Impact of On-Site Cardiac Surgery on Clinical Outcomes After Transfemoral Transcatheter Aortic Valve Replacement

Objectives

This study sought to investigate the outcome of high-risk and inoperable patients with severe symptomatic aortic stenosis undergoing transfemoral transcatheter aortic valve replacement (TAVR) in hospitals with (iOSCS) versus without institutional on-site cardiac surgery (no-iOSCS).

胸腔镜心脏外科手术现状及展望

胸腔镜应用于心脏外科已有十多年,相对于传统心脏外科手术具有减少外科创伤、减缓疼痛、失血少、恢复快、美容效果好等优点。国外胸腔镜心脏外科多以机器人辅助完成多种心脏手术,国内一般单用胸腔镜辅助完成房间隔缺损修补术、室间隔缺损修补术、二尖瓣置换术,以及心房颤动射频消融术,现将胸腔镜辅助心脏外科手术的现状及进展进行综述。     

Delirium: An Independent Predictor of Functional Decline After Cardiac Surgery

OBJECTIVES: To determine whether patients who developed delirium after cardiac surgery were at risk of functional decline. DESIGN: Prospective cohort study. SETTING: Two academic hospitals and a Veterans Affairs Medical Center. PARTICIPANTS: One hundred ninety patients aged 60 and older undergoing elective or urgent cardiac surgery. MEASUREMENTS: Delirium was assessed daily and was diagnosed according to the Confusion Assessment Method. Before surgery and 1 and 12 months postoperatively, patients were assessed for function using the instrumental activities of daily living (IADL) scale. Functional decline was defined as a decrease in ability to perform one IADL at follow‐up. RESULTS: Delirium occurred in 43.1% (n=82) of the patients (mean age 73.7±6.7). Functional decline occurred in 36.3% (n=65/179) at 1 month and in 14.6% (n=26/178) at 12 months. Delirium was associated with greater risk of functional decline at 1 month (relative risk (RR)=1.9, 95% confidence interval (CI)=1.3–2.8) and tended toward greater risk at 12 months (RR=1.9, 95% CI=0.9–3.8). After adjustment for age, cognition, comorbidity, and baseline function, delirium remained significantly associated with functional decline at 1 month (adjusted RR=1.8, 95% CI=1.2–2.6) but not at 12 months (adjusted RR=1.5, 95% CI=0.6–3.3). CONCLUSION: Delirium was independently associated with functional decline at 1 month and had a trend toward association at 12 months. These findings provide justification for intervention trials to evaluate whether delirium prevention or treatment strategies might improve postoperative functional recovery.     

Intraoperative Echocardiography and Minimally Invasive Cardiac Surgery

The term minimally invasive cardiac surgery encompasses a number of different techniques, each with its own rationale, origin, and development, but all focusing on limiting the physiologic trespass of cardiac surgery on the patient. In this article, we discuss the application of intraoperative echocardiography to three types of these procedures: Offpump coronary artery bypass graft (OPCABG) surgery, valvular surgery through limited thoracic incisions, and port-access heart surgery.     

术中超声心动图在心脏外科的应用价值

术中超声心动图包括经食道和心外膜超声心动图 ,在心脏外科体外循环前能完善诊断 ,有效降低围术期的并发症。本文概述该项技术在心脏外科手术中的应用价值。     

Higher Rate of Recurrent Atrial Flutter and Atrial Fibrillation Following Atrial Flutter Ablation After Cardiac Surgery

Atrial Flutter After Cardiac Surgery . Introduction: Atrial flutter (AFL) is common after cardiac surgery. However, the types of post‐cardiac surgery AFL, its response to catheter‐based radiofrequency ablation, and its relationship to atrial fibrillation (AF) are unknown. Methods and Results: We retrospectively studied all patients who underwent mapping and ablation for AFL after cardiac surgery from January 1990 to July 2004. One hundred randomly selected patients without prior cardiac surgery (PCS) who underwent mapping and ablation of AFL served as the control population. A total of 236 patients formed the study population (mean age 62 + 13 years, 22% female) and 100 patients formed the control population (mean age 60 + 13 years, 25% female). The majority of patients without PCS had cavo‐tricuspid isthmus (CTI)‐dependent AFL when compared to patients with PCS (93% vs 72%, respectively, P < 0.0001). In contrast, scar‐related AFL was more common in patients with PCS as compared to patients without PCS (22% vs 3%, P < 0.0001). Predictors of scar related AFL in multivariable regression analysis included PCS and left‐sided AFL. Acute success rates and complications were similar between the groups. When compared to patients with AFL ablation without PCS, those that had AFL after PCS had higher rates of recurrence of both AFL (1% vs 12%, P < 0.0001; mean time to recurrence 1.85 years) and AF (16% vs 28%, P = 0.02; mean time to recurrence 2.67 years). Conclusion: Despite ablation of AFL, patients with PCS have a higher rate of AFL and AF when compared to patients without PCS who underwent ablation of atrial flutter during long‐term follow‐up. (J Cardiovasc Electrophysiol, Vol. pp. 760‐765, July 2010)     

