Application of the descending branch of the lateral circumflex femoral artery in coronary artery bypass grafting.

OBJECTIVE: To investigate a technical method for harvesting and using the descending branch of the lateral circumflex femoral artery (DLCFA) in coronary artery bypass grafting (CABG). METHODS: Between January 2017 and January 2019, 40 patients (36 in the planed selection group and 4 in the temporary decision group) with mean age of 49.1 ± 7.5 years received DLCFA as an arterial conduit in CABG. In all patients, the DLCFA was successfully harvested via an anterior thigh incision. Depending on the location of the target vessel, the DLCFA was used as a free graft or a composite graft. RESULTS: Of the 44 patients in the planned selection group, DLCFA harvesting was abandoned in 8 patients because computed tomographic angiography revealed anatomical variation or stenosis of the superficial femoral artery. Of the 5 patients in the temporary decision group, harvesting was abandoned in 1 because of short length and thin caliber. On an average, 3.7 ± 0.9 distal anastomoses were created during CABG, with no adverse effects. The length of the harvested DLCFA was 9.9 ± 1.7 cm, with an average proximal lumen diameter of 3.4 ± 0.7 mm. The DLCFA was used as a free graft in 26 patients and as a "Y"-shape composite graft in 14 patients. Total arterial CABG was performed in 75% of the patients. CONCLUSIONS: The DLCFA is an alternative conduit for CABG. It can be harvested easily and safely. However, preoperative computed tomographic angiography examination is necessary for the smooth application of the DLCFA, and an appropriate strategy for graft establishment should be considered.

Global Unmet Needs in Cardiac Surgery.

More than 6 billion people live outside industrialized countries and have insufficient access to cardiac surgery. Given the recently confirmed high prevailing mortality for rheumatic heart disease in many of these countries together with increasing numbers of patients needing interventions for lifestyle diseases due to an accelerating epidemiological transition, a significant need for cardiac surgery could be assumed. Yet, need estimates were largely based on extrapolated screening studies while true service levels remained unknown. A multi-author effort representing 16 high-, middle-, and low-income countries was undertaken to narrow the need assessment for cardiac surgery including rheumatic and lifestyle cardiac diseases as well as congenital heart disease on the basis of existing data deduction. Actual levels of cardiac surgery were determined in each of these countries on the basis of questionnaires, national databases, or annual reports of national societies. Need estimates range from 200 operations per million in low-income countries that are nonendemic for rheumatic heart disease to >1,000 operations per million in high-income countries representing the end of the epidemiological transition. Actually provided levels of cardiac surgery range from 0.5 per million in the assessed low- and lower-middle income countries (average 107 ± 113 per million; representing a population of 1.6 billion) to 500 in the upper-middle-income countries (average 270 ± 163 per million representing a population of 1.9 billion). By combining need estimates with the assessment of de facto provided levels of cardiac surgery, it emerged that a significant degree of underdelivery of often lifesaving open heart surgery does not only prevail in low-income countries but is also disturbingly high in middle-income countries.

[Extracorporeal cardiopulmonary resuscitation in adult patients with cardiac arrest].

OBJECTIVE: To review the experience of extracorporeal cardiopulmonary resuscitation (E-CPR) for cardiac arrest in adults. METHODS: From July 2005 to July 2009, extracorporeal life-support (ECLS) was performed for 10-15 minutes failed in CPR in 11 patients (male 7, female 4, age 24-71 years) with cardiac arrest. In 7 patients after cardiac operation, regular cardiopulmonary bypass was urgently established through re-opening of sternotomy incision, followed by extracorporeal membrane oxygenation (ECMO) for continuous support. In other 4 patients, ECMO implantation was directly performed through the femoral vessels during the CPR. RESULTS: With E-CPR support, although the average CPR duration prolonged to (51+/-14) minutes (30-90 minutes), successful resuscitation was achieved in 10 patients with restoration of spontaneous heart beat. Median support duration of ECMO was 126 hours, ranged from 2 to 223 hours. Six patients could be successfully weaned from ECMO. However, the final discharge rate was 36.4% (4/11). Additional intra-aortic balloon pump was used in 2 patients, with 1 patient survived. Continuous renal replacement therapy (CRRT) was necessary in 3 patients because of acute renal failure. CONCLUSION: The use of E-CPR can rescue some adult patients who fail to survive with conventional in-hospital CPR. Further studies are warranted to evaluate in order to better define patients who may benefit from E-CPR.

