Objective To summarize the results and methods of left subclavian artery revascularization by stented trunk fenestration for acute Stanford type A aortic dissection.Methods Clinical data of 67 patients (54 male and 13 female,mean age of (50 ± 10) years) underwent surgical treatment of left subclavian artery fenestration for acute Stanford A aortic dissection in Department of Cardiothoracic Surgery,Changhai Hospital,Second Military Medical College between September 2008 and December 2014 were analyzed retrospectively.The origin of the left subclavian artery was in the true lumen and no dissection existed near the artery's starting.There were 18 cases of Marfan's syndrome.Preoperative echocardiography showed moderate to severe aortic regurgitation in 10 cases,and mitral regurgitation in 3 cases.Electrocardiogram showed myocardial ischemia in 5 cases.Three patients had acute impaired renal function.All the patients received total arch replacement combined with stented elephant trunk implantation.Left subclavian artery revascularization was performed by stented trunk fenestration as follows:firstly,stented elephant trunk was implanted to completely cover the left subclavian artery,then part of stented trunk's polyester lining was removed which is located at the origin of left subclavian artery.Aortic root procedures included aortic valve replacement in 2 cases,Bentall procedure in 21 cases and aortic valve sparing in 44 cases.Three patients received mitral valve repair and 6 patients received coronary artery bypass grafting.Results The cardiopulmonary bypass time,cross-clamp time,and circulatory arrest time were (179 ± 32) minutes,(112 ± 25) minutes,and (26 ± 10) minutes,respectively.The in-hospital mortality was 7.5％ (5/67):2 patients died of multiple organ failure,1 patient died of acute renal failure and another 2 patients died of severe infection shock.Two patients required reexploration for root bleeding.Transient neurology dysfunction developed in 6 patients.Six patients received tracheotomy and prolonged ventilation due to pulmonary infection.All patients discharged from the hospital were followed up for 1 to 5 years.During long-term follow-up,the survival rate was 100％ and 89.8％ at 1 and 5 years,respectively.CT angiography was performed once per year after discharged.The left subclavian artery perfusion was good.No dissection or anastomosis leakage was identified in any case.Stroke and left limb ischemia did not develope.Conclusion For acute Stanford type A aortic dissection whose origin of the left subclavian artery is in the true lumen and no dissection existed near the artery's starting,the left subclavian artery revascularization by stented trunk fenestration technique during total arch replacement combined with stented elephant trunk implantation is reliable and effective.

Objective To summarize the results and methods of left subclavian artery revascularization by stented trunk fenestration for acute Stanford type A aortic dissection.Methods Clinical data of 67 patients (54 male and 13 female,mean age of (50 ± 10) years) underwent surgical treatment of left subclavian artery fenestration for acute Stanford A aortic dissection in Department of Cardiothoracic Surgery,Changhai Hospital,Second Military Medical College between September 2008 and December 2014 were analyzed retrospectively.The origin of the left subclavian artery was in the true lumen and no dissection existed near the artery's starting.There were 18 cases of Marfan's syndrome.Preoperative echocardiography showed moderate to severe aortic regurgitation in 10 cases,and mitral regurgitation in 3 cases.Electrocardiogram showed myocardial ischemia in 5 cases.Three patients had acute impaired renal function.All the patients received total arch replacement combined with stented elephant trunk implantation.Left subclavian artery revascularization was performed by stented trunk fenestration as follows:firstly,stented elephant trunk was implanted to completely cover the left subclavian artery,then part of stented trunk's polyester lining was removed which is located at the origin of left subclavian artery.Aortic root procedures included aortic valve replacement in 2 cases,Bentall procedure in 21 cases and aortic valve sparing in 44 cases.Three patients received mitral valve repair and 6 patients received coronary artery bypass grafting.Results The cardiopulmonary bypass time,cross-clamp time,and circulatory arrest time were (179 ± 32) minutes,(112 ± 25) minutes,and (26 ± 10) minutes,respectively.The in-hospital mortality was 7.5％ (5/67):2 patients died of multiple organ failure,1 patient died of acute renal failure and another 2 patients died of severe infection shock.Two patients required reexploration for root bleeding.Transient neurology dysfunction developed in 6 patients.Six patients received tracheotomy and prolonged ventilation due to pulmonary infection.All patients discharged from the hospital were followed up for 1 to 5 years.During long-term follow-up,the survival rate was 100％ and 89.8％ at 1 and 5 years,respectively.CT angiography was performed once per year after discharged.The left subclavian artery perfusion was good.No dissection or anastomosis leakage was identified in any case.Stroke and left limb ischemia did not develope.Conclusion For acute Stanford type A aortic dissection whose origin of the left subclavian artery is in the true lumen and no dissection existed near the artery's starting,the left subclavian artery revascularization by stented trunk fenestration technique during total arch replacement combined with stented elephant trunk implantation is reliable and effective.

