这项工作得到了瑞士心血管基金会的赠款 (N° 32119) 的支持。

该议定书遵循了人类研究伦理学委员会的机构准则。
1. 患者选择 (表 1)
<ol><li>确定有必要隔离主动脉瓣置换的患者14。</li>
	<li>在这些患者中选择一个没有主要的胸畸形 (Kypho 脊柱侧凸) 的亚组, 以前的放疗史或右半胸腔手术, 需要紧急手术, 并手术治疗活动性心内膜炎。</li>
	<li>进行胸部计算机断层扫描 (CT) 检查, 以排除患者的升主动脉动脉瘤≥4.5 厘米。</li>
	<li>根据胸部 CT (图 1和2和表 1) 提供的测量结果作出最终决定。选择在第二或第三肋间空间, 根据更接近的距离主动脉插管点和主动脉环。</li>
</ol>2. 手术准备
<ol><li>按照以前描述的14, 为成人心脏手术患者的机构指南和建议准备手术病人。</li>
	<li>把外部除颤器垫放在背部和左胸前方前的悬垂。</li>
</ol>3. 手术
<ol><li>通过右前小切口进入心脏<ol>
<li>切割皮肤横向超过8厘米与18刀片刀在选择肋间空间, 开始1厘米右侧的胸骨边缘。</li>
		<li>用烙切开胸和肋间肌肉的表面层。为避免右肺损伤, 先用 Metzenbaum 剪刀进入右胸膜。然后用烙扩大肋间肌的开口。</li>
		<li>保留右内胸椎椎弓根通过释放它的筋膜和软组织周围使用 Metzenbaum 剪刀。</li>
		<li>将软组织牵引器插入右胸膜, 并将其固定在伤口上。注意不要伤害右内胸蒂。</li>
		<li>将最小的接入牵引器放在软组织牵引器上, 轻轻地慢慢地打开。</li>
		<li>用 Carpentier 钳抓住 cranially 上覆的脂肪, 用烙切开。注意不要伤害右膈神经。</li>
		<li>打开右心房的心包与烙和地方 2/0 polyglactin 留缝线两侧的开放, 以传播心包。</li>
		<li>继续打开心包 cranially 在上升主动脉和 caudally 在右心房。放置 2/0 polyglactin 留缝线两侧的开口, 传播心包。</li>
		<li>检查远端心包反射线上方的上升主动脉和主动脉根部的基础, 准备放置的主动脉插管钱包字符串。</li>
		<li>验证右上肺静脉的解剖位置, 以放置左心室通气孔。</li>
		<li>为了暴露出上升主动脉的远端, 用阿利斯钳上的花生纱布轻轻推下上升的主动脉。</li>
		<li>将第一个钱包字符串放置在远端心包反射线下方的主动脉插管上, 使用4/0 聚丙烯缝合。完成主动脉插管的准备, 通过添加第二个钱包字符串围绕第一个使用4/0 聚丙烯缝合。</li>
		<li>给300国际单位肝素/千克 (浓度 5000 U/毫升) 通过 IV 线。</li>
	</ol></li>
	<li>将病人连接到体外循环<ol>
<li>首先穿刺右股静脉, 并将导丝通过针进入静脉。用11刃刀扩大皮肤开口。扩大穿刺部位的连续扩张器, 并介绍经皮股骨静脉套管在导丝下经食管超声心动图控制 (图表 3)。</li>
		<li>用阿利斯钳上的花生纱布轻轻推下提升主动脉, 在钱包的中间刺入上升的主动脉。Cannulate 在导丝上的主动脉。</li>
		<li>启动心肺旁路, 使病人降温至30摄氏度 (图 4)。为改善静脉回流, 让 perfusionnist 应用辅助负压-50 mmHG。</li>
		<li>轻轻推上上腔静脉向左侧, 并放置一个钱包字符串在右上肺静脉与4/0 聚丙烯单丝缝合。插入左心室通气通过钱包字符串卸载左心。</li>
	</ol></li>
	<li>准备阀门的切除和更换<ol>
<li>使用具有可伸缩刚性轴的挠性夹具, 在主动脉套管下方交叉夹住升主动脉。</li>
		<li>执行倒置 L aortotomy 平行和在水平的中管交界, 延伸到非冠状动脉佛氏窦。用阿利斯钳收回 aortotomy 的下脊。</li>
		<li>在主动脉返流的情况下, 将顺晶体停搏液直接送到冠状动脉内。</li>
		<li>将 aortotomy 通过非冠状动脉窦延伸至1厘米以上的主动脉环。检查左、右冠状动脉的提亚。</li>
		<li>将5/0 聚丙烯缝合在 aortotomy 的下脊上, 并将其表面固定在右心室的前部, 以改善主动脉瓣的暴露。</li>
		<li>在 aortotomy 的上脊上再放置5/0 聚丙烯缝合线, 并将其表面固定在心包上, 以改善主动脉瓣的暴露。</li>
		<li>抓取右, 非冠状动脉, 左冠状动脉尖带内钳和使用内剪。通过 aortotomy 检查二尖瓣。</li>
		<li>使用商用阀门 sizers 确定要插入的阀门的标签尺寸。选择一个舒适通过主动脉室连接的粒。</li>
		<li>将第一个编织聚酯2/0 与 pledget U 缝合在合生面之间的左和右冠状动脉窦, 使用一个内针持有人。通过从心室的缝合, 使 pledget 在心室一侧。</li>
		<li>继续放置编织聚酯2/0 与 pledget U 缝线顺时针, 以完成右冠状动脉窦。</li>
		<li>将顺时针编织聚酯2/0 与 pledget U 缝合在非冠状动脉窦。</li>
		<li>通过放置逆时针编织聚酯2/0 与 pledget U 缝合在左冠状动脉窦, 开始在合生面之间的右, 左冠状动脉鼻窦, 完成环缝缝合。</li>
		<li>使用莱德针固定器将编织聚酯2/0 缝线传递到阀门假肢的缝纫环上。</li>
		<li>滑下阀门假肢, 卸下阀座。系上缝合线, 检查它们与主动脉环的间隙。验证左、右冠状动脉的提亚是通畅的。</li>
		<li>用 Metzenbaum 剪刀剪下绑缝线。去除 aortotomy 上脊的5/0 外露缝线。</li>
		<li>关闭 aortotomy 由两个5/0 聚丙烯运行半缝合。将第一个放在非冠状动脉窦 aortotomy 的最低点, 并系上它。然后来到倒 aortotomy 的角度。把缝合的末端放在轻微的张力下。</li>
		<li>继续关闭的 aortotomy 由第二5/0 聚丙烯运行半缝合从左端开始, 并朝右侧, 以满足第一个半缝合的结束。把两头绑在一起, 切掉它们。</li>
		<li>在松开主动脉前, 将心室起搏导线放在右心室。</li>
		<li>让工作台倾斜在向健位置。将泵流量减少到50% 的全流量。在左心室通气口的温柔吸入下, 慢慢移除主动脉交叉钳14。</li>
		<li>恢复全流程的心肺旁路。检查 aortotomy 闭合的止血情况。取出左心室通气孔并系上它的钱包绳。检查止血。</li>
		<li>复温病人到37摄氏度。将病人与心肺旁路分离。当达到稳定的血压时, 在1:1 的比例 (3 毫克/千克对应于300的肝素)14中, 用精蛋白注入 IV 中和肝素。</li>
		<li>准备通过捆绑第一个钱包字符串来去除主动脉插管。让助手轻轻地移除主动脉插管, 并完成捆绑的钱包字符串。</li>
		<li>双安全的主动脉插管部位与一个数字八4/0 聚丙烯缝合。割断缝合线</li>
		<li>取出股静脉插管, 用人工压迫止血20分钟。</li>
		<li>放置一个心包和一个右胸导管。调整心包与三松散捆绑编织 2/0 polyglactin 缝合。</li>
		<li>用两条编织 0 polyglactin 缝线调整肋骨。以标准的方式关闭伤口。</li>
	</ol></li>
</ol>4. 术后病人护理
<ol><li>在转移到重症监护病房后, 为患者提供心脏外科手术的标准术后护理14。</li>
</ol>