[Clinical analysis of unroofed coronary sinus syndrome with atrioventricular canal defect].

OBJECTIVE: To analyze symptoms, associated anomalies, diagnostic approach, and surgical procedures in patients with unroofed coronary sinus syndrome and atrioventricular canal defect. METHODS: The clinical data of 20 patients with unroofed coronary sinus syndrome from September 1999 to October 2007 were reviewed retrospectively. There were 10 male and 10 female patients. The age ranged from 6 months to 38 years old, with a mean of (11.4 +/- 11.0) years old. The body weight ranged from 6.7 to 73.0 kg, with a mean of (28.4 +/- 21.3) kg. There were 18 cases of partial atrioventricular canal defect, 2 cases of complete atrioventricular canal defect, and 12 cases of common atrium. The initial diagnosis of unroofed coronary sinus syndrome was made by the surgeon at repair of a partial or complete atrioventricular canal defect in 20 patients. Complex unroofed coronary sinus with left superior vena cava (LSVC) directly draining into the left atrium was found in 11 cases, 1 case of LSVC was ligated, 10 cases were reconstructed the intraatrial baffle or the intracardiac tunnel to drain LSVC to right atrium. The other 9 patients with simple unroofed coronary sinus were repaired with other procedures. The associated cardiac lesions were corrected concomitantly. RESULTS: Death occurred in 1 patient with complex congenital cardiac disease due to pulmonary infection. In the 14 early survivors, who had been followed up from 4 months to 3 years, there was no death and severe complications. CONCLUSIONS: When associated with a partial or complete atrioventricular canal defect, LSVC and a common atrium, unroofed coronary sinus syndrome should be considered as a possible additional finding. Repair according to the type of unroofed coronary sinus syndrome is effective.

Extracorporeal membrane oxygenation for treatment of cardiac failure in adult patients.

This report reviews our experience in venoarterial extracorporeal membrane oxygenation (ECMO) support treatment in adult patients with cardiac failure, as well as analysis of the risk factors of early mortality. From February 2005 to June 2008, 45 patients undergoing cardiogenic shock required temporary ECMO support. They were divided into three groups: post-cardiotomy (n=31) and post-transplantation (n=5) heart failure, decompensated heart failure (n=9). ECMO implantation was performed through the femoral vessels, or axillary artery, or through the right atrium and ascending aorta. Average support duration was 126.7+/-104.3 h. Twenty-seven patients could be successfully weaned from support (60%); additionally, five were bridged to heart transplantation. The in-hospital mortality was 42% (19/45). Twenty-six patients (58%) could be successfully discharged. Additional intra-aortic balloon pumps were used in 11 patients, and six of them were successfully discharged. The mortality rate was obviously high for patients with acute renal failure treated by continuous renal replacement therapy (CRRT) under ECMO support (7/9 patients). The dominant mode of death was multisystem organ failure (9/19). ECMO offers effective cardiopulmonary support in adults. The better outcome requires a multidisciplinary approach to prevent complications unique to itself and limit organ injury before and during this support.

[Extracorporeal membrane oxygenation for treatment of cardiorespiratory function failure in adult patients].

