Myocardial and cerebral protection are always the major concerns in neonatal aortic arch surgery. From the application of deep hypothermic circulatory arrest technology to continuous cardio-cerebral perfusion strategy adopted in many cardiac centers recently, each perfusion method has its own pros and cons, so there is no consensus on which one is the most suitable. This review aims to summarize the development and research progress of various perfusion methods, so that to provide a foundation for further development.
Objective To investigate diagnostic and treatment strategies of patients with congenital heart diseases and right aortic arch. Methods Clinical data of 27 children who underwent surgical correction for congenital heartdiseases and right aortic arch in Children’s Heart Center of Beijing Children’s Hospital from January 1，2012 to April 1，2013 were retrospectively analyzed. There were 20 male and 7 female patients with their age of 10.96±12.08 months and body weight of 7.70±3.13 kg. All the patients had right aortic arch，including 14 children with tetralogy of Fallot，9 childrenwith ventricular septal defect，1 child with patent ductus arteriosus，1 child with pulmonary artery sling and 2 children with isolated double aortic arch. Thirteen children were found to have a vascular ring including aberrant left subclavian artery and double aortic arch. All the patients received surgical correction for their intracardiac anomalies and concomitant transposition of the left subclavian artery for aberrant left subclavian artery or division of the nondominal arch for double aortic arch. Results Three children died perioperatively including 1 child who was unable to be weaned from cardiopulmonary bypass，1 child without vascular ring who died 7 days postoperatively，and 1 child with double aortic arch who died of acuterespiratory distress syndrome. There was another child who gave up further postoperative treatment. Twenty-three children were followed up for 3-17 months after discharge. Echocardiography showed satisfactory correction of their intracardiac anomalies. All the patients alive recovered well with good pulses in arteries of both arms. Conclusion Careful strategiesare needed for surgical correction of patients with congenital heart diseases and concomitant right aortic arch. Comprehensivepreoperative evaluation including contrast-enhanced CT and magnetic resonance imaging is helpful for clinical decision making in diagnosis and treatment. Clinical outcomes of 1-stage surgical correction of vascular ring and other concomitant intracardiac anomalies are satisfactory with good short-term results.
Coarctation of the aorta and interrupted aortic arch are congenital anomalies affecting the aortic arch. Because of the poor natural prognosis, many patients will need early surgical repair or even emergency surgery. With the improvement of the surgical techniques, cardiopulmonary bypass techniques and perioperative intensive care, surgical mortality has now dramatically decreased. However, aortic arch restenosis, left ventricular outflow tract obstruction and long-term hypertension are problems that may be still encountered during the follow-up period. By reviewing large amounts of literature and discussing among experts, we achieved a consensus on many aspects of the management strategy. We hope this consensus will help Chinese colleagues further improve the overall surgical outcomes of coarctation of aorta and interrupted aortic arch.
Antegrade cerebral perfusion (ACP) and retrograde cerebral perfusion (RCP) are the two major types of brain protection during aortic arch surgery. Which one is better has still been debated. By summarizing and analyzing the research progress of the comparative research of antegrade cerebral perfusion and retrograde cerebral perfusion in aortic arch surgery, we have found that there was no significant difference between ACP and RCP in terms of temporary nerve dysfunction (TND), permanent nerve dysfunction (PND), stroke, early mortality, morbidity, long-time survival, and a composite outcome of hospital death, bleeding, prolonged ventilation, need for dialysis, infection and stroke. But RCP resulted in a high incidence of prolonged mean ICU-stay and hospital-stay, longer mean extubation time as well as higher cost. And the surgeon is given more time to reconstruct the vessels of the arch since mean operative time is longer in the ACP. So we think that antegrade cerebral perfusion might be preferred as the brain protection method for complicated aortic arch procedures. If a surgeon confirms that the surgery is not very sophisticated and can be completed in a short time, it is better to choose RCP because of no catheter or cannula in the surgical field to impede the surgeon. The article aims at providing a reference to cardiac surgeries when choosing cerebral protection strategy in aortic arch surgery.
ObjectiveTo summarize the treatment results of double aortic arch (DAA) by minimally invasive surgical technique. MethodsWe retrospectively analyzed the clinical data of DAA patients who underwent minimally invasive surgeries in our center between October 2016 and August 2021. ResultsThere were 11 males and 4 females with a mean age of 3-61 (20.00±18.80) years. There were 8 patients of DAA and 7 patients of DAA complicated with distal left-sided aortic arch atresia and ligamentum connection. All patients received operations through minimal subaxillary incision, 13 patients were through left side and 2 patients were through right side. One patient with ventricular septal defect was performed operations concurrently under the cardiopulmonary bypass through right minimal subaxillary incision. All patients had symptom improvement without surgery related complications or death in postoperative period. The duration of operation was 30-192 (61.93±40.19) min and mechanical ventilation time was 2-9 (5.33±2.53) h. The length of ICU stay was 18-124 (51.00±38.07) h and hospital stay time was 8-21 (12.67±3.42) d. All patients had symptomatic relief with good growth and exercise tolerance during the follow-up of 6 (3, 9) months. ConclusionMinimally invasive surgical technique is a safe, effective and cosmetic approach with good results for DAA treatment.