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A., Tch&#233;tch&#233;, D., Forrest, J., Hellig, F., Lansky, A., Moat, N. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+SURTAVI+study:+TAVI+for+patients+with+intermediate+risk.">The SURTAVI study: TAVI for patients with intermediate risk.</a> EuroIntervention. 13 (5), 617-620 (2017).</li></ol>

作者没有什么可透露的。

在本协议中, 我们详细描述了右前小切口在孤立主动脉瓣置换术中的技术, 并着重介绍了该手术患者的选择标准。至于其他治疗干预, 正确的病人选择是成功完成手术的关键。本协议对患者的最佳 CT 测量方法进行了准确的描述, 并根据经验, 考虑了硝博士和同事在该领域的广泛工作10。这些最佳的 CT 测量增加了一些有价值的标准,即, 从主动脉环中的冠状动脉开口的距离, 到硝的建议, 只有当: (1) 升主动脉是向右 (超过一半位于右侧的右胸骨边界) 在主肺动脉水平, (2) 上升主动脉和胸骨之间的距离不超过10厘米, (3) 之间的角度中线和升主动脉 (α角) 的倾角大于 45°10。这些 CT 选择标准与 "硝" et推荐的不同。10. 首先, 在本议定书中, 从第二和第三肋间间隙到右无名动脉的起源的3维 CT 重建是至关重要的。距离越短, 中央动脉插管就越安全。第二, 在胸部3维 CT 测量的旁边, 从第二和第三肋间间隙到主动脉瓣环的距离, 对瓣膜程序本身的简易性估计是强制性的。因此, 该协议的病人选择是基于两个关键距离,即工作距离主动脉瓣和中央动脉插管地点。因此, 从肋间空间到主动脉环和主动脉插管的距离标准提供了更准确的信息, 对患者的选择和术前规划比距离的制定更有帮助。上升主动脉到胸骨和同事使用的胸部10。其他组不例行使用 CT 测量为右前小切口的病人选择16,17,18。然而, 为了补偿跳过这一步, 这些作者管理在进入胸腔空间的肋骨脱位, 然后在操作结束时 refixation 的脱臼肋骨 (s) 与一个盘子在行动的结尾16,17,18. 然而, 这一策略可能会降低病人的舒适度, 并可能导致更多的出血从骨折的骨骼表面。
本议定书的一个重要方面是通过中央主动脉插管进行动脉灌注。在最小通路心脏瓣膜手术中动脉灌注的部位, 特别是在右前小切口中, 仍然有争议。虽然一些中心和外科医生报告说, 随着外周股动脉插管的发生, 中风的风险增加, 与中央主动脉插管19,20相比, 其他作者报告说, 增加的风险中心主动脉插管21后的描边, 或者两个策略22之间未报告任何差异。这种差异可能不仅是由于中风的不同定义, 而且还有相关的并发症, 如老年和周围动脉血管疾病20,23。其他与股骨动脉灌注相关的潜在并发症有感染、淋巴瘘、动脉壁夹层和远端肢体缺血24。与套管和同事们相比, 他们使用短的主动脉为中心主动脉插管 25, 我们使用商业上可用的动脉套管足够长的时间, 使套管尖端可以放置在下降的起源大动脉.这一策略的基本原理是避免将动脉灌注入主动脉弓, 并有潜在的脱位和栓塞的弓血管。
在本协议中, 我们获得的胸膜空间和心脏没有故意骨折或脱位的肋骨, 与其他协议16,17,18。根据丰富的经验, 一个温和和逐步开放的摊铺避免无意骨折肋骨。在相同的组织保存线, 我们没有系统地结扎右内胸血管, 并保留结扎的解剖变化, 这些血管, 他们是横向超过1厘米左右的胸骨边缘。肋骨的系统性骨折可能会增加骨折骨表面的出血量, 并导致病人的不适, 尽管手术结束后的25。
根据现有的右前方小切口手术 (1.5%) 的早期死亡率与接受全胸骨的患者相比 (1.8%)(表 4), 并报告了 STS 数据库 (2.4%)26中独立的主动脉瓣置换的结果。与全胸骨相比, 右小切口没有增加术后早期并发症, 包括再次手术治疗出血和中风。两组患者的再手术率 (RAMT 2%、fs 2.3%) 略小于 STS 数据库 (3.9%) 中报告的比例, 而中风的发病率略高 (RAMT 2.6%、FS 3.5%、STS 1.1%)26。这种差异的原因可能在于这些患者和 STS 数据库中使用的中风的定义。在本议定书中, 所有临床诊断的围手术期脑血管事件, 包括可逆性瞬变缺陷被计算为中风, 而 STS 数据库报告的永久性中风26。此外, 在研究的病人中, 新发心房颤动的发病率减少了 RAMT 方法 (18%) 相比, FS 组 (30%, p= 0.02) 和 STS 数据库 (31%)26。这一发现是根据对 RAMT 的研究, 报告18.1% 和27.9% 的新发心房颤动患者 ( p = 0.03)27。这种差异可能是由于在 RAMT 与 FS 方法相比, 消除了右心房的直接插管。事实上, 右心房插管部位的疤痕可能是心房心律失常的局部来源。这一假说值得进一步调查。RAMT (0%) 与 FS 方法 (1.2%、 p= 0.02) 相比, 早期患者预后的另一个改善是深部伤口感染的消失。与 FS 相比, RAMT 的访问大大降低了本议定书对疼痛药物和输血需求的需求。由于减少了术后新发心房颤动、输血需求和深部伤口感染的发生率, 以及通过减少止痛药提高患者的舒适度, RAMT 方法大大缩短了与 FS 方法相比, 医院住院的情况。这项观察是根据其他研究报告类似的减少住院时间, 这可能有助于节省成本16,27。
在本议定书中, 与完全胸骨相比, 主动脉瓣切除和新瓣膜假体的植入保持不变。这可能解释通过完全胸骨的常规 AVR 的同样好结果的成就, 并使这一方法是一个有吸引力的替代 TAVI 的中间风险亚群的患者28。
该协议中 RAMT 和 FS 群之间的比较的局限性是由于这些数据的回溯性。虽然由 Euroscore15反映的两个组的风险配置文件在这些组之间是可比较的, 但其他不受控制的参数可能影响了报告的比较。本协议中报告的技术的局限性由最佳的 CT 测量和表 1中报告的其他标准表示。在这些患者中, 主动脉瓣置换应通过常规的完全或部分胸骨的途径进行。
总之, 本协议所描述的右前微型开胸术可以根据所描述的标准在选定的患者中进行, 并与完整的胸骨方法取得较好的效果。额外的手术时间不利于患者, 并得到改善患者舒适性和加速早期康复的奖励。这种微创方法可以是一个可行的替代 TAVI 在中间风险患者的人群需要主动脉瓣置换。

在心脏瓣膜病变诊断为血流动力学相关和临床上特别注意, 主动脉瓣狭窄是最常见的瓣膜病理学在美国和发达国家1, 2.在心血管健康研究中, 2% 的患者有坦率的主动脉狭窄, 随着年龄的增长明显增加: 1.3% 岁65-75 岁的患者, 2.4% 岁以上75-85 岁的患者, 4% 岁以上的病人中, 只有85年以上1。对于出现严重主动脉瓣狭窄的症状患者, 主动脉瓣置换术是美国心脏瓣膜病患者管理协会指导方针中的一项建议3。
常规手术主动脉瓣置换通过中位全胸骨 (FS) 已确立为治疗主动脉瓣狭窄的金标准, 并在发病率和死亡率方面取得了优异的结果4。这些结果鼓励将治疗适应症扩大到老年患者和高危患者。在这些患者亚群中已经实施了许多治疗策略, 以维持常规外科主动脉瓣膜置换术在普通人群中取得的良好效果。在这些替代治疗方式中, 经导管主动脉瓣植入 (TAVI) 于2002年由 Cribier 和同事5介绍。最初在垂死的病人, TAVI 迅速出现作为治疗的选择严重的主动脉狭窄谁不适合常规手术主动脉瓣替换6,7, 或作为一个较小的侵入性高危患者手术方法89。
尽管在选定的患者亚群中 TAVI 的结果有所改善, 许多症状性主动脉瓣狭窄患者仍然是手术主动脉瓣置换的候选者。在这些患者中, FS 主动脉瓣置换术是心脏外科医生最常用的方法。然而, 已开发出各种 "微创" 技术, 其基本原理是减少手术创伤10。所有这些最低限度的接入技术都旨在通过缩短住院率和潜在的节省全球成本来改善患者的舒适度, 减少手术后的疼痛, 加速患者的康复.10。在微创切口方法中, 上半胸骨 (UHS) 和右前小切口 (RAMT) 已成为文献11中报道的主要技术。右前小切口主动脉瓣置换术最初报告贝奈特家庭式et 等。12和上部半胸骨首先由几个作者11描述。除切口选择外, 目前采用两种动脉灌注策略: i) 外周股动脉插管, 比 ii.) 中央主动脉插管更为频繁。
尽管有报告说, 在微创主动脉瓣置换术后患者结局有了改善, 但对限制性手术和外周动脉灌注策略的缺点的担忧13导致许多心脏外科医生不让他们的病人受益于潜在的优势, 最小的访问方法的主动脉瓣置换。本协议的目的是详细描述这一技术的微创主动脉瓣置换通过右前小切口无肋骨切除/骨折, 并与中央主动脉插管动脉灌注。通过这项协议, 更多的心脏外科医生可以执行右前小切口主动脉瓣置换在某些病人组。讨论了患者的选择和技术的局限性。早期的结果与一组接受独立的主动脉瓣置换的患者进行比较, 完全胸骨。