OBJECTIVE: To explore the experience on venoarterial extracorporeal membrane oxygenation (ECMO) in adult patients with cardiac failure. METHODS: From February 2005 to June 2008, 45 patients (male 34, female 11) undergoing cardiogenic shock required temporary ECMO support. Average age was (49.0 +/- 14.1) years. Average body weight was (67.0 +/- 12.8) kg. Coronary heart disease occupied in 21 cases, valve disease occupied in 8 cases, and cardiomyopathy occupied in 7 cases. All the patients could be divided into 3 groups: post-cardiotomy (group 1, n = 31), post-transplantation (group 2, n = 5), decompensate of chronic heart failure (group 3, n = 9). Fourteen patients need cardiac resuscitation before ECMO support. ECMO implantation was performed through the femoral vessels or axillary artery or through the right atrium and ascending aorta. RESULTS: Average support duration of ECMO was (126.7 +/- 104.3) h. Twenty-seven patients could be successfully weaned from support (60.0%), additionally, 5 were bridged to heart transplantation. The in-hospital mortality was 42.2% (19/45). Twenty-six patients (57.8%) could be successfully discharged. The discharge rate was 58.1% in group 1, 4/5 in group 2 and was 4/9 in group 3. Twelve patients were re-operated for hemostasis. Three patients need femoral arterial thrombectomy because of ischemia of lower extremity. Additional intra-aortic balloon pumps were used in 11 patients, with 6 patients successfully discharged. The mortality rate for patients with acute renal failure treated by continuous renal replacement therapy under ECMO support was obviously high (7/9). The dominant mode of death was multisystem organ failure (9/19). CONCLUSION: Early indication, control of complications, and paying attention to the treatment after ECMO support could improve our results with increasing experience.

[Surgical treatment of aortico-left ventricular tunnel].

OBJECTIVE: To review 9 aortico-left ventricular tunnel (ALVT) patients in our hospital, describe the clinical features, diagnosis, treatments and follow-up. METHODS: We identified 9 patients from July 2002 to August 2008. Clinical and surgical details were reviewed. 7 patients were in NYHA class I and 2 in class III, 8 of 9 patients were diagnosed by echocardiography before operation. RESULTS: All patients underwent surgery under standard cardiopulmonary bypass. 2 with direct suture, 5 by patch closure of the aortic end and 1 by patch closure of both aortic end and left ventricular end of the AVLT. 1 underwent aortic valve replacement after incision of the ALVT. One patient died 2 month after operation because of endocarditis and acute heart failure. At follow-up (3 month to 6 years), 3 patients were in NYHA class I, 3 in Class II, 1 in class III and missed 1. No aortic regurgitation or trace in 2, little in 1, little to moderate in 2. The aortic mechanical valve is normal in 1 and paravalvular leakage in 1 patient. CONCLUSION: Aortico-left ventricular tunnel is a rare cardiac malformation with a good post-operative outcome. Surgery is an effective treatment. Long-term follow-up for post-operation is essential.

[Mechanical circulation support as emergency bridging for heart transplantation].

OBJECTIVE: To investigate the experience of patients in acute cardiogenic shock required insertion of mechanical circulation support devices (MCS) before undergoing standard pretransplant evaluations. METHODS: From February 2005 to August 2007, 10 patients including 7 male and 3 female required emergency bridging placement of MCS. Average age was (40 +/- 16.2) years old. Mean body weight was (70.8 +/- 18.1) kg. There were 5 patients of dilated cardiomyopathy, 2 patients of arrhythmic right ventricular cardiomyopathy, 2 patients of ischemic cardiomyopathy and 1 patient of end-stage valvular heart disease. All patients were accompanied with acute decompensation of congestive heart failure. Before implantation of MCS, all patients received treatment of three or more inotropic drugs at maximal dosages, 6 patients suffered from ventricular tachycardia, 4 patients required cardio-pulmonary resuscitation treatment and 3 patients suffered from definite function defect of liver and kidney. MCS included ECMO for 8 patients, BVS5000 and MEDOS for 1 patient respectively. RESULTS: The duration of MCS supporting was 3 to 44 d with a mean of (11.5 +/- 13.9) d. Four patients were successfully supported for getting heart transplantation, 1 patient received kidney transplantation simultaneously. Two patients recovered from acute heart failure, discharged and remained on regular heart transplantation list. One patient died from cerebral embolism after 44 days' support and 1 died from multiple organ failure after 3 days' support. Because of severe infection, MCS treatment of 2 patients was terminated ahead of schedule by their family and the patients were lost finally. CONCLUSIONS: The use of MCS devices for acute catastrophic situation appears warranted despite the abbreviated transplant evaluations. It is important for improving the outcomes with beginning MCS support before multiple organ system failure occurs, and accurately identifying individuals who can benefit from MCS.

[Clinical experience of BVS5000 left ventricular assist devices in heart failure patients].

