Use of muscular VSD Amplatzer occluder for closing right ventricular free wall perforation after hybrid procedure.

In some patients, so cold hybrid cardiologic procedures are performed whereas a heart is exposed surgically to puncture directly the heart cavity. After performing the interventional procedure, the opening in ventricular wall is closed surgically. We present our initial experience with closing the right ventricular (RV) cavity opening with the muscular ventricular septal defect Amplatzer occluder (A-MVSDO). In four sheep, heart was exposed surgically and punctured under direct vision by needle and guide wire, 14F and 26F sheath were introduced into right ventricle and the A-MVSDO was introduced causing closure of the RV opening. In all four cases, the occluder was successfully placed closing the opening in RV. No major bleeding after occlusion was observed. Following complications were observed: pneumothorax in two animals, rhythm disturbances and thrombus suspected in one. A-MVSDO occluder seems to be a useful device to close RV opening after hybrid interventional cardiologic procedure.     

Left ventricular surgical remodeling 2.0

Left ventricular surgical remodeling has been, for a long time, the procedure applied for large dyskinetic, or akinetic, areas as a consequence of a myocardial infarction, mainly located in the left anterior descending area. Many surgical techniques were developed, aimed to a pure reduction of the volume of the left ventricular (LV) cavity or to add to volume reduction a more physiologic conical shape. The expansion of interventional procedures invaded most of the fields before treated only by cardiac surgeons. In this issue, Pillay describes a hybrid technique, involving both interventional cardiologists and cardiac surgeons, aimed to LV volume reduction after an anterior myocardial infarction. A series of internal (right ventricular septum) and external (anterior wall) anchors are implanted to approximate the LV free wall to the anterior septum, consequently excluding the scarred myocardium. Although some limitations of this study, the authors have to be commended for having revitalized a procedure almost eliminated from the surgical scenario.     

Two cases using "epi-endocardial patch repair" for postinfarction left ventricular rupture

The treatment points of left ventricular (LV) free wall rupture after acute myocardial infarction (MI), so far, are to prevent a deterioration of LV function after MI and to prevent a recurrence or extension of the dissection of the infarcted/necrotic myocardium to stop bleeding. We report two cases of LV rupture after myocardial infarction that underwent epicardial patch repair using deep epicardial sutures reaching LV subendocardial area ("epi-endocardial patch" repair). The procedure was done under beating condition with cardiopulmonary bypass in the first case and with preoperatively percutaneous cardiopulmonary support system (PCPS) in the second case to prevent a deterioration of LV function. Hemostasis was effective and complete, and extension of the intramuscular dissection was well blocked. The patients recovered LV function soon. The epi-endocardial sutures can be placed safely without inducing new ischemia, and the method might be possible with beating condition.     

杂交技术治疗室间隔完整型肺动脉闭锁

目的 总结杂交技术经胸肺动脉瓣球囊扩张成形术治疗室间隔完整型肺动脉闭锁的即刻疗效及近、中期随访结果.方法 2005年3月至2010年3月,采用超声引导经胸肺动脉瓣球囊扩张成形术治疗室间隔完整型肺动脉膜性闭锁30例,年龄1天～48个月,平均(4.59±3.21)个月.胸骨正中切口,于右室流出道距离肺动脉瓣环下约2 cm缝荷包线,然后置入导丝.在超声引导下置入穿刺鞘管.确认穿刺针对准膜性闭锁的瓣膜后,在钢丝引导下放入球囊扩张管进行扩张,超声提示肺动脉瓣开放满意.＜3个月病婴行改良Blalock-Taussig(B-T)体肺分流术,并同期行动脉导管结扎术.＞3个月病婴行球囊扩张术后,如血氧饱和度改善明显,不常规行改良B-T分流术,并保留动脉导管开放,如血氧饱和度改善不明显,则考虑行改良B-T分流术,结扎或保留动脉导管.＞5个月病儿行球囊扩张后血氧饱和度改善不满意,且重度右心发育不良,则选择双向Glenn术.结果 30例行球囊扩张均取得成功,同期行动脉导管结扎术25例,改良B-T分流术8例,双向Glenn术2例.均未出现严重并发症.1例术后因低氧血症,术后第3天行动脉导管结扎术和改良B-T分流术;余者术后血流动力学稳定,顺利出院.术后随访1.5～62.0个月,平均(18.7±17.2)个月.血氧饱和度由术前0.73±0.08上升至0.94±0.04,心功能Ⅰ级.院外死亡5例,25例生长发育良好.结论 杂交技术经胸肺动脉瓣球囊扩张成形术是一种治疗新生儿及婴幼儿室间隔完整型肺动脉膜性闭锁的安全、有效的方法.