<table border="0" cellpadding="0" cellspacing="0" style="width:761px;" width="761">
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		<col />
		<col />
		<col />
		<col />
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	<tbody>
		<tr height="20">
			<td height="20" style="height:20px;width:368px;">Heart surgery infrastructure:</td>
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			<td style="width:151px;"></td>
			<td style="width:80px;"></td>
		</tr>
		<tr height="20">
			<td height="20" style="height:20px;">Heart Lung Machine</td>
			<td>Stockert</td>
			<td>SIII</td>
			<td></td>
		</tr>
		<tr height="20">
			<td height="20" style="height:20px;">EOPA 24Fr. arterial cannula</td>
			<td>Medtronic</td>
			<td>77624</td>
			<td></td>
		</tr>
		<tr height="20">
			<td height="20" style="height:20px;">FemFlex arterial cannula</td>
			<td>Edwards</td>
			<td>FEMII20A</td>
			<td></td>
		</tr>
		<tr height="20">
			<td height="20" style="height:20px;">Quickdraw 25Fr. femoral venous cannula</td>
			<td>Edwards</td>
			<td>QD25</td>
			<td></td>
		</tr>
		<tr height="20">
			<td height="20" style="height:20px;">Biomedicus 25Fr. Nextgen venous cannula</td>
			<td>Medtronic</td>
			<td>96670-125</td>
			<td></td>
		</tr>
		<tr height="20">
			<td height="20" style="height:20px;">LV vent catheter 17Fr.</td>
			<td>Edwards</td>
			<td>E061</td>
			<td></td>
		</tr>
		<tr height="20">
			<td height="20" style="height:20px;">Antegrade 9Fr. cardioplegia cannula</td>
			<td>Edwards</td>
			<td>AR012V</td>
			<td></td>
		</tr>
		<tr height="20">
			<td height="20" style="height:20px;">Coronary artery ostial cannula 90&#176;</td>
			<td>Medtronic</td>
			<td>30155</td>
			<td></td>
		</tr>
		<tr height="20">
			<td height="20" style="height:20px;">Coronary artery ostial cannula 45&#176;</td>
			<td>Medtronic</td>
			<td>30255</td>
			<td></td>
		</tr>
		<tr height="20">
			<td height="20" style="height:20px;">Soft tissue retractor</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;">STAR soft tissue atraumatic retractor</td>
			<td>Estech</td>
			<td>EC400220</td>
			<td></td>
		</tr>
		<tr height="20">
			<td height="20" style="height:20px;">Soft tissue retractor</td>
			<td>Edwards</td>
			<td>TRM</td>
			<td></td>
		</tr>
		<tr height="23">
			<td height="23" style="height:23px;">Electrocautery</td>
			<td>Covidien</td>
			<td>Force FXTM</td>
			<td></td>
		</tr>
		<tr height="20">
			<td height="20" style="height:20px;">Sutures:</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr height="20">
			<td height="20" style="height:20px;">Polypropylene 4/0</td>
			<td>Ethicon</td>
			<td>8871H</td>
			<td></td>
		</tr>
		<tr height="20">
			<td height="20" style="height:20px;">Polypropylene 5/0</td>
			<td>Ethicon</td>
			<td>8870H</td>
			<td></td>
		</tr>
		<tr height="20">
			<td height="20" style="height:20px;">Braided polyesther 2/0 ligature with polybutylate coating&#160;</td>
			<td>Ethicon</td>
			<td>X305H</td>
			<td></td>
		</tr>
		<tr height="20">
			<td height="20" style="height:20px;">Braided polyesther2/0 with pledgets V5</td>
			<td>Ethicon</td>
			<td>MEH7715N</td>
			<td></td>
		</tr>
		<tr height="20">
			<td height="20" style="height:20px;">Braided polyglactin 2/0 suture</td>
			<td>Ethicon</td>
			<td>V114H</td>
			<td></td>
		</tr>
		<tr height="20">
			<td height="20" style="height:20px;">Braided polyglactin 0 suture</td>
			<td>Ethicon</td>
			<td>W9996</td>
			<td></td>
		</tr>
		<tr height="20">
			<td height="20" style="height:20px;">Drugs:</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr height="20">
			<td height="20" style="height:20px;">Midazolam</td>
			<td>Roche Pharma</td>
			<td>N05CD08</td>
			<td></td>
		</tr>
		<tr height="20">
			<td height="20" style="height:20px;">Rocuronium</td>
			<td>MSD Merck Sharp &#38; Dohme&#160;</td>
			<td>M03AC09</td>
			<td></td>
		</tr>
		<tr height="20">
			<td height="20" style="height:20px;">Propofol</td>
			<td>Fresenius Kabi</td>
			<td>N01AX10</td>
			<td></td>
		</tr>
		<tr height="20">
			<td height="20" style="height:20px;">Fentanil</td>
			<td>Actavis</td>