OBJECTIVE: To explore the experience of Abiomed BVS5000 as a mean of left ventricular support on clinical treatment for severe heart failure patients. METHODS: From February 2004 to April 2006, 12 male patients were supported with Abiomed BVS5000 as a left ventricular assist device. The average age was (55.2 +/- 9.6) years old (range from 39 to 68 years old). Mean body surface area was (1.76 +/- 0.1) m2 (range from 1.6 to 1.9 m2). Devices were inserted for post-cardiotomy shock after coronary artery bypass grafting in 11 patients (92%) and in 1 dilated cardiomyopathy patient for acute cardiogenic shock. Modified cannulation methods by inserting the arterial cannulae in femoral artery and inserting the venous cannula in left atrial through bovine jugular vein were used in 7 patients. In this way, the device could be taken off without resternotomy when support was finished. A comparison was made between the modified method and routine left atrium-to-ascending aorta cannulating method. RESULTS: The average duration of support was (8.8 +/- 11.2) d (range from 3 to 43 d), with support flow rate of 3.8 to 4.5 L/min. There were 9 patients (75%) weaned from support and 8 patients (67%) discharged from the hospital Four patients (33%) were dead. The most common morbidity was adverse neurologic events. There was no statistic difference between modified and routine method on average BVS5000 support duration, assisted flow rate, mechanical ventilation duration, stay of intensive care unit and thoracic drainage. CONCLUSIONS: The Abiomed BVS5000 is valuable to support patients with acute cardiogenic shock for short-term use. With using modified cannulating method, the weaning procedure can be effectively simplified.

Clinical application of BVS5000 left ventricular assist device in heart failure patients.

BACKGROUND: Mechanical ventricular assistance is an important therapeutic method for severe heart failure patients. A variety of ventricular assist devices have been designed for use. The purpose of this report was to describe the experience of using Abiomed BVS5000 as a means of left ventricular support as a clinical treatment for heart failure patients. METHODS: From February 2004 to April 2006, 12 male patients were supported with Abiomed BVS5000 left ventricular assist device (LVAD) at Fu Wai Hospital. The average age was (55.2 +/- 9.6) years (range 39 to 68 years). The mean body surface area was (1.76 +/- 0.1) m(2) (range 1.6 to 1.9 m(2)). Devices were inserted for post-cardiotomy shock after coronary artery bypass graft in 11 patients (92%) and in 1 dilated cardiomyopathy patient for acute cardiogenic shock. Modified cannulation methods by inserting the arterial cannulae in femoral artery and inserting the venous cannula in left atrium through a segment of bovine jugular vein were used in 7 patients. In this way, the device could be taken off without re-sternotomy when support was finished. A comparison was made between the modified method and routine left atrium-to-ascending aorta cannulating method. RESULTS: The median duration of support was 5 (3 - 43) days, with support flow rate of 3.8 - 4.5 L/min. There were 9 (75%) patients weaned from support and 8 (67%) patients discharged from the hospital. Four (33%) patients were dead. The most common morbidity was adverse neurological events. There is no statistical difference between modified and routine method on average in BVS5000 support duration, in assisted flow rate, in mechanical ventilation duration, in the intensive care unit stay and thoracic drainage. CONCLUSIONS: The Abiomed BVS5000 is valuable to support patients with acute cardiogenic shock for short-term use. By the modified cannulating method, the weaning procedure can be effectively simplified. Optimization of inserting indication remains challenging and attributes to a successful assist program.

[Pathological changes of radial artery used for coronary artery bypass grafting and its related risk factors for intimal hyperplasia].