ObjectiveTo evaluate the advantages and disadvantages of patch aortoplasty and extended side-to-end anastomosis for the treatment of coarctation of the aorta (CoA) and hypoplastic aortic arch, and provide a more reasonable surgical choice. MethodsClinical data of 45 patients who underwent surgical correction for CoA and hypoplastic aortic arch in Beijing Anzhen Hospital from June 2008 to June 2013 were retrospectively analyzed. According to different surgical strategies for aortic arch hypoplasia, all the 45 patients were divided into 2 groups. In group I, there were 26 patients including 15 males and 11 females with their age of 0.5-6.8 (0.9±2.5) years and body weight of 5.0-20.3 (9.5±7.3) kg, who received patch aortoplasty and whose preoperative pressure gradient between right upper and lower limbs was 38.3±15.6 mm Hg. In groupⅡ, there were 19 patients including 14 males and 5 females with their age of 0.6-7.5 (1.0±2.7) years and body weight of 5.5-21.5 (10.2±6.6) kg, who received extended side-to-end anastomosis and whose preoperative pressure gradient between right upper and lower limbs was 40.7±16.1 mm Hg. Postoperative changes of pressure gradient between right upper and lower limbs of the 2 groups were examined and compared with preoperative values. ResultsTwo patients died postoperatively (4.4%) including 1 patient with low cardiac output syndrome and the other patient with severe lung infection. None of the patients in either group had renal failure or neurological complications. Postoperatively, there were 28 patients whose systolic blood pressure (SBP) of lower extremities was 10-20 mm Hg higher than that of upper extremities, 13 patients whose SBP gradient between upper and limbs was less than 10 mm Hg, and 4 patients whose upper limb SBP was 20 mm Hg higher than lower limb SBP. Postoperative average pressure gradient of right upper and lower extremities was 3.2±13.5 mm Hg and significantly lower than preoperative value (P < 0.05). Postoperative pressure gradient of upper and lower extremities was significantly lower than preoperative value in both groups (P < 0.05). There was no statistical difference in preoperative and postoperative changes of pressure gradient of upper and lower extremities between the 2 groups (P > 0.05). Thirty-eighty patients (88.4%) were followed up from 3 months to 5 years. During follow-up, there was 1 patient whose blood flow velocity of the descending aorta was increasingly accelerated. Pressure gradient across the aortic arch was larger than 40 mm Hg. Computer tomography showed aortic arch restenosis. This patient received reoperation 8 months after the first discharge. Three patients whose aortic pressure gradient was larger than 20 mm Hg were still followed up. Aortic arch pressure gradient was less than 20 mm Hg in all the other patients. ConclusionBoth patch aortoplasty and extended sideto-end anastomosis are ideal surgical methods for the treatment of CoA and hypoplastic aortic arch. Appropriate surgical method should be chosen according to individual conditions of pediatric patients.
Objective To evaluate the outcome of surgical repair of interrupted aortic arch (IAA) combined with anomalies. Methods We retrospectively analyzed the clinical data of 48 patients with IAA combined with anomalies undergoing one-stage biventricular repair in Shanghai Children's Medical Center from November 2006 to April 2016. There were 25 males and 23 females with a median age of 29 d (range, 8 to 91 d) and a mean weight of 3.80±0.67 kg. All patients underwent end-to-end anastomosis with patch augmentation, and relief of left ventricular outflow tract obstruction (LVOTO) was performed in 11 patients. Results In IAA children with anomalies, 39 (81.3%) suffered noncomplex lesions and 9 (18.8%) complex lesions. Mean follow-up was 72.1±19.7 months for 38 patients. There were 6 in-hospital deaths and 3 patients died during follow-up. The early survival rate was 87.5%, 5-year rate 83.3% and 10-year rate 81.3%. Reintervention was required in 10 patients, including 8 with subsequent LVOTO and 2 with anastomotic stenosis. Conclusion End-to-end anastomosis with patch augmentation is effective for IAA.
