Red blood cell (RBC) transfusions are frequently used in cardiac surgery. A minority of patients assume most of the blood products transfusion during and after cardiac operations. Observational analysis of transfusion in patients undergoing cardiac surgery has uniformly demonstrated that RBC transfusion is associated with a significantly increasing risk of all-cause mortality and other serious adverse outcomes. In addition, it is an established fact that such patients can tolerate relatively low hemoglubin (Hb) levels. Consequently, it becomes widely accepted that appropriate limitation of transfusions could confer a substantial benefit to patients and decrease the use of limited resource. As a result, a restrictive threshold for blood transfusion is likely to be favored under most circumstances. However, an increasing amount of data differing from the observational analysis shows that clinical outcomes in patients who received transfusions with restrictive thresholds for Hb level are not superior to those with liberal thresholds. It has created a new uncertainty regarding the use of a restrictive threshold for transfusion during the perioperative period of cardiac surgery.
Thoracoscopic minimally invasive technology has been used in mitral valve plasty since 1990s. Totally thoracoscopic mitral valve plasty has the advantages of small trauma, beautiful incision and rapid postoperative recovery. It is favored by more and more patients and cardiac surgeons. However, according to the reports, the proportion of totally thoracoscopic mitral valve surgery in China is still low. Mitral valve plasty via the totally thoracoscopic approach is still controversial in terms of population adaptation, perioperative complications and long-term prognosis. In addition, the technical difficulty and the long training cycle of surgeons also limit the popularization of this technology. By summarizing the existing literature, this paper analyzes the application and development of totally thoracoscopic approach in comparison with the traditional median thoracotomy mitral valve plasty.
Functional tricuspid regurgitation is referred to tricuspid regurgitation due to enlargement of right ventricular and dilation of tricuspid annulus. Patients with chronic progressive tricuspid regurgitation have poor prognosis, poor quality of life and heavy economic burden. This article provides a comprehensive review of functional tricuspid regurgitation in terms of anatomical basis, pathological stage, imaging assessment and surgical decision making.
Mitral valve prolapse (MVP) is a common heart valve disease that affects 2%-3% of the general population. It can be manifested as mitral valve regurgitation and is the main indication for mitral valve surgery. MVP includes two forms of syndrome and non-syndrome. Syndromic MVP is associated with connective tissue diseases, such as Marfan syndrome. Non-syndromic MVP includes diffuse myxomatous mitral valve disease or Barlow’s disease and fibroelastic deficiency. MVP is a common disease in which late systolic clicks or mitral valve leaflets shift upward into the left atrium during ventricular systole, with or without mitral regurgitation. Echocardiography defines MVP as the prolapse of one or two leaflets of the mitral valve into the left atrium during systole, exceeding the level of the annulus line by more than 2 mm. In recent years, the development of genomics and imaging technology has enabled us to better understand the pathogenesis of MVP and provide possibilities for further prevention and treatment. This article reviews the research progress of MVP in epidemiology, etiology, histopathology, diagnosis and genetics.
A 23-year-old male patient was diagnosed with congenitally corrected transposition of the great arteries (ccTGA) at the age of 3 during a routine physical examination. Due to the absence of significant symptoms, the patient was managed conservatively with follow-up without surgical treatment. He developed chest tightness one year prior to admission, with symptom exacerbation in the recent month. Echocardiography demonstrated significantly worsened morphological tricuspid regurgitation. The patient presented to Guangdong Provincial People’s Hospital for surgical evaluation. Given the patient’s age and clinical presentation, a totally thoracoscopic morphological tricuspid valve replacement was performed. Postoperative assessment showed good prosthetic valve function, with no regurgitation or paravalvular leakage; the electrocardiogram confirmed sinus rhythm without atrioventricular block. Extubation occurred within 12 hours postoperatively, and the patient was transferred from the intensive care unit (ICU) on postoperative day 2. At the three-month follow-up, the patient was asymptomatic and had resumed normal activities. This report describes the first case of a totally thoracoscopic morphological tricuspid valve replacement in a ccTGA patient in China. This initial experience suggests that the totally thoracoscopic approach for morphological tricuspid valve replacement in ccTGA patients is a feasible, safe, and effective minimally invasive option associated with rapid recovery.