Abstract：

Objective In patients with pulmonary atresia and intact ventricular septum ( PAIVS) without right ventricular-dependent coronaries, catheter techniques including the use of a sniff wire, lasers, and radiofrequency have been the most widely used initial therapy. However, percutaneous perforation and balloon valvuloplasty were associated with higher rate of procedural failure and serious complications. Methods We report our experience with a hybrid approach for pulmonary atresia with intact ventricular septum, combining surgery and interventional catheterization techniques. Between March 2005 and March 2010, hybrid procedure was carried out successfully in 30 newboms and infants with favorable anatomy. The age ranged from 1 day to 48 months with a mean of (4.59 ±3.21) months. The heart was exposed through median sternotomy. A pursestring suture was placed in the right ventricular outflow tract 2 cm away from the pulmonary trunk. Then a 16-gauge intravenous catheter was punctured through the right ventrical and perforated the atretic PV with the guidance of echocardiography. A guide wire was then inserted into the sheath and used to guide the balloon across the PV. Sequential dilations were performed until a full opening of the PV with the guidance of epicardial echocardiography. In patients ＜ 3 months PDA ligation was performed followed by modified Blalock-Taussig (B-T) shunt. In patients ＞ 3 months PDA ligation was not performed. A modified B-T shunt was inserted if severe systemic oxygen desaturation occurred after PDA ligation. Bidirectional Glenn shunt was performed for severe hypoplasia. Hybrid procedure was achieved in all patients. The simultaneous procedures included 25 cases of PDA ligation. 6 newborns underwent modified B-T shunt placement (3.5 to 5 mm) after pulmonary valvuloplasty and PDA ligation, and 2 patients ＞ 1 month underwent modified B-T shunt. Another 2 patients were selected for univentricular palliative surgery because of a diminutive monopartite right ventricle and bidirectional Glenn procedure was performed. No pericardial effusion or cardiac tamponade was observed in all patients. Another case without PDA ligation underwent a modified B-T shunt because of hypoxemia three days after hybrid procedure, and the rest patients were discharged without any further surgical intervention.During the follow-up period of 1.5 to 62.0 months, 5 patients died. 25 (83.3%) survived and were all in New York Heart Association functional class 1. Peripheral oxygen saturation increased from 0.73 ± 0.08 to 0.94 ± 0.04 (P ＜ 0.05). One patient remains in a single-ventricle pathway, whereas 24 patients achieved a two-ventricle circulation. Results Conclusion Perventricular balloon pulmonary valvuloplasty using a hybrid approach is a safe and feasible procedure for patients with PAIVS.     

Surgical strategy for left ventricular free wall rupture after acute myocardial infarction

BACKGROUND: Left ventricular free wall rupture is usually fatal without surgical intervention. However, the most appropriate surgical procedure remains controversial. METHODS: Seventeen patients (14 men, 3 women) who developed left ventricular free wall rupture after acute myocardial infarction were treated surgically. Their mean age was 65.4 years (range, 55 to 79 years). The following surgical procedures were performed: infarctectomy and patch reconstruction in 1 patient, direct closure with or without patch covering in 4 patients, simple patch covering anchored by running suture in 4 patients, and a sutureless technique in 7 patients. Endventricular patch closure was performed in 1 patient with ventricular septal perforation. RESULTS: One of 3 patients with a blow-out type rupture and 1 of 13 patients with an oozing type rupture died shortly after operation. The overall surgical mortality rate was 11.8%. CONCLUSIONS: Selection of the optimal procedure for each cardiac condition is important for obtaining good results. For patients with ongoing squirting bleeding, patch covering is the technique of choice. For oozing, the sutureless technique is preferable.     