			<td>N01AH01</td>
			<td></td>
		</tr>
		<tr height="20">
			<td height="20" style="height:20px;">Heparin</td>
			<td>Braun</td>
			<td>B01AB01</td>
			<td></td>
		</tr>
		<tr height="20">
			<td height="20" style="height:20px;">Protamin</td>
			<td>MEDA Pharmaceutical</td>
			<td>V03AB14</td>
			<td></td>
		</tr>
		<tr height="20">
			<td height="20" style="height:20px;">Custodiol cardioplegia solution</td>
			<td>Dr. F. K&#246;hler Chemie GmbH</td>
			<td>B05CX10</td>
			<td></td>
		</tr>
		<tr height="20">
			<td height="20" style="height:20px;">Instruments:</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr height="20">
			<td height="20" style="height:20px;">Window access retractor SI</td>
			<td>Estech</td>
			<td>400-400</td>
			<td></td>
		</tr>
		<tr height="20">
			<td height="20" style="height:20px;">SI retractor blade 40W50L</td>
			<td>Estech</td>
			<td>400-172</td>
			<td></td>
		</tr>
		<tr height="20">
			<td height="20" style="height:20px;">Ceramo atraumatic forceps 2.8x15/350</td>
			<td>Fehling</td>
			<td>FE-MRA-3</td>
			<td></td>
		</tr>
		<tr height="20">
			<td height="20" style="height:20px;">Ceramo HCR valve forceps 3.0x15/350</td>
			<td>Fehling</td>
			<td>FE-MRA-0</td>
			<td></td>
		</tr>
		<tr height="20">
			<td height="20" style="height:20px;">Ceramo HCR needle holder 2x10/340</td>
			<td>Fehling</td>
			<td>FE-MRB-2</td>
			<td></td>
		</tr>
		<tr height="20">
			<td height="20" style="height:20px;">Ceramo TC HCR needle holder curved 3x10/340</td>
			<td>Fehling</td>
			<td>FE-MRG-9</td>
			<td></td>
		</tr>
		<tr height="20">
			<td height="20" style="height:20px;">Ceramo HCR valve scissors 350</td>
			<td>Fehling</td>
			<td>FE-MRA-7</td>
			<td></td>
		</tr>
		<tr height="20">
			<td height="20" style="height:20px;">Ceramo HCR curved scissors 350</td>
			<td>Fehling</td>
			<td>FE-MRA-6</td>
			<td></td>
		</tr>
		<tr height="20">
			<td height="20" style="height:20px;">Cygnet flexible arched aortic clamp</td>
			<td>Vitalitec</td>
			<td>V10143</td>
			<td></td>
		</tr>
		<tr height="20">
			<td height="20" style="height:20px;">Intrack insert set double traction</td>
			<td>Vitalitec</td>
			<td>N10122</td>
			<td></td>
		</tr>
		<tr height="20">
			<td height="20" style="height:20px;">Dissection forceps Carpentier</td>
			<td>Delacroix-Chevalier</td>
			<td>DC13110-28&#160;</td>
			<td></td>
		</tr>
		<tr height="20">
			<td height="20" style="height:20px;">Scissors Metzenbaum</td>
			<td>Delacroix-Chevalier</td>
			<td>B351751</td>
			<td></td>
		</tr>
		<tr height="20">
			<td height="20" style="height:20px;">Needle holder Ryder</td>
			<td>Delacroix-Chevalier</td>
			<td>DC51130-20&#160;</td>
			<td></td>
		</tr>
		<tr height="20">
			<td height="20" style="height:20px;">Dissection forceps DeBakey</td>
			<td>Delacroix-Chevalier</td>
			<td>DC12000-21&#160;</td>
			<td></td>
		</tr>
		<tr height="20">
			<td height="20" style="height:20px;">Lung retractor</td>
			<td>Delacroix-Chevalier</td>
			<td>B803990</td>
			<td></td>
		</tr>
		<tr height="20">
			<td height="20" style="height:20px;">Allis clamp</td>
			<td>Delacroix-Chevalier</td>
			<td>DC45907-25&#160;</td>
			<td></td>
		</tr>
		<tr height="20">
			<td height="20" style="height:20px;">O&#8217;Shaugnessy Dissector</td>
			<td>Delacroix-Chevalier</td>
			<td>B60650</td>
			<td></td>
		</tr>
		<tr height="20">
			<td height="20" style="height:20px;">18 blade knife</td>
			<td>Delacroix-Chevalier</td>
			<td>B130180</td>
			<td></td>
		</tr>
		<tr height="20">
			<td height="20" style="height:20px;">11 blade knife</td>
			<td>Premiere</td>
			<td>9311-2PK</td>
			<td></td>
		</tr>
		<tr height="20">
			<td height="20" style="height:20px;">Leriche haemostatic clamp</td>
			<td>Delacroix-Chevalier</td>
			<td>B86555</td>
			<td></td>
		</tr>
		<tr height="20">
			<td height="20" style="height:20px;">Data analysis</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr height="20">
			<td height="20" style="height:20px;">Mann-Whitney and Chi-square tests</td>
			<td>GraphPad</td>
			<td>Prism 7</td>
			<td></td>
		</tr>
	</tbody>
</table>

