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半身体外循环技术在主动脉缩窄矫治术中的应用

目的 探讨心脏不停跳下半身体外循环（partial cardiopulmonary bypass，PCB）在主动脉缩窄矫治术中的应用。 方法 回顾性分析 2016 年 3 月至 2017 年 8 月我院经左后外侧切口行缩窄主动脉段置换术 5 例男性主动脉缩窄患者的临床资料，平均年龄（22.80±14.22）岁。术中经降主动脉和左肺动脉分别插入动脉灌注管和静脉引流管，连接人工膜肺和滚轴泵，建立 PCB。采用心脏不停跳的方法，避免深低温（鼻咽温度 33℃ 以上），控制灌注流量在 15～50 ml/（kg·min），维持上肢血压 60～100 mm Hg 和下肢血压 50～80 mm Hg。 结果 PCB 平均转流时间为（77.40±17.85）min，均平稳脱离体外循环。术后平均住 ICU 时间（25.00±14.17）h。所有患者无截瘫、肾损害等并发症。短期随访没有主动脉再狭窄现象。 结论 心脏不停跳下经降主动脉和左肺动脉插管建立 PCB 的技术在青少年或成人主动脉缩窄矫治术中安全、可行，能避免深低温及内脏和脊髓损伤。

一期手术治疗主动脉缩窄合并动脉导管未闭一例

The role of increased preoperative ventricular-arterial stiffening in the hypertension of infants with coarctation of the aorta

ObjectiveTo explore the role of increased preoperative ventricular-arterial stiffening in hypertensive infants with coarctation of the aorta (CoA).MethodsA retrospective study was conducted in 314 infants with CoA (CoA group, 193 males and 121 females, aged 5.4±2.2 months), and 314 infants receiving tumor chemotherapy with normal cardiovascular function and without pneumonia (control group, 189 males and 125 females, aged 4.4±3.8 months), who were admitted to our hospital from 2015 to 2017. The clinical data of the two groups were compared.ResultsThere were statistical differences in effective aortic elastance index (Eai), effective left ventricular end-systolic elasticity index (Eesi), ventricle-artery coupling index (VACi), N-terminal pro-brain natriuretic peptide (NT-proBNP) levels, and ratios of left ventricular hypertrophy, dilation and systolic dysfunction between the two groups (P<0.05). Compared with non-hypertensive CoA infants, CoA infants with hypertension had higher Eai, Eesi, NT-ProBNP level and proportion of left ventricular hypertrophy (P<0.05). Compared with concomitant ventricular septal defect, infants with isolated CoA had higher Eai, Eesi, NT-proBNP level, incidence of hypertension and higher proportion of left ventricular hypertrophy, dilation and systolic dysfunction (P<0.05). Eai and Eesi were positively correlated with NT-proBNP level, left ventricular hypertrophy and fractional shortening of left ventricle (P<0.05), while Eai and Eesi were negatively correlated with left ventricular end diastolic volume index, left ventricular end systolic volume index and concomitant ventricular septal defect (P<0.05). Hypertension was related to preoperative left ventricular hypertrophy, Eai, Eesi and NT-ProBNP. Eai was an independent risk factor for hypertension.ConclusionPreoperative ventricular-arterial stiffening is increased in infants with aortic coarctation, which is related to the occurrence of hypertension. Isolated CoA shows more significant increase in ventricular-arterial stiffening, higher ventricular overload and incidence of hypertension.

Surgical strategy for treatment of complex aortic coarctation

ObjectiveTo summarize the clinical experience of the treatment for complex aortic coarctation with extra anatomic bypass and anatomic correction techniques. MethodsThe clinical data of patients with complex aortic coarctation treated in the First Affiliated Hospital of Nanjing Medical University and Friendship Hospital of Ili Kazakh Autonomous Prefecture between April 2012 and November 2020 were retrospectively reviewed. ResultsA total of 12 patients were enrolled, including 5 males and 7 females aged 11-54 (34.3±16.2) years. Extra anatomic bypass grafting was performed in 8 patients and anatomic correction was performed in 4 patients. The operations were successful in all patients. There was no perioperative death. The average cardiopulmonary bypass time was 203.0±46.0 min (7 median incision patients), and the average intraoperative blood loss was 665.0±102.0 mL. The average postoperative ventilator support time was 32.3±7.5 h, and the average postoperative hospital stay time was 10.2±4.3 d. The mean drainage volume of median incision was 1 580.0±360.0 mL, and the mean drainage time was 9.3±2.7 d. The mean drainage volume of left thoracotomy was 890.0±235.0 mL, and the mean drainage time was 4.8±2.5 d. One patient had a transient hoarse after operation and recovered 6 months later. The follow-up period ranged from 2 to 10 years with an average time of 81.0±27.0 months. All patients had a recovery of hypertension, cardiac afterload after 2 years postoperatively. One patient who received an artificial blood vessel replacement in situ was examined stenosis recurrence at the third year after discharge. Others were asymptomatic during the follow-up period. There were no death or other complications. ConclusionThe treatment strategy for complex aortic coarctation should be individualized according to the anatomical features and concomitant heart diseases. Extra anatomic bypass technique is a safe and feasible choice.