杂交(hybrid)手术在复杂性先天性心脏病治疗中的初步应用

目的探讨结合介入器械和实时影像学的术中"杂交"(hybrid)手术对复杂性先天性心脏病的治疗价值.方法2005年3月～10月,我院行hybrid手术治疗7例复杂性先天性心脏病.球囊扩张组3例均为室间隔完整型肺动脉闭锁(PAIVS)的新生儿.缺损封堵组4例,其中1例右冠状动脉异常起源于肺动脉合并房间隔缺损,1例右侧肺静脉异位引流合并房间隔缺损(ASD),2例多发室间隔缺损(VSD).正中进胸,在超声引导下经右室流出道置入球囊扩张管扩张肺动脉瓣或经右心房植入封堵器.多发室间隔缺损于体外循环下经三尖瓣植入封堵器.合并的其他心脏病变同期常规外科矫正.术后心脏超声随访.结果7例均顺利出院,无一例手术死亡.3例PAIVS术后中位住院时间10 d,余4例均在术后7 d出院.随访1～6个月,7例生长发育良好,人工体肺分流管通畅,未发现中度以上的肺动脉瓣再狭窄,ASD和多发VSD术后均未发现明显残余分流及封堵器移位,均无影响瓣膜功能等并发症发生.结论hybrid手术可以不采用体外循环,减少手术创伤,对于提高复杂性先天性心脏病的疗效具有重要的意义.     

Modified Komeda-David operation for postinfarction ventricular septal perforation

The infarct exclusion technique with a xeno-pericardial patch which Komeda and associates firstly reported in 1990 is one of the best procedure to close ventricular septal perforation. A large patch can protect the perforation and the surrounding weak tissue from the internal left ventricular pressure. However, suturing this large patch to the left ventricular wall through the small incision is not technically easy because of the patch design in the ventricle. We modified the design of the patch. This round shaped bovine pericardial patch was sutured continuously to the left ventricular wall. Then, excessive part of the patch was trimmed to make a corn shape. Finally, the corn shaped patch fit the left ventricular wall naturally.     

Right ventricular free wall perforation during pericardiocentesis,and an inappropriate device selection for percutaneous treatment

Right ventricular (RV) perforation is a rare but life‐threatening complication of pericardiocentesis and is usually treated surgically. We presented a case of RV free wall perforation, which occurred during pericardiocentesis and tried to be closed percutaneously with the Amplatzer vascular plug‐III (AVP‐III) device. The occluder device sealed the perforation, but it was in an insecure position; therefore, the patient underwent surgical repair. As an AVP‐III device, with a middle disk thicker than the RV myocardium, it may cause the RV myocardium to stretch outwards, so it should not be used for the treatment of RV perforation by the transcatheter way.     

Endoscopic perforations of colon and rectum

Although fiberoptic examination of the colon is nowdays considered to be safe procedure, endoscopic perforation remains rare, but serious and potentially life threatening complication. General incidence od diagnostic and interventional perforations of colon ranges, according to the literature between 0.1-0.9%, or for diagnostic procedure about 0.17%, and for interventional 0.41%, with general mortality rate of 0.006%. In spite of the general trend for diminishing this occdurence, it is necessary to compare various experiences in order to achieve an algorrhithm of early diagnostic and the way of the surgical management of this particular kind of perforation. The aim of this work is to present the experience in 1995-2004 period, upon 7 (0.12%) cases of surgically treated perforations of colon after 5,680 performed diagnostic colonoscopies. In all 7 cases the reason for perforation was not basically pathologiocal process. 4 cases of perforations were recognized immediately, and they were managed by direct suture of the perforation. In 3 cases diagnosis was late from 1 to 3 days, and two-step operative procedure was performed in septic condition. Subjective and clinical signs of perforations were not always unifrom, but in all 7 cases there were clear X-ray signs of free intraabdominal air. Surgical treatment was successfull, and without deaths. In the algorrhithm of surgical diagnostic and procedure, the same principles and criteria used for civilian injuries of colon are to be used.     