Objective To summarize the early results and clinical experience of using the J-Valve for transcatheter valve-in-valve implantation in patients with degenerated bioprosthesis at different anatomic positions. Methods A retrospective analysis was conducted to evaluate the short-term outcomes of 39 consecutive patients who underwent transcatheter valve-in-valve implantation using the J-Valve System in the Department of Cardiac Surgery of Guangdong Provincial People’s Hospital from April 2020 to August 2021 due to bioprosthetic degeneration at different anatomic positions. Among them, 35 patients underwent transcatheter mitral valve-in-valve (TMViV) implantation, 1 transcatheter aortic valve-in-valve (TAViV) implantation, 1 transcatheter tricuspid valve-in-valve (TTViV) implantation, 1 TMViV implantation with simultaneous TAViV implantation, and another one TMViV implantation with simultaneous transcatheter aortic valve replacement (TAVR) and perivalvular leakage (PVL) closure. Results Among the 35 patients who underwent isolated TMViV implantation, 17 were male and 18 were female with a mean age of 72.6±10.8 years. Mean duration between two operations was 10.5±2.7 years. The mean Society of Thoracic Surgeons and EuroSCORE Ⅱ scores were 12.95%±9.61% and 13.91%±8.94%, respectively. The device success rate was 97.1% and no death occured during the operation. One patient was transferred to thoracotomy due to device displacement, 1 was re-opened for uncontrolled bleeding, and 1 presented left ventricular outflow tract obstruction. One patient underwent craniotomy due to intracranial hemorrhage within 30 days after surgery, and no other complications occurred including death, stroke, permanent pacemaker implantation, cardiac tamponade, or re-hospitalization. The mean follow-up time was 6.0±4.4 months, the mean mitral valve gradient was significantly improved (10.4±2.0 mm Hg vs. 5.5±1.2 mm Hg, P<0.05), and the New York Heart Association class≤Ⅱ in all the patients at the last follow-up. Among the other 4 patients who did not undergo isolated TMViV implantation, the transapical TAViV implantation and the trans-right atrium TTViV implantation were successful without intra- or post-operative complications. The patient who underwent TMViV and TAViV implantation simultaneously via transapical approach died of severe pulmonary hemorrhage and multiple organ failure 16 days after surgery. The other patient who underwent transapical TMViV combined with TAVR and PVL closure died of septic shock 10 days after the surgery. Conclusion Transcatheter valve-in-valve implantation using the J-Valve system is shown to be a safe and effective procedure to treat mitral, aortic and tricuspid bioprosthetic valve dysfunction in high-risk patients, providing a new alternative to surgical surgery for degenerated bioprosthesis at different anatomic positions. However, simultaneous different valves intervention should be very cautious.
Objective To explore the evolving strategies and compare perioperative and long-term outcomes of tricuspid valve replacement (TVR) in recent 20 years in our hospital.MethodsBetween 1998 and 2018, the clinical data of 608 patients who underwent TVR at the Department of Cardiac Surgery, Guangdong Provincial People’s Hospital were retrospectively analyzed. There were 201 males and 407 females, with a median age of 47.0 (36.0, 57.0) years. Patients were divided into a biological tricuspid valve (BTV, n=427) group and a mechanical tricuspid valve (MTV, n=181) group. Propensity score matching was used to balance the baseline difference. Surgical strategy evolving, postoperative and long-term outcomes were analyzed between the two groups.ResultsSince 2008, the usage ratio of biological valves was significantly higher than that of mechanical valves. Seventy-nine (13.0%) patients died in hospital after TVR. Before propensity score matching, the postoperative mortality of the BTV group was higher than that of the MTV group (15.2% vs. 7.7%, P=0.012), and there was no statistical difference between the two groups after matching (10.4% vs. 7.2%, P=0.372). The duration of postoperative ventilator support in the BTV group was longer than that in the MTV group [22.0 (15.0, 37.0) h vs. 19.0 (11.0, 27.0) h, P=0.003], and the incidence of postoperative dialysis and re-thoracotomy exploring for bleeding was higher in the BTV group (8.9 % vs. 2.8%, 9.4% vs. 6.6%, respectively). However, there was no statistical difference in mortality after matching. The median follow-up time of discharged patients was 101.0 (65.0, 147.0) months, ranged from 1 to 265 months, and the follow-up rate was 82.2%. During the follow-up period, there were 101 deaths (19.1%) of whom 68 were from the BTV group and 33 from the MTV group. The survival rates at 1 year, 5 years, 10 years, 15 years and 20 years of all patients were 85.0% (95%CI 82.2-87.9), 78.9% (95%CI 75.7-82.4), 71.1% (95%CI 67.3-75.3), 59.7% (95%CI 54.2-65.6) and 51.7% (95%CI 43.3-60.7), and there was no statistical difference between the two groups after matching (P=0.46). The median time of tricuspid valve failure was 84.0 (54.0-111.0) months.ConclusionTVR is associated with high perioperative risks. There is no statistical difference in early mortality and long-term survival between biological and mechanical valve, while patients with mechanical valve has higher risk of re-operation for valve failure. Therefore, the type of prosthetic valve can be selected according to the patients' age, physical condition and the doctors’ experience.