OBJECTIVE: To examine the degree of intimal hyperplasia and the prevalence of atherosclerosis in radial arteries taken from the patients undergoing coronary artery bypass grafting (CABG), and to analyze the risk factors to obtain some helpful information for choosing arterial conduits. METHODS: Forty-one radial arteries and 11 internal mammary arteries samples were collected. The average age of patients was 48.5 years, and they all were male. Intimal hyperplasia, atherosclerosis, medial calcification were evaluated by routine histological methods, and the severity of diseases was measured on the percentage of luminal narrowing and the intima-to-media ratio (the intima area/media area). The risk factors for coronary heart disease were also analyzed. RESULTS: Ninety-three percent (38 of 41) of radial arteries showed mild intimal hyperplasia, which was not regarded to influence blood flowing after CABG. As a part of them, 54% (22/41) of radial arteries had a lower than 25% of luminal narrowing, meanwhile 39% (16/41) of radial arteries had the percentage of luminal narrowing between 25% and 50%. Only 7% (3 of 41) of radial arteries were found to have occlusive lesions, which made arterial lumen decreased more than 75%. The 3 patients including 2 with severe atherosclerosis and another 1 aged 17 years was involved by fibromuscular dysplasia. The later vessel was discarded after harvesting. The percentage of luminal narrowing and the intima-to-media ratio were higher in radial artery than that in internal mammary artery (t = 3.00, 2.49, P < 0.05). The two parameters were positively correlated with age (r = 0.398, 0.310, P < 0.05), but this study failed to show any relationship between intimal hyperplasia of radial artery and coronary lesions and other risk factors. Medial calcification was not found by routine histological method in all cases. CONCLUSION: Only mild intimal hyperplasia and no medial calcification are found in radial arteries used for CABG in the patients. Because the risk factors could not yet predict the severity of radial arterial lesions, this study strongly suggests that the Doppler ultrasonography and pre-operation clinical consideration should be emphasized to screen out some arteries with occlusive lesions.

Total cavopulmonary connection with off-pump technique.

The aim of this study was to evaluate an off-pump technique for total cavopulmonary connection. Between May 2000 and June 2004, 16 patients underwent total cavopulmonary connection without cardiopulmonary bypass. There were 8 males and 8 females, with a mean age of 9.8 +/- 6.2 years and a mean weight of 27.7 +/- 14.9 kg. Preoperative percutaneous oxygen saturation was 75% +/- 6%, and pulmonary arterial pressure was 12.6 +/- 2.7 mm Hg. Postoperative outcomes were retrospectively compared with a group of 17 patients who underwent total cavopulmonary connection with an extracardiac conduit under cardiopulmonary bypass. Two patients died early postoperatively. Chylothorax occurred in 2 patients and 3 underwent reoperation for fenestration between the extracardiac conduit and the right atrium in the early postoperative period. All survivors were acyanotic. On discharge from hospital, the percutaneous oxygen saturation breathing air was 95% +/- 3%. Patients in the off-pump group demonstrated significantly shorter extubation time and intensive care unit stay. This connection technique is easy to perform and helpful in the early management of patients with a functional univentricular heart. However, much remains to be learned about this unique physiologic system.

Clinical application of bidirectional Glenn shunt with off-pump technique.

A study was conducted to evaluate the outcomes of the bidirectional Glenn shunt technique performed off-pump. Between April 1999 and April 2001, 36 patients underwent bidirectional Glenn shunt, unilateral in 28 patients and bilateral in 8 patients, without using cardiopulmonary bypass. The patients consisted of 25 males and 11 females with a mean age of 5.7 +/- 5.4 years and a mean body surface area of 0.72 +/- 0.34 m2. Preoperative percutaneous oxygen saturation was 75% +/- 7%, and pulmonary arterial pressure was 14.3 +/- 3.6 mmHg. There was no operative mortality. Chylothorax occurred in 1 patient in the early postoperative period. All the other patients were discharged without complications. Mean arterial oxygen saturation at discharge was 92.7% +/- 4.0%. This shunt technique is easy to perform and is helpful in the early management of patients with a functionally univentricular heart. However, much remains to be learned about this unusual physiological system.

Single-stage treatment of aortic coarctation and aortic valve disease.

Surgical management of thoracic aortic coarctation associated with severe aortic valve disease is difficult in most cases. As staged procedures are associated with a higher rate of morbidity and mortality, simultaneous operative management of both lesions is desirable. From 1997 to 2001, 9 patients (8 males and 1 female with a mean age of 30.1 +/- 10.4 years) with this condition underwent simultaneous ascending aorta-infrarenal abdominal aorta bypass graft and aortic valve replacement. One patient died from failure of the extracorporeal circulation during the operation. Another patient suffered from partial intestinal obstruction in the early postoperative period but was successfully treated. The underlying pathology was successfully corrected in the 8 surviving patients, whose blood pressure in the upper limbs was reduced while that in the lower limbs rose. Being easier to manage, the single-stage approach with extraanatomic bypass is safe and effective for managing this aortic complication.