technique and patient selection criteria of right anterior mini-thoracotomy for minimal access aortic valve replacement

主动脉瓣狭窄已成为发达国家最普遍的心脏瓣膜病, 是由于这些人群的衰老引起的。病理发生率随着年龄的增长而增加65年。常规手术主动脉瓣置换通过中位胸骨已成为患者护理的黄金标准症状性主动脉瓣狭窄。然而, 随着患者风险状况的恶化, 采取了其他的治疗策略, 试图维持已建立的外科治疗取得的优良效果。其中一种方法是由经导管主动脉瓣植入术表示。尽管经导管主动脉瓣置换术治疗症状性主动脉瓣狭窄的高危患者的预后有所改善, 但许多患者仍保留手术主动脉瓣置换术的候选条件。为减少外科手术后主动脉瓣瓣膜置换患者的手术创伤, 在过去的十年中, 微创治疗方法引起了人们的兴趣。自1993年引入右前方开胸术进行主动脉瓣置换手术以来, 右前小切口和上半胸骨已成为心脏外科医生执行最小进入主动脉的主要切口方法。阀门更换。在切口位置旁边, 动脉插管部位代表主动脉瓣膜置换术中的第二个主要标志。两个最常用的动脉插管部位包括中央主动脉和股骨周围的方法。为了减少这些病人的手术创伤, 我们选择了一个右前方小切口的中心主动脉插管的方法。本协议详细描述了一种微创主动脉瓣置换技术, 并为患者选择标准提供建议, 包括心脏计算机层析成像测量。讨论了这种技术的适应症和局限性, 以及它的替代方案。