Objective To investigate the methods and effectiveness of multi ple surgical treatment for complex aortic arch and descending aorta disease, including cardiopulmonary bypass operation, hybrid operation, and total endovascular aneurysm repair (EVAR). Methods Between October 2006 and September 2011, 48 patients with complex aortic arch anddescending aorta disease were treated. There were 31 males and 17 females, aged from 28 to 81 years (mean, 52.4 years). The disease duration ranged from 1 to 90 days (mean, 10.2 days). There were 30 cases of type B aortic dissection involving the aortic arch, 11 cases of thoracic aortic aneurysm, 3 cases of thoracic pseudoaneurysme, 3 cases of penetrating aortic ulcer, and 1 case of aortoesophageal fistula. Cardiopulmonary bypass operation, hybrid operation, and total EVAR were performed in 15, 12, and 21 cases, respectively. Results In the patients undergoing cardiopulmonary bypass operation, the following complications occurred: 1 case of bleeding, 1 case of coma, 3 cases of psychiatric disorders, 4 cases of pneumonia, 2 cases of acute renal insufficiency, and 2 cases of multi-organ dysfunction; finally 3 patients died. In the patients undergoing hybrid operation, cerebral infarction and renal function failure occurred in 1 case. In the patients undergoing total EVAR, no complication occurred. A total of 41 patients were followed up 2 to 60 months (mean, 28.6 months). Sl ight left subclavian steal syndrome occurred in 3 cases, but self rel ieved. Other patients recovered to normal l ife. Conclusion In the surgical treatments of complex aortic arch and descending aorta disease, cardiopulmonary bypass operation will be gradually replaced by EVAR because of the surgical trauma and risk, hybrid operation is an important technique, and total EVAR will be the future progress.
【摘要】目的 探讨胸部X线片检查发现的主动脉弓钙化与冠心病的不同临床表现类型的相关性。方法 回顾分析2006年7月-2008年2月期间经冠状动脉造影证实的冠心病患者的临床资料,对比分析胸部平片所见的主动脉弓钙化情况与冠心病不同临床类型的相互关系。结果 116例经冠状动脉造影证实的冠心病患者纳入研究。其中,稳定型心绞痛40例,急性冠脉综合征76例(不稳定型心绞痛21例、非ST段抬高心肌梗死38例、ST段抬高心肌梗死17例)。40例稳定型心绞痛患者中,有主动脉弓钙化者21例,占52.5%;76例急性冠脉综合征患者中,有主动脉弓钙化者22例,占28.9%。与急性冠脉综合征相比,更多的稳定型心绞痛患者合并有主动脉弓钙化(χ2=6232,P=0013)。结论 在不同的冠心病临床类型,主动脉弓钙化更易在稳定型心绞痛患者中发现。【Abstract】 Objective To investigate the relationships between calcification of aortic arch and different clinical classification of coronary artery disease. Methods The clinical data of patients with coronary artery diease who diagnosed by arteriography from July 2006 to February 2008, were retrospectively analyzed. The Xray data on calcification of aortic arch and clinical characteristics of patients with coronary artery disease confirmed by coronary angiography were analyzed. The relationship between coronary calcification of aortic arch which showed by Xray and different clinical classification of coronary artery disease were comparatively analyzed. Results Among the total of 116 patients, 40 stable angina and 76 acute coronary syndrome were included, and 21 (52.5%) and 22 (28.9%) patients with calcification of aortic arch were observed respectively. In comparison to patients with acute coronary syndrome, more stable angina patients were complicated with calcification of aortic arch (χ2 =6232,P=0013). Conclusion It is more likely to document calcification of aortic arch in patients with stable angina.
ObjectiveTo summarize clinical experience of total aortic arch reconstruction with triple-branched stent graft placement in elderly patients with Stanford type A aortic dissection (SAAD). MethodsFrom December 2008 to December 2012, 46 elderly SAAD patients underwent total aortic arch reconstruction with triple-branched stent graft placement under deep hypothermic circulatory arrest and selective cerebral perfusion (SCP)in Department of Cardiova-scular Surgery, Henan Provincial Chest Hospital. There were 37 male and 9 female patients with their age of 65-75 (68.2±5.0)years. There were 6 patients undergoing modified David procedure, 1 patient undergoing Bentall procedure, 2 patients undergoing Wheat procedure, and 37 patients undergoing ascending aortic replacement. ResultsThere was no in-hos-pital death. Cardiopulmonary bypass time was 135-183 (131.1±10.5)minutes, aortic cross-clamping time was 81-100 (61.5±18.3)minutes, and SCP time was 19-28 (24.4±5.6)minutes. Postoperative complications included low cardiac output syndrome in 3 patients, acute renal failure in 2 patients, pleural effusion in 5 patients, lung infection in 2 patients, and sternal dehiscence in 1 patient, who were all cured after treatment. All the patients were followed up for 3 to 12 months without complication related to the stent graft. ConclusionTotal aortic arch reconstruction with triple-branched stent graft placement is an easy surgical procedure for SAAD with a high successful rate and low morbidity, and especially suitable for elderly patients who can't bear traditional operation.