Objective To observe the effect of exercise preconditioning (EP) on pressure overload-induced pathological cardiac hypertrophy and explore related mechanisms.Methods Ten-week-old male Sprague-Dawley rats (n =80) were randomly divided into four groups via random number table method: sham, TAC,EP + sham and EP + TAC.Two EP groups were subjected to 4 weeks of treadmill training, and followed by sham and TAC operations.Eight weeks after the surgery, mean arterial pressure (MAP), cardiac morphology, mRNA expressions of the B-type natriuretic peptide (BNP) and heat shock protein (HSP) 70 and protein expression of the BNP, heat shock transcription factor 1 (HSF1), HSP70, nuclear factor κB (NF-κB) p65, and interleukin-2 (IL-2) were examined.Results (1) Pathological cardiac hypertrophy index: eight weeks after TAC, MAP, heart size, HW/BW, cross-sectional area of the cardiomyocytes (CSA) and mRNA and protein expressions of BNP in the LV were all significantly higher in the TAC and EP + TAC groups than respective sham groups (all P ＜ 0.05).HW/BW, CSA, and mRNA and protein expressions of BNP in the LV were significantly lower in EP + TAC group than in TAC group (all P ＜0.05).(2) mRNA and protein expressions of HSF1 and HSP70 and nuclear HSF1 levels were significantly downregulated post TAC, however, EP treatment significantly increased the expression of HSFl and nuclear HSF1 levels in TAC rats (all P ＜ 0.05).(3) mRNA and protein expressions of NF-κB p65 and IL-2 were significantly increased in the TAC and EP + TAC groups compared with the respective sham groups (all P ＜ 0.05), which were significantly downregulated in EP + TAC group compared to TAC group (all P ＜ 0.05).Conclusions EP could effectively reduce the cardiac hypertrophic responses induced by TAC possibly through upregulating the expressions of HSF1 and HSP70 and inhibiting the expression of NF-κB p65 and its nuclear translocation.

Objective: To explore the effect of exercise preconditioning (EP) on pathological cardiac hypertrophy and heart failure (HF) in pressure over-loaded experimental rats.
Methods:A total of 60 SD rats at the age of 6 weeks were randomly divided into 3 groups, n=20 in each group. Sham-operation group, Transverse aortic constriction (TAC) group and EP + TAC group. The cardiac function and structure were evaluated by echocardiography, patholgical changes and HF biomarkers were examined for EP effect at 4 and 8 weeks after TAC.
Results:Compared with Sham-operation group, the cardiac function and structure had obvious changes in the other 2 groups. Compared with TAC group, the ejection fraction in EP+ TAC group increased 15%, the heart weight index and left ventricular weight index decrease 15.7%and 20%respectively at 8 weeks after TAC, all P<0.05. Compared with Sham-operation group, the mRNA and protein expressions of ANP and BNP increased in TAC group at 4 and 8 weeks after TAC, increased in EP+TAC group at 8 week after TAC. Compared with TAC group, the mRNA expressions of ANP and BNP in EP+TAC group decreased 47%and 62%at 4 weeks after TAC, decreased 44%and 28.1%at 8 weeks after TAC, all P<0.05;the protein expression of ANP and BNP in EP+TAC group decreased 22.3%and 48%at 4 weeks after TAC, decreased 21.5%and 38.3%at 8 weeks after TAC, all P<0.01.
Conclusion: EP may improve cardiac pathological hypertrophy in pressure over-loaded rats at the early stage, and delay the heart failure process.

Objective To assess the Chinese System for Cardiac Operative Risk Evaluation (SinoSCORE) model in patients undergoing heart valve surgery at our center.Methods From January 2009 to December 2011,2098 consecutive adult patients who underwent heart valve surgery at our center were collected and scored according to the SinoSCORE model.All patients were divided into three risk subgroups.The entire cohort and each risk subgroup were analysed.Calibration of the SinoSCORE model was assessed by the Hosmer-Lemeshow(H-L) test.Discrimination was tested by calculating the area under the receiver operating characteristic (ROC) curve.Results Observed mortality of all 2098 patients was 3.00％.Despite there were significant differences between the SinoSCORE population and our own population sample,the SinoSCORE model showed good calibration(Hosmer-Lemeshow:P =0.783) and discriminative power (area under the ROC curve of 0.752)in predicting in-hospital mortality at the entire cohort.Conclusion The SinoSCORE model give an accurate prediction for individual operative risk in heart valve surgery patients at our center.