TEE在外科微创房、室间隔缺损封堵术中的应用

目的探讨TEE引导下外科微创封堵治疗房间隔缺损(ASD)、室间隔缺损(VSD)的价值。方法 58例ASD和129例VSD患者接受TEE引导下外科微创封堵治疗。术中行胸壁小切口暴露心脏,于TEE监测下选择右心房或右心室穿刺点,指引动脉止血鞘通过缺口后释放封堵装置,待TEE多切面证实封堵器位置良好、无明显残余分流及瓣膜并发症后释放封堵器。结果 58例ASD均封堵成功,术后即刻TEE见8例封堵器周围微量残余分流。129例VSD中,114例VSD封堵成功,其中19例术后即刻TEE检查见残余分流,2例右心室流出道血流速度增快,1例变更右心室壁穿刺点后导丝顺利进入缺口;15例转行体外循环下心内直视修补术。结论 TEE可用于指导外科微创封堵治疗ASD和VSD,包括测量缺损大小和位置、选择封堵器型号、确定手术路径、引导封堵器释放和评估治疗效果。     

Infarction exclusion technique with transmural sutures for postinfarction ventricular septal rupture.

We present a case of postinfarction ventricular septal rupture (VSR) who underwent successful repair using a modified infarction exclusion technique. In our procedure a heterologous pericardial patch is sutured to healthy endocardium in the free wall and septum all around the infarcted area. Interrupted circular mattress sutures were placed through the ventricular wall in such a way as to exclude the VSR and the infarcted muscle of the left ventricle. We describe herein a novel procedure for repairing postinfarction VSR, by the transmural infarction exclusion technique.     

经胸骨下段小切口行室间隔封堵的近期疗效评价

目的评价经胸骨下段小切口封堵器治疗膜周部室间隔缺损（ventricular septal defect,VSD）的近期疗效。方法2007年1月-2008年8月,采用Amplatzer膜部VSD封堵器对41例膜周部VSD进行封堵治疗。男14例,女27例。体重9.0-71 kg,（46.3±16.1）kg,经胸超声心动图显示均为膜周部VSD,破口3-8.5 mm。全麻后经胸骨下段切口显露右室,经右室放置封堵器。出院前和术后1个月进行经胸超声心动图、心电图、X线胸片等检查。结果41例均成功进行封堵,术后气管带管时间2.5-17 h,（6.2±3.3）h。ICU滞留时间8-21 h,（15.1±4.3）h。引流量35-210 ml,（80±33）ml。41例随访3-15个月,（7.9±4.1）月,无传导阻滞,无主动脉瓣关闭不全,无封堵器移位、脱落,无血栓形成,三尖瓣无反流,无血红蛋白尿。1例术后出院前发现有残余分流,约1 mm。结论经胸骨下段小切口行VSD封堵近期效果良好。     

Spontaneous Ventricular Arrhythmias Following Partial Left Ventriculectomy for Nonischemic Dilated Cardiomyopathy: Relation to Hemodynamics and Survival