机器人辅助内镜下心脏手术应用进展

近十年来,心脏微创外科手术得到了长足发展,其中最引人注目的是机器人系统在心脏手术中的应用。借助机器人系统,心脏外科医生可以更好地通过胸部小切口完成各种心脏手术。而随着配套手术器械的改进,三维视觉系统的建立以及反馈系统的使用,国外已有多位医生在机器人辅助下完全完成了内镜下的心脏手术。     

心脏介入术并发急性心包填塞的临床分析

【】 目的 总结心脏介入术中并发急性心包填塞的防治体会。方法 回顾性分析6例心脏介入术中发生急性心包填塞患者的发病特点、发生原因及处理措施。结果 二尖瓣球囊扩张术(PBMV)中1例为房间隔穿刺位置过高致右心房穿孔而发生急性心包填塞,经紧急心外科手术救治成功,1例为送入穿刺鞘致心房穿孔所致,超声引导下心包穿刺置管引流48h后痊愈;冠状动脉介入治疗术(PCI)中1例为反复推送导丝穿破高度狭窄钙化的左前降支所致, 经紧急心外科手术救治成功,1例为急性前壁心肌梗死PCI时发生,经对症治疗及置管引流48小时后痊愈;射频消融术(RFCA)中1例为放置左上肺静脉电极导管时不慎将左心耳穿破所致,行猪尾导管引流、输血、升压等措施后心包填塞症状缓解;心脏永久性起搏器植入术中1例为电极损伤冠状静脉所致,行超声下猪尾导管心包穿刺引流及输血等治疗后,病情稳定。结论：急性心包填塞是心脏介入术的严重并发症,积极预防、及时发现、果断处理是防治的关键措施。     

33例心内直视手术不用库血的体会

目的：采用综合方法进行血液保护，以期在心内直视手术中不用库血，从而避免感染输血性疾病。方法：综合方法包括①适宜的麻醉深度，避免术中血压过高；②术前经桡动脉或腔静脉放出自体血贮存，放血量为１０～１５ｍｌ／ｋｇ；③术中应用抑肽酶或止血芳酸。抑肽酶总量成人为４００万ｋＩＵ，儿童为２００万ｋＩＵ。止血芳酸用量为４０ｍｇ／ｋｇ；④转流后机器血全部回输，每输１００ｍｌ机器血补给鱼精蛋白５～１０ｍｇ，同时加强利尿，浓缩血液；⑤术中认真止血，术野局部用三磷酸腺苷浸泡。结果：３３例患者，当术后血红蛋白超过９０ｇ／Ｌ，血细胞比容大于０．３０时，围术期可不用库血。术后２４小时引流总量为３２～４１０ｍｌ，平均２０６ｍｌ。出院时血红蛋白均超过１１０ｇ／Ｌ，而血细胞比容大于０．４０。结论：行心脏直视手术患者，术中用综合方法行血液保护，围术期可不输库血     

Two-dimensional, Non-Doppler Strain Imaging during Anesthesia and Cardiac Surgery

Transesophageal echochardiography (TEE) has become an essential intraoperative monitor during general anesthesia for cardiac surgical procedures. In clinical practice, ventricular function is visually evaluated using gray scale and Doppler modes, despite the fact that subjective interpretation is influenced by level of experience and training. Echocardiographic strain imaging measures cardiac deformation and provides objective quantification of regional myocardial function. Non-Doppler strain, which is derived by tracking speckles from two-dimensional (2D) images, bypasses the limitations of Doppler-based strain measurements and evaluates the complex myocardial deformation along three dimensions. As a result, longitudinal shortening, circumferential thinning and radial thickening can be quantified using standard midesophageal and transgastric views, being acquired during a comprehensive TEE examination. Once non-Doppler strain becomes available on "real time," it will have the potential to become a valuable tool for detection of ischemia on the regional level and objective quantification of global ventricular function.     

A Novel Approach to Robotic Cardiac Surgery Using Haptics and Vision

Cardiovascular disease is one of the leading causes of death in the United States and also a major disease nationwide. Over 700,000 coronary artery bypass graft (CABG) procedures are performed annually all around the world, of which 350,000 are performed in the United States. The use of mechanical stabilizers to isolate and immobilize the surface region of the heart is not without its limitations such as hemodynamic deterioration, and arrythmia induction requiring inotropic support. Consequently, the use of mechanical stabilizers leads to a poor immobilization of the surgical field in spite of significant forces of traction and retraction used with these devices. The primary goal of this research is to develop effective haptic (sense of touch) and visual servoing methods with the long-term goal of eliminating the need for mechanical stabilizers and extracorporeal support for CABG procedures. We present in this paper the results from our initial work in the area of tracking a deformable membrane using vision and providing haptic feedback to the user, based on the visual information through the vision hardware and the material properties of the membrane. In our first experiment, we track the deformation of a rubber membrane in real-time through stereovision while providing haptic feedback to the user interacting with the reconstructed membrane through the PHANToM haptic device. In the second experiment, we verify the ability of our vision system to track a point on a surface undergoing a complex 3D motion.