Objective To summary the methods and results of first and second operations on patients with aortic valve disease and non-specific aortitis.Methods The total 34 patients including 23 cases with aortitis and 11 cases with Behcet disease were studied from Jan 2000 to Dec 2010.The first operation was Bentall procedure in 18 cases and AVR in 16 cases.Fourteen of 16 cases who had AVR developed severe paravalvular leakage,and undewent the second operation including 10 aortic root replacement (8 valve-conduit and 2 homograft) and 4 non-anatomic AVR.Results Eighteen patients who had first operation of Bentall procedure all survive without aortic pseudoaneurysm after the follow-up of 6 months to 11 years.Fourteen redo cases all survive except for one case died of repture of aortic pseudoaneurysm 1.2 years postoperatively.Conclusion Preoperative diagnosis in these patients is very difficulty.The first operation of root replacement is of choice.The second operation is very difficulty to handle,root replacement can achieve satisfactory results.Non-anatomic AVR is easy to perform,and good hemo stasis intraoperatively,and is a satisfied alternative method with good results.

Objective The aim of the study was to analyze the predictive value of the European system for cardiac operative risk evaluation score (EuroSCORE) and the Society of Thoracic Surgeons predicted risk of mortality (STS-PROM) in -dult patients undergoing aortic valve replacement (AVR).Methods We carried out a retrospective statistical analysis on 521 adult patients undergoing AVR between 1999 and 2008 in Changhai hospital.Patients with concomitant coronary artery bypass grafting were also included.Excluded from this study were patients having surgery for congenital heart defects,aneurysm of thoracic aorta and atrial fibrillation.Operative mortality was defined as death before discharge from the hospital.The mortality risk calculation of EuroSCORE and STS-PROM for aortic valve procedures was performed by the online available EuroSCORE or STS score calculator.Based on the additive EuroSCORE risk calculation,patients were divided into low-risk,medium-risk and high-risk groups.The valuation of three different algorithms depended on the assessment of two features:calibration and discrimination.A comparison of observed and predicted mortality rates was also performed.Results A total of 521 patients were identified as having undergone aortic valve replacement.In-hospital mortality was 4％ (21 cases) overall.The expected mortality for the additive,logistic EuroSCORE and the STS-PROM was 3.36％,2.82％ and 1.25％,respectively.The observed to expected ratio was 1.2 for additive EuroSCORE,1.43 for logistic EuroSCORE and 3.23 for STS-PROM.The STS-PROM underpredicted observed mortality significantly ( P ＜ 0.01 ) and showed poor calibration in predicting in-hospital mortality in the entire cohort,medium- and high-risk subgroups.The logistic EuroSCORE underpredicted observed mortality in the mediumrisk subgroup ( P ＜ 0.05 ).EuroSCORE underpredicted in-hospital mortality in the high-risk subgroup with the observed-expected mortality rate of 1.84 for additive EuroSCORE and 1.46 for logistic EuroSCORE.The EuroSCORE in three subgroups showed poor discrimination in predicting mortality as well as the STS-PROM did in the medium- and high-risk subgroups ( ROC ＜ 0.7).Conclusion Both the EuroSCORE and the STS-PROM give an imprecise prediction for individual operative risk in patients undergoing aortic valve replacement in our study.These algorithms seem unsuitable to identify a high-risk patient population undergoing isolated AVR.It is necessary to construct a risk stratification model for valve surgery according to the profiles of Chinese patients.