在表 2、表3、和表 4中使用非参数的曼恩惠特尼测试, 对连续变量 (显示为方法) 进行统计分析。分类变量以百分比形式显示在表 2、表3、和表 4中, 并通过卡方测试进行比较。统计分析是使用商用软件进行的, 其统计意义阈值设置在p< 0.05 中。
表 2描述了患者的特征。在196例符合选择标准的患者中, 根据所描述的右前小切口方案进行主动脉瓣置换 (表 1)。同期171例经全胸骨的主动脉瓣膜置换患者的患者特点相似。这种方法的采用取决于病人的选择, 以及根据 CT 测量的选择标准, 包括技术可行性 (表 1)。
操作内数据显示在表 3中。在手术前的 CT 检查基础上, 通过第三肋间间隙在80% 和20% 的患者中, 获得胸腔和心脏的通路。在一例患者中, 在心肺旁路术后, 增加了腹部周长和体积损失。由于怀疑腹部问题, 进行了剖腹手术, 并修复了经皮空心一侧髂静脉的医源性撕裂。为了缩短心脏和全球手术时间, 切口由横向胸骨延长, 并以标准方式进行主动脉瓣置换术。病人手术后表现良好。该病人的数据包括在右小切口组。正如预期的, 与完整的胸骨方法相比, 右前小切口需要显著延长缺血性, 心肺和手术时间。生物与机械瓣膜替代物的比例在各组间没有差异。
表 4演示了早期手术后的结果。尽管手术时间较长, 但除了周围插管并发症外, 右前小切口没有增加主要的心血管和脑血管事件的发生率与全胸骨切口相比。接受右前小切口的患者倾向于较早拔, 在重症监护病房停留较短时间, 而非全胸骨手术, 尽管差异没有统计学意义。然而, 与完全胸骨相比, 右前小切口明显减少了对疼痛药物和输血需求的需要, 新发心房颤动和深部伤口感染的发病率以及全球长度住院。此外, 患者报告的美容效果非常满意 (图 5)。
<img alt="Figure 1" class="xfigimg" src="/files/ftp_upload/57323/57323fig1.jpg"> 图 1:3 维胸部 CT 重建术前规划.从中锁骨线到主动脉插管部位 (右无名动脉的起源) 和第二和第三肋间空间 (ICS) 的主动脉瓣的测量报告在这个图像 (1 毫米的比例 = 2.9 毫米)。在这种情况下, 第二个 ic 是选择的切口方式的微型开胸术, 而与主动脉瓣膜的距离, 到插管地点的路程比第三个 ics 短。<a href="//cloudflare-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/57323/57323fig1large.jpg" target="_blank">请单击此处查看此图的较大版本.</a>
<img alt="Figure 2" class="xfigimg" src="/files/ftp_upload/57323/57323fig2.jpg"> 图 2: 与在同一病人的手术前规划的 CT 测量图 1。(A) 环形调整大小。最大和最短的主动脉环都大于20毫米 criterium 为选择的病人在表1。(B) 从左冠状动脉口到主动脉环的距离。此距离大于12毫米 criterium, 用于选择表1中给出的病人。(C) 从右冠状动脉口到主动脉环的距离。这个距离大于12毫米 criterium 为选择在表 1 (1 毫米在刻度 = 2.9 毫米) 给出的患者。该病人的 ct 测量符合 ct 标准, 为右前小切口胸部进入第二个 ic 的病人选择。RV = 右心室, LA = 左心房, 道 = 降主动脉, LMCA = 左主冠状动脉, LV = 左心室, RCA = 右冠状动脉, Ao = 升主动脉。<a href="//cloudflare-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/57323/57323fig2large.jpg" target="_blank">请单击此处查看此图的较大版本.</a>
<img alt="Figure 3" class="xfigimg" src="/files/ftp_upload/57323/57323fig3.jpg"> 图 3: 经食管超声心动图进行双房查看.静脉套管插入经皮通过右股静脉, 并通过下腔静脉 (静脉) 的起源的上腔静脉 (SVC) (1 毫米的规模 = 2.9 毫米)。LA = 左心房, RA = 右心房。<a href="//cloudflare-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/57323/57323fig3large.jpg" target="_blank">请单击此处查看此图的较大版本.</a>
<img alt="Figure 4" class="xfigimg" src="/files/ftp_upload/57323/57323fig4.jpg"> 图 4: 心肺设置的全局视图.病人的头在照片的左边。<a href="//cloudflare-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/57323/57323fig4large.jpg" target="_blank">请单击此处查看此图的较大版本.</a>
<img alt="Figure 5" class="xfigimg" src="/files/ftp_upload/57323/57323fig5.jpg"> 图 5: 伤口整形.一周后通过右前小切口主动脉瓣置换术, 伤口的一般外观令人满意。<a href="//cloudflare-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/57323/57323fig5large.jpg" target="_blank">请单击此处查看此图的较大版本.</a>
<table fo:keep-together.within-page="1"><tbody>
<tr>
<td colspan="2">缺席:</td>
		</tr>
<tr>
<td>胸部畸形</td>
			<td></td>
		</tr>
<tr>
<td>前右半胸部手术或放疗</td>
			<td></td>
		</tr>
<tr>
<td>升主动脉动脉瘤</td>
			<td></td>
		</tr>
<tr>
<td>紧急行动</td>
			<td></td>
		</tr>
<tr>
<td>活动性心内膜炎</td>
			<td></td>
		</tr>
<tr>
<td></td>
			<td></td>
		</tr>
<tr>
<td colspan="2">胸部 CT 的最佳测量方法</td>
		</tr>
<tr>
<td>肋间空间至主动脉瓣</td>
			<td>< 120 mm</td>
		</tr>
<tr>
<td>肋间空间到主动脉插管地点 *</td>
			<td>< 120 mm</td>
		</tr>
<tr>
<td>主动脉瓣环形直径</td>
			<td>> 20 mm</td>
		</tr>
<tr>
<td>右冠状动脉口主动脉瓣环</td>
			<td>> 12 mm</td>
		</tr>
<tr>
<td>左冠状动脉口到主动脉瓣环</td>
			<td>> 12 mm</td>
		</tr>
<tr>
<td></td>
			<td></td>
		</tr>
<tr>
<td colspan="2">* 右无名动脉的起源</td>
		</tr>
</tbody></table>表 1: 用于独立主动脉瓣膜置换术的右前小切口选择标准.在排除了主要的胸部畸形患者, 前右半胸部照射或手术和上升的主动脉瘤, 胸部 CT 提供的最佳测量, 允许选择的病人的程序和选择肋间空间用于切口。
<table fo:keep-together.within-page="1"><tbody>
<tr>
<td></td>
			<td>右前小切口</td>
			<td>全胸骨</td>
			<td>p 值</td>
		</tr>
<tr>
<td>n</td>
			<td>196</td>
			<td>171</td>
			<td></td>
		</tr>
<tr>
<td></td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
<tr>
<td>年龄、年份</td>
			<td>70±10</td>
			<td>68±13</td>
			<td>0.26</td>
		</tr>
<tr>
<td>LVEF < 0.35 (%)</td>
			<td>2 (1)</td>
			<td>4 (2.3)</td>
			<td>0。2</td>
		</tr>
<tr>
<td>红细胞%</td>
			<td>38.9±2</td>
			<td>37.2±1。6</td>
			<td>0.09</td>
		</tr>
<tr>
<td>本机瓣膜病</td>
			<td></td>
			<td></td>