ObjectiveTo compare the efficacy and safety of mitral valvuloplasty via minimally invasive approach with those of mitral valvuloplasty via traditional median sternotomy.MethodsA total of 1 221 patients undergoing mitral valvuloplasty from January 2015 to August 2018 in Guangdong Provincial People's Hospital were analyzed retrospectively, including 721 males and 500 females, with an average age of 47.2±15.1 years. According to the different surgical methods, they were divided into a study group (n=654), who received mitral valvuloplasty via the totally thoracoscopic approach, and a control group (n=567), who received mitral valvuloplasty via traditional median sternotomy. Clinical data, surgical results, and perioperative outcomes of the two groups were compared.ResultsThere was no significant difference in preoperative general data between the two groups (P>0.05). Compared with the control group, the study group had longer cardiopulmonary bypass time and aortic cross-clamping time (146.7±42.4 min vs. 122.7±30.6 min, 96.2±32.7 min vs. 78.3±23.8 min, both P=0.000), and shorter total operation time (227.4±55.3 min vs. 238.1±56.4 min, P=0.001). There was no significant difference in the incidence of secondary cross-clamping and mitral valve replacement between the two groups (3.7% vs. 2.6%, P=0.312; 1.7% vs. 1.4%, P=0.690). The blood transfusion rate and the incidence of respiratory tract infection and postoperative poor wound healing were lower (13.0% vs. 24.5%, 2.1% vs. 18.0%, 1.5% vs. 5.3%, all P=0.000) and the postoperative hospital stay was shorter (6.2±4.4 d vs. 11.5±8.8 d, P=0.000) in the study group. There was no significant difference in hospitalization expense between the two groups (95 847.9±31 322.0 yuan vs. 99 673.1±47 930.3 yuan, P=0.149). Within 30 d after surgery, 1 patient died in the study group and 4 patients died in the control group. Before discharge, there were 4 and 5 patients with severe mitral valve regurgitation in the study group and the control group, respectively.ConclusionCompared with mitral valvuloplasty via traditional median sternotomy, minimally invasive mitral valvuloplasty is superior in shortening operation time and postoperative hospital stay, lowering blood transfusion rate, and reducing postoperative complications, which can achieve better clinical outcomes.
ObjectiveTo investigate the predictive value of right atrial myocardial fibrosis in the prognosis of isolated tricuspid regurgitation surgery after left heart valve surgery. MethodsThe patients who underwent tricuspid valvuloplasty by the same operator in Guangdong Provincial People's Hospital from April 2016 to August 2021 due to long-term isolated severe tricuspid regurgitation after left heart valve surgery were included in the study. According to the degree of right atrial myocardial fibrosis, the patients were divided into three groups: a mild group, a moderate group, and a severe group. The clinical data of these patients were compared and analyzed. ResultsA total of 75 patients were enrolled, including 16 males and 59 females with an average age of 57.0±8.4 years. There were 30 patients in the mild group, 29 patients in the moderate group and 16 patients in the severe group. In terms of the preoperative data, there were statistical differences in cardiac function grade, right atrial diameter, tricuspid incompetence area among the three groups (P<0.05). In terms of the postoperative data, there were statistical differences among the three groups in the cardiopulmonary bypass time, mechanical ventilation time, ICU monitoring time, complication rate and mortality (P<0.05). Further pairwise comparison showed that, compared with the mild group, the severe group had longer mechanical ventilation time (P=0.024), longer ICU monitoring time (P=0.003) and higher incidence of postoperative complications (P=0.024), while the moderate group had no statistical difference in all aspects (P>0.05); compared with the moderate group, the severe group had longer ICU monitoring time (P=0.021) and higher incidence of complications (P=0.006). ConclusionThe early outcome of tricuspid valvuloplasty in patients with isolated tricuspid regurgitation after left heart valve surgery with severe right atrial myocardial fibrosis is worse than that in the patients with mild and moderate fibrosis, suggesting that the degree of myocardial fibrosis in the right atrium can be a predictor of the effect of tricuspid regurgitation surgery and a judgement indicator of the surgery timing.
Objective To evaluate the efficacy of a combination of beating-heart minimally invasive approach and leaflets augmentation technique treating severe tricuspid regurgitation (TR) after cardiac surgery. Methods From January 2015 to August 2017, patients undergoing reoperative tricuspid valve repair (TVP) with minimally invasive approach and leaflets augmentation were enrolled. Cardiopulmonary bypass (CPB) was established via femoral vessels and the procedures were performed on beating heart with normothermic CPB. A bovine pericardial patch was sutured to leaflets to augment the native anterior and posterior leaflets. Other repair techniques, such as ring implantation and leaflet mobilization, were also applied as needed. Results A total of 28 patients (mean age 55.6±10.1 years, 5 males, 23 females) were enrolled. One patient was converted to median sternotomy due to pleural cavity adhesion. Twenty-seven patients underwent totally endoscopic TVP with leaflets augmentation. No patients was transferred to tricuspid valve replacement. Two patients died in hospital. All patients were followed up for 7.4±5.0 months and there was no late death and reoperation. Regurgitation area was converted from 20.7±10.1 cm2 to 3.3±3.3 cm2 after TVP according to the latest echocardiography (P<0.001). Conclusion Minimally TVP with leaflets augmentation is effective in treating severe isolated TR after primary cardiac surgery. It can significantly increase success rate of tricuspid valvuloplasty and decrease the surgical trauma.