小儿主动脉缩窄或主动脉离断合并心内畸形的诊断与外科治疗

目的　探讨主动脉缩窄（CoA）或主动脉离断（IAA）合并心内畸形的诊断及手术方式选择。　方法　2003年1月至2010年3月济宁医学院附属医院手术治疗14例小儿CoA（9例）或IAA（5例）合并心内畸形 ［包括室间隔缺损（VSD）、房间隔缺损（ASD）、房室隔缺损（APSD）等畸形，但不包括单纯合并动脉导管未闭（PDA）］ 患者， 其中男10例，女4例；年龄0.7～12.0 （3.2±4.5）岁；体重5.5～25.5 （10.2±5.5） kg。分期手术3例，经胸骨正中切口径路一期手术矫治11例。　结果　手术死亡2例，其中1例为分期手术，二次手术行VSD修补术后死于急性左心衰竭；1例术前诊断为VSD＋PDA合并重度肺动脉高压，术前未发现IAA，术后死于急性肾功能衰竭。随访12例，随访时间6～84 （32±22）个月，患者恢复良好。复查心脏超声心动图提示：胸主动脉轻度狭窄2例，继续随访观察。　结论　多层螺旋CT和核磁共振成像是目前诊断CoA和IAA的首选检查方法。经胸骨正中切口径路一期手术治疗CoA或IAA合并心内畸形婴幼儿，可获较好的显露及疗效。

The potential role of calnexin in the activation of cardiac fibroblasts

Calnexin is a lectin-like molecular chaperone protein on the endoplasmic reticulum, mediating unfolded protein responses, the endoplasmic reticulum Ca2+ homeostasis, and Ca2+ signals conduction. In recent years, studies have found that calnexin plays a key role in the heart diseases. This study aims to explore the role of calnexin in the activation of cardiac fibroblasts. A transverse aortic constriction (TAC) mouse model was established to observe the activation of cardiac fibroblasts in vivo, and the in vitro cardiac fibroblasts activation model was established by transforming growth factor β1 (TGFβ1) stimulation. The adenovirus was respectively used to gene overexpression and silencing calnexin in cardiac fibroblasts to elucidate the relationship between calnexin and cardiac fibroblasts activation, as well as the possible underlying mechanism. We confirmed the establishment of TAC model by echocardiography, hematoxylin-eosin, Masson, and Sirius red staining, and detecting the expression of cardiac fibrosis markers in cardiac tissues. After TGFβ1 stimulation, markers of the activation of cardiac fibroblast, and proliferation and migration of cardiac fibroblast were detected by quantitative PCR, Western blot, EdU assay, and wound healing assay respectively. The results showed that the calnexin expression was reduced in both the TAC mice model and the activated cardiac fibroblasts. The overexpression of calnexin relieved cardiac fibroblasts activation, in contrast, the silencing of calnexin promoted cardiac fibroblasts activation. Furthermore, we found that the endoplasmic reticulum stress was activated during cardiac fibroblasts activation, and endoplasmic reticulum stress was relieved after overexpression of calnexin. Conversely, after the silencing of calnexin, endoplasmic reticulum stress was further aggravated, accompanying with the activation of cardiac fibroblasts. Our data suggest that the overexpression of calnexin may prevent cardiac fibroblasts against activation by alleviating endoplasmic reticulum stress.

停循环技术应用于升主动脉-胸降主动脉人工血管旁路移植治疗主动脉缩窄

目的总结经单一胸部正中切口采用低温停循环技术行解剖外升主动脉-胸降主动脉人工血管旁路移植术治疗主动脉缩窄的经验。方法回顾性分析 2009 年 12 月至 2018 年 5 月我院连续 12 例主动脉缩窄患者的临床资料。其中男女各 6 例，年龄 13～42 岁，均有高血压症状，上下肢动脉收缩压差 46～85（57.1±16.8）mm Hg。手术经胸部正中切口，采用体外循环及深低温停循环技术，行升主动脉-心包后胸降主动脉人工血管旁路移植术。结果人工血管平均直径 14～20（17.2±1.8）mm，体外循环时间 69～197（115.9±40.6）min，主动脉阻断时间 41～142（69.8±30.7）min，深低温停循环时间 9～27（16.8±4.1）min。所有患者均未输血，无严重并发症。术后上下肢动脉收缩压差值为 –12～22（14.3±4.8）mm Hg，较术前显著下降（P<0.01）。所有患者均康复出院，平均随访 3～91（41.9±21.5）个月，随访期间仅 1 例患者术后需要服用 1 种降压药物，其余患者均正常。结论深低温停循环下经胸部切口行解剖外人工血管旁路移植术治疗主动脉缩窄安全有效，未来需要更多病例进一步验证。

Patch Aortoplasty for Infant Coarctation of the Aorta with Hypoplastic Aortic Arch