			<td>0.16</td>
		</tr>
<tr>
<td>作为</td>
			<td>155</td>
			<td>135</td>
			<td></td>
		</tr>
<tr>
<td>ai</td>
			<td>34</td>
			<td>27</td>
			<td></td>
		</tr>
<tr>
<td>AS + AI</td>
			<td>7</td>
			<td>9</td>
			<td></td>
		</tr>
<tr>
<td>COPD (%)</td>
			<td>13 (6.6)</td>
			<td>14 (8.2)</td>
			<td>0。8</td>
		</tr>
<tr>
<td>CVD (%)</td>
			<td>17 (8.7)</td>
			<td>16 (9.4)</td>
			<td>0。9</td>
		</tr>
<tr>
<td>PVD (%)</td>
			<td>10 (5.1)</td>
			<td>11 (6.4)</td>
			<td>0.14</td>
		</tr>
<tr>
<td>糖尿病 (%)</td>
			<td>29 (14.8)</td>
			<td>18 (10.5)</td>
			<td>0.42</td>
		</tr>
<tr>
<td>动脉性高血压 (%)</td>
			<td>91 (46)</td>
			<td>105 (61)</td>
			<td>0.27</td>
		</tr>
<tr>
<td>CHF (%)</td>
			<td>3 (1.5)</td>
			<td>8 (4.7)</td>
			<td>0.26</td>
		</tr>
<tr>
<td>Euroscore *</td>
			<td>3.8±2。0</td>
			<td>2.6±2。4</td>
			<td>0。7</td>
		</tr>
<tr>
<td></td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
<tr>
<td></td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
<tr>
<td colspan="4">LVEF: 左心室射血分数</td>
		</tr>
<tr>
<td colspan="4">AS: 主动脉狭窄</td>
		</tr>
<tr>
<td colspan="4">AI: 主动脉功能不全</td>
		</tr>
<tr>
<td colspan="4">COPD: 慢性阻塞性肺疾病</td>
		</tr>
<tr>
<td colspan="4">CVD: 脑血管病</td>
		</tr>
<tr>
<td colspan="4">外周血管疾病</td>
		</tr>
<tr>
<td colspan="4">CHF: 充血性心力衰竭</td>
		</tr>
<tr>
<td></td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
<tr>
<td colspan="4">* 参考15</td>
		</tr>
</tbody></table>表 2: 病人的特点.右前小型开胸手术患者的手术前情况与完全胸骨的手术病人比较。
<table fo:keep-together.within-page="1"><tbody>
<tr>
<td></td>
			<td>右前小切口</td>
			<td>全胸骨</td>
			<td>p 值</td>
		</tr>
<tr>
<td>n</td>
			<td>196</td>
			<td>171</td>
			<td></td>
		</tr>
<tr>
<td></td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
<tr>
<td>手术时间 (分钟)</td>
			<td>274±60</td>
			<td>209±48</td>
			<td>0.0001</td>
		</tr>
<tr>
<td>体外循环时间 (分钟)</td>
			<td>157±36</td>
			<td>110±27</td>
			<td>0.0001</td>
		</tr>
<tr>
<td>交叉钳位时间 (分钟)</td>
			<td>108±23</td>
			<td>62±15</td>
			<td>0.0001</td>
		</tr>
<tr>
<td>生物阀 (%)</td>
			<td>161 (82)</td>
			<td>121 (71)</td>
			<td>0.09</td>
		</tr>
<tr>
<td></td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
<tr>
<td colspan="4">体外循环: 心肺旁路</td>
		</tr>
</tbody></table>表 3: 操作内数据.右前小切口两个胸骨的手术时间和瓣膜替代物的类型, 完全的方法。
<table fo:keep-together.within-page="1"><tbody>
<tr>
<td></td>
			<td>右前小切口</td>
			<td>全胸骨</td>
			<td>p 值</td>
		</tr>
<tr>
<td>n</td>
			<td>196</td>
			<td>171</td>
			<td></td>
		</tr>
<tr>
<td></td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
<tr>
<td>早期死亡率 (%)</td>
			<td>3 (1.5)</td>
			<td>3 (1.8)</td>
			<td>0。1</td>
		</tr>
<tr>
<td>出血再术 (%)</td>
			<td>4 (2)</td>
			<td>4 (2.3)</td>
			<td>0。6</td>
		</tr>
<tr>
<td>围手术期 (%)</td>
			<td>1 (0.5)</td>
			<td>2 (1.2)</td>
			<td>0。3</td>
		</tr>
<tr>
<td>描边 (%)</td>
			<td>5 (2.6)</td>
			<td>6 (3.5)</td>
			<td>0。7</td>
		</tr>
<tr>
<td>通风时间 (小时)</td>
			<td>10.2±6。3</td>
			<td>14.4±20</td>
			<td>0.09</td>
		</tr>
<tr>
<td>ICU 住宿 (d)</td>
			<td>2±3。3</td>
			<td>3.7±14</td>
			<td>0。4</td>
		</tr>
<tr>
<td>新发病 Afib (%)</td>
			<td>35 (18)</td>
			<td>51 (30)</td>
			<td>0.02</td>
		</tr>
<tr>
<td>红细胞 (包/病人)</td>
			<td>1.6±2。8</td>
			<td>2.1±2。1</td>
			<td>0.002</td>
		</tr>
<tr>
<td>MS (毫克/天) *</td>
			<td>39.7±22。8</td>
			<td>52.5±26。3</td>
			<td>0.007</td>
		</tr>
<tr>
<td>深部伤口感染 (%)</td>
			<td>0 (0)</td>
			<td>2 (1.2)</td>
			<td>0.02</td>
		</tr>
<tr>
<td>住院住宿 (d)</td>
			<td>8.2±2。7</td>
			<td>10.2±7。3</td>
			<td>0.04</td>
		</tr>
<tr>
<td></td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
<tr>
<td colspan="4">MI: 心肌梗死</td>
		</tr>
<tr>
<td colspan="4">ICU: 重症监护病房</td>
		</tr>
<tr>
<td colspan="4">Afib: 心房颤动</td>
		</tr>
<tr>
<td colspan="4">红细胞: 血红细胞</td>
		</tr>
<tr>
<td colspan="4">MS: 硫酸吗啡治疗术后前5天</td>
		</tr>
<tr>
<td colspan="4">* 前3天</td>
		</tr>
</tbody></table>表 4: 早期结果.在手术时间较长的情况下, 右前小切口在不增加重大不良反应的情况下, 导致早期效果更好。