The study assessed the value of ambulatory electrocardiogram (AECG) monitoring for identification of patients who are at increased risk for cardiac death or arrhythmic event following partial left ventriculectomy (PLV). Furthermore, the impact of PLV and its hemodynamics on the occurrence of spontaneous ventricular arrhythmias was assessed in long-term survivors. In 32 idiopathic dilated cardiomyopathy patients who underwent PLV, ambulatory ECG (AECG) was performed preoperatively, early postoperatively, and 6 months and 12 months after surgery. In 17 of 19 patients who survived > 12 months after the procedure, left ventricular (LV) angiography was performed at the same time points and was used to calculate LV ejection fraction, and end-diastolic and end-systolic wall stress. During a mean follow-up of 478 +/- 405 days, 11 cardiac events occurred. Cox univariate regression revealed frequency of premature ventricular contractions > 30/hour at baseline (p = 0.0213) and duration of heart failure symptoms (p = 0.0226) as predictors of cardiac death or arrhythmic event after PLV. In a multivariate analysis, only frequency of premature ventricular contractions > 30/hour was a significant predictor. There was no change in the frequency or severity of ventricular arrhythmias after PLV. However, frequency of premature ventricular contractions correlated with LV end-diastolic stress (r = 0.35, p = 0.013), and ejection fraction (r = -0.34, p = 0.016). Preoperative AECG monitoring may help stratification of PLV patients. Serial AECG did not show that PLV influence the incidence or the complexity of spontaneous ventricular arrhythmias. In contrast, it appears that a hemodynamically "successful" procedure may decrease the incidence of ventricular arrhythmias.     

Anesthesia for high‐risk procedures in the catheterization laboratory

Recent advances in catheterization and imaging technology allow for more complex procedures to be performed in the catheterization laboratory. A number of lesions are now amenable to a percutaneous procedure, eliminating or at least postponing the need for a surgical intervention. Due to the increase in the complexity of the procedures performed, the involvement of anesthesiologists and their close collaboration with the interventional cardiologists have increased. It is important to understand the physiology and pathophysiology of the patients and to anticipate the plans and the potential complications in order to manage them. We are witnessing a rise in the number of complex interventions in newborns and infants, such as balloon valvotomy (critical aortic stenosis, pulmonary stenosis), radio frequency perforation (of pulmonary atresia and intact ventricular septum), right ventricular outflow tract stenting (in Tetralogy of Fallot), ductal stenting (in some ductus‐dependent pulmonary circulation), and combined with a surgical procedure (hybrid procedure for hypoplastic left heart syndrome). Multiple registries have been created in order to understand and improve outcomes of patients with congenital heart disease undergoing catheterization procedures and to develop performance and quality metrics, from which data regarding anesthetic‐related risks can be extrapolated. Experienced personnel and a multidisciplinary team approach with direct communication among the team members is a must to ensure anticipation and management of critical events when they occur.     

两种封堵器治疗主动脉窦瘤破裂的疗效及安全性

目的探讨应用动脉导管未闭(PDA)封堵器和室间隔缺损(VSD)封堵器治疗主动脉窦瘤破裂的疗效和安全性。方法对19例主动脉窦瘤破裂患者,按所用封堵器分为PDA封堵器组和VSD封堵器组,根据升主动脉造影结果,选择比破口直径大2~5mm的PDA封堵器或VSD封堵器进行经导管介入封堵。术后随访观察临床症状、心电图、残余分流、封堵器形态、有无瓣膜反流等情况。结果两组患者年龄、发病时间和术前TTE所示破口直径、主动脉造影示破口直径差异均无统计学意义(P均0.05)。19例均经升主动脉造影确诊为主动脉窦瘤破裂,其中15例右冠状动脉窦瘤破裂入右心室,3例为右冠状动脉窦瘤破裂入右心房,1例无冠状动脉窦瘤破裂入右心室;共使用PDA封堵器10枚,VSD封堵器11枚,成功率分别为60.00%(6/10)和90.91%(10/11)。术后随访6个月~6年,未发生血栓事件,无瓣膜反流,无心律失常、感染性心内膜炎、心力哀竭及死亡。结论经导管介入治疗主动脉窦瘤破裂安全有效;应用VSD封堵器较PDA封堵器有一定优势。     