Abstract: Objective To summarize the clinical experiences of resection with patch aortoplasty for infant coarctation of the aorta combined with aortic arch hypoplasia. Methods Between May 2007 and December 2009, 49 patients including 30 males and 19 females with coarctation with hypoplastic aortic arch underwent coarctation resection and patch aortoplasty in Shanghai Children’s Medical Center, School of Medicine, Shanghai Jiaotong University. The age of the patients ranged from 23 days to 3 years and 1 month with thirtyfour patients under 6 months, ten between 6 months and 1 year old, and five more than 1 year old. The surgery under deep hypothermia cardiopulmonary bypass with selective cerebral perfusion were performed in 31 cases and circulation arrest in 15 cases; under moderate hypothermia cardiopulmonary bypass in 3 cases. Pericardia patch was used in 31 cases, pulmonary autograft patch in 14 cases and xenograft pericardia patch in 4 cases. The associated intracardiac anomalies were repaired in the same stage. Results One case died from circulation failure during the perioperative period. The operative mortality was 204% (1/49). Low cardiac output syndrome and renal failure respectively occurred in 5 cases and 1 case who were cured afterwards by correspondent treatments. No residual obstruction was detected by echocardiography after the operation. Followup was carried out in fortyeight cases for a minimum of 4 months and a maximum of 3 years. Echocardiographic examination showed that the gradient through the aortic arch was more than 40 mm Hg and computed tomography showed recoarctation in 1 case who underwent reoperation eight months after the operation; the gradient was more than 20 mm Hg in 2 cases who were under continuous observation; all the rest cases had a fine aortic arch morphology and for these patients, the blood velocity at descending aortic arch was not obviously changed during the followup period compared with that right after operation, the computed tomography showed a normal aortic arch geometry. Left bronchus compression was relieved obviously or totally disappeared in patients who suffered from left bronchus stenosis before the operation without any aortic aneurysm detected. Conclusion Coarctation resection with patch aortoplasty is considered as an optimal surgical method for management of infant coarctation with hypoplastic aortic arch.

Extraanatomic Aortic Bypass Grafting Through Median Sternotomy for Onestage Treatment of Aortic Coarctation and Associated Cardiac Diseases

Objective To summarize the experience of extraanatomic aortic bypass grafting through median sternotomy for onestage treatment of aortic coarctation and associated cardiac diseases, and to improve surgical effect of the diseases. Methods Between July 1997 and July 2008, 31 consecutive patients(20 male,11 female; age 31.9±11.7 years) with aortic coarctation and associated cardiac anomalies underwent onestage surgical repair through median sternotomy. The associated cardiac anomalies included: aortic valve insufficiency or stenosis(n=22); mitral valve insufficiency or stenosis (n=9); patent ductus arteriosus (n=5); ascending aortic aneurysm (n=4); ventricular septal defect (n=3); coronary artery disease (n=2). Extra-anatomic aortic bypass grafting was used to repair the coarctation. Routing of the grafts was: ascendingto posterior pericardial descending aorta (n=9) and ascendingtoinfrarenal abdominal aorta (n=22). Concomitant cardiac procedures included: aortic valve replacement in 16; Bentall procedures in 6; mitral valve repair or replacement in 9; ascending aortic replacement or aortoplasty in 4; patent ductus arteriosus closure in 5; ventricular septal defect closure in 3 and coronary artery bypass grafting in 2. Results One patient died of septic shock 39 days after operation with an inhospital mortality of 3.2%. Mean systolic blood pressure gradient between upper and lower extremities decreased from 64.2±25.3 mm Hg preoperatively to 13.7±10.2 mm Hg postoperatively (Plt;0.05). Twentyseven patients were followed up from 4 to 73 months, there were no late deaths，reoperations or graftrelated complications. Conclusion Extraanatomic aortic bypass grafting can be performed simultaneously through median approach in patients with aortic coarctation and associated cardiac diseases. It is an effective and safe treatment option for onestage surgical repair in adults and adolescents. Both ascendingto posterior pericardial descending aorta and ascendingtoinfrarenal abdominal aorta bypass have favorable results.

One-stage repair of aortic coarctation combined with cardiac anomalies and severe pneumonia

Objective To analyze the clinical outcome of one-stage repair of aortic coarctation combined with cardiac anomalies and pneumonia. Methods We retrospectively reviewed the clinical data of 26 patients with severe pneumonia undergoing repair of aortic coartation between January 2014 and August 2015, among whom 7 patients (26.9%) received tracheal intubation, 5 patients double incision, and 21 patients single incision. Long-term follow-up results were obtained from outpatient department. Results Two patients died from operations. The mean hospital stay was 18.5±4.5 d, bypass time 93.5±36.4 min, and mechanical ventilation time 89.5±41.3 min. Postoperative complication mainly was pneumonia. During 6-month follow-up at outpatient department, incidence of pneumonia decreased, and children’s growth and development remarkably improved. Conclusion In the case of uncontrollable pneumonia, one-stage repair of aortic coarctation associated with cardiac anomalies still can receive a good outcome.