Objective To investigate the surgical technique and clinical outcomes of reconstruction of the annulus and the intervalvular fibrous body during valve replacements. Methods Fifty-nine patients underwent reconstruction of the annulus or the intervalvular fibrous body during the valve replacement. Indications for the operation were small aortic annulus which may cause patient/prosthesis mismatch in 43, active infective endocarditis with the abscess in the periannulus tissue in 13, extensive calcification of the aortic annulus in 2 and an active bleeding complication of the aortic root after aortic and mitral valve replacement in 1. The reconstruction was done with fresh autologous pericardium. Results The aortic clamping time in reconstruction of the intervalvular fibrous body with double valve replacement was longer than that of the regular double valve replacement. Four patients died in the perioperative period, giving an overall in- hospital mortality of 6.7%. Postoperative complication were: re-sternotomy for bleeding in 2, Ⅲ degree A-V block in 2, respiratory dysfunction in 2, and acute renal failure in 2. Patients were followed up for 6 months by echocardiography study, and no periannular leakage was found. Conclusion Reconstruction of the annulus is an effective technique for patients with a small aortic annulus, extensive calcification of the interventricular fibrous body and active infective endocarditis with abscess. Although the operative procedure is challenging and taking more time, the technique is safe and reproducible.

Objective The results of Aortic valve replacement (AVR). Combined with ascending aortic replacement(group A) or aortoplasty (group B) in patients with aortic valve disease and ascending aortic dilatation were analysed to assess the clinical outcomes and respective indications. Methods Among the two groups, the age, gender, NYHA class, types of aortic valve lesions and left ventricular ejection fraction were not different statically. The ascending aortic diameters in group A[(50.41 ±3.71) mm] and group B [(48.29±2.18) mm] were not statically different. Ascending aortic replacement was performed in Group A. A Dacron tube(diameter 28 ～ 30mm) was routinely wrapped around the ascending aorta after aortoplasty in group B. Results There was 1 postoperative death in group B, blood transfusion volume and postoperative complications were not stasticaly different in the two groups. Cardiopulmonary bypass time [(110.52 ± 27.51) min] and aortic across clumping time [(71.70 ± 17.13)min] in group A were significantly longer than that of group B [(97.31 ± 19.46) min,P=0. 004; (57.13 ±19.46) min, respectively. P=0.025]. Conclusion Aortic valve disease, especially bicuspid valve disease often combines with ascending aortic dilatation or aneurysm. In younger patients, ascending aorta should be actively treated surgically when the diameter is equal or more than 40mm. Aortoplasty with external reinforcement of a Dacron tube is simpler and safer than aortic replacement in patient without aortic atherosclerosis or ulceration, and large aneurysm.

BACKGROUND: Autologous vein transplantation is a common means for clinical treatment of coronary atherosclerotic heart disease. Identification of basic pathological changes of autologous vein transplantation will provide basis for further studies on how to protect transplanted vein and reduce the possibility of restenosis of transplanted vein.OBJECTIVE: This study was designed to investigate effects of hyperlipemia, an independent influential factor, on venous endothelial functions and histomorphology.DESIGN, TIME AND SETTING: This study, a randomized controlled animal experiment, was performed at the key laboratory of Department of Cardiothoracic Surgery, Changhai Hospital, Second Military Medical University of Chinese PLA.MATERIALS: A total of 50 healthy adult male rabbits were randomly and equally divided into a control group and a hyperlipemia group.METHODS: In the control group, rats were daily fed with normal diet 100-120 g. In the hyperlipemia group, rats were daily fed with normal diet 100-120 g plus cholesterol 1g. For all rats, water was freely available.MAIN OUTCOME MEASURES: Prior to and 2,4,8, and 12 weeks after feeding, blood sample and cervical vein specimens were taken for detection of blood lipid levels and observation of endothelial nitricoxide synthase (eNOS)expression, nitric oxide (NO) production, and histomorphologic change. Prior to harvesting vein sample, blood flow of jugular vein and carotid artery was examined using ultrasonic Doppler flowmeter. Simultaneously, histopathological changes including the thickness of intima and media, the diameter of the veins, and the presence of lipid or atherosclerotic plaque were observed.RESULTS: Eight weeks after feeding, blood lipid levels in the hyperlipemia group were significantly higher than those prior to feeding and in the control group (P<0.01), and maintained at this level. Obvious lipid plaques formed in the carotid artery of rabbits in the hyperlipemia group. Eight and twelve weeks after feeding, eNOS expression levels and NO production in the jugular veins were lower than those prior to feeding and in the control group (P<0.05). Simultaneously, endothelial denudation was noticed and the elastic fibers almost disappeared in the hyperlipemia group; there were no foam cells or lipid plaques.CONCLUSION: Hyperlipemia may result in endothelium dysfunction and histomorphological change of venous conduit.Nevertheless, autogenous vein transplanted into artery system, will greatly influence the remodeling of transplanted vein,even lead to restenosis of transplanted vein.