasty technique can got similarly surgical outcomes with near and late curative effect.

Objective:To examine the efficacy of two surgical procedures on post-infarction left ventricular aneurysm.Methods:The clinic data of 254 patients with post-infarction left ventricular aneurysm, who underwent surgical ventricular reconstruction between January 1997 and December 2019 in Department of Cardiovascular Surgery, Nanjing Hospital Affiliated to Nanjing Medical University was analyzed retrospectively. There were 183 males and 71 females aged from 31 to 81 years, with a median age of 64.6 years. Based on the size of the ventricular aneurysm, there were 73 patient received linear reconstruction (linear group) and 181 patients received endoventricular patch plasty technique (patch plasty group). Ejection fraction, left ventricular systolic and end diastolic volume and left ventricular systolic and end diastolic volume index were recorded preoperatively, 2-week, 3-month, 1-year and 5-year after operation. The survival curves were plotted with Kaplan-Meier method and the survival rates were compared by Log-rank test.Results:All patients underwent surgery with a mean cardiopulmonay bypass duration of (92±32) minutes (44 to 196 minutes) and aortic cross clamp duration of (67±22) minutes (33 to 152 minutes).There were 9 perioperative deaths with a mortality rate of 3.5%. Angina pectoris of other cases are relief and heart function improved greatly. Five years after operation, the percentage of cardiac function (New Yord Heart Association) class Ⅲ to Ⅳ patients decreased from 96.1%(244/254) to 9.9%(16/161). There was no significant difference in survival rate between linear group and patch plasty group at 1-, 3-, 5-years postoperatively (96%, 91%, 77% vs. 96%, 90%, 79%, P=0.562). Ejection fraction increased from (39±10)% (range: 22% to 50%) preoperatively to (46±6)% (range: 39% to 54%) 1-year postoperatively in the linear group, while increased from (38±13)% (range: 26% to 51%) preoperatively to (50±6)% (range: 39% to 55%) in the patch plasty group. Conclusions:Left ventricular reconstruction is quite effective for patients with post-infarction left ventricular aneurysm. The choice of operative approaches is determined by the size and range of ventricular aneurysm. Both linear reconstruction and endoventricular patch plasty technique can got similarly surgical outcomes with near and late curative effect.

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 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.