Watch this Scientific Journal Video about Technique and Patient Selection Criteria of Right Anterior Mini-Thoracotomy for Minimal Access Aortic Valve Replacement at JoVE.com

Technique and Patient Selection Criteria of Right Anterior Mini-Thoracotomy for Minimal Access Aortic Valve Replacement

右前小切口主动脉瓣置换术的技术及患者选择标准

本协议的目的是详细描述的技术, 微创主动脉瓣置换通过右前小切口和中央主动脉插管。这种技术有可能提高患者的舒适度, 通过减少手术后的发病率, 促进降低住院时间和全球成本。

Aortic valve stenosis has become the most prevalent valvular heart disease in developed countries, and is due to the aging of these populations. The ...

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Nanyang Technological University

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JoVE Journal

Medicine

11.6K 次观看.  Institut de Cardiologie. 本协议的目的是详细描述的技术, 微创主动脉瓣置换通过右前小切口和中央主动脉插管。这种技术有可能提高患者的舒适度, 通过减少手术后的发病率, 促进降低住院时间和全球成本。

视频: Technique and Patient Selection Criteria of Right Anterior Mini-Thoracotomy for Minimal Access Aortic Valve Replacement

Performing and Processing FNA of Anterior Fat Pad for Amyloid

Historically, heart, liver, and kidney biopsies were performed to demonstrate amyloid deposits in amyloidosis. Since the clinical presentation of this disease is so variable and non-specific, the associated risks of these biopsies are too great for the diagnostic yield. Other sites that have a lower biopsy risk, such as skin or gingival, are also relatively invasive and expensive. In addition, these biopsies may not always have sufficient amyloid deposits to establish a diagnosis. Fat pad aspiration has demonstrated good clinical correlation with low cost and minimal morbidity. However, there are no standardized protocols for performing this procedure or processing the aspirated specimen, which leads to variable and