Left ventricular free wall rupture in an elderly patient; report of a case

We successfully repaired left ventricular free wall rupture in a 91-year-old woman. She was admitted to our hospital because of consciousness loss. Blood pressure was only 60 mmHg on arrival. Contrast-enhanced computed tomography (CT) demonstrated massive pericardial effusion and transmural contrast defect of the left ventricular lateral wall in the delayed phase. Upon surgery there was massive clot around the heart. A localized infracted area on the left ventricular lateral wall was exposed using off-pump coronary artery bypass (OPCAB) technique. There was mild bleeding only during diastolic phase. Three mattress sutures of 3-0 prolene with Teflon felt strips were placed to control the bleeding under beating heart. A sheet of collagen and fibrin glue was also applied. Postoperative course was uneventful. This type of left ventricular rupture could be less invasively repaired by off-pump technique. As far as we investigated, this is the oldest patient of ventricular free wall rupture successfully repaired.     

A surgical case of ventricular septal perforation after repairing left ventricular free wall rupture.

A 78-year-old woman with diagnosis of acute myocardial infarction (AMI) in the anteroseptal area fell into cardiogenic shock suddenly just before starting percutaneous coronary intervention (PCI). Echocardiography showed left ventricular free wall rupture, then an emergent operation was performed by sutureless patch repair using collagen fleece with fibrinogen-based impregnation. Eight days later from the initial operation, the onset of ventricular septal perforation (VSP) was recognized. Fifteen days after, the infarct exclusion technique with endocardial patch was performed. She has been doing well 4 months after the operation without residual shunt. To our best knowledge, this is the first surgical case report that free wall rupture of left ventricle and VSP which are serious complications after myocardial infarction happened in succession.     

Endoscopic transgastric drainage of pancreatic pseudocyst with the use of Nd:YAG laser

Pancreatic pseudocysts have been successfully managed with endoscopic drainage recently. This report describes a case of endoscopic transgastric drainage using endoscopic ultrasonography (EUS) and an Nd:YAG laser. EUS was used to detect an optimal puncture site of the pseudocyst and to reduce the risk of bleeding and perforation. An Nd:YAG laser was used to minimize the risk of bleeding and to penetrate the thick wall of the pseudocyst. After transgastric cystgastrostomy was performed, an internal stent was placed between the pseudocyst and the stomach. There were no complications associated with endoscopic interventions. Complete resolution of the pseudocyst was observed. Endoscopic transgastric drainage of pancreatic pseudocysts is a recommended approach for selected patients with pancreatic pseudocysts that are uncomplicated and are located adjacent to the stomach. Safe and effective drainage can be achieved without hemorrhage and perforation with the use of EUS, an Nd:YAG laser, and a stent. Furthermore, the Nd:YAG laser facilitated passage through a markedly indurated pseudocyst wall and it seemed to be an effective instrument, especially for pseudocysts with a thick wall.     

Functional consequences of the right ventricular isolation procedure

The right ventricular free wall was surgically isolated from the remainder of the heart in eight dogs to evaluate the functional consequences of this procedure. Each dog was instrumented with ultrasonic dimension transducers in the right and left ventricular free walls, intracavitary micromanometers, and pulmonary artery flow probes. Volume loading and vena caval occlusions were performed to assess diastolic compliance and systolic function. Right ventricular unstressed myocardial segment length increased from 14.2 +/- 0.7 to 15.0 +/- 0.8 mm (p less than 0.5). There was an accompanying significant postoperative loss of right ventricular diastolic compliance (p less than 0.005). Regional right ventricular systolic function and regional left ventricular diastolic compliance and systolic function were preserved after the procedure. Postoperatively, when the right ventricular free wall was not paced and left silent, right ventricular stroke work decreased from 7.0 +/- 0.8 to 2.7 +/- 0.5 gm-m/m2 (p less than 0.05). These data demonstrate that the diastolic compliance of the right ventricular free wall decreases significantly after right ventricular isolation. However, there were no changes in regional right ventricular systolic or regional left ventricular function. The isolated right ventricular free wall contributes significantly to postoperative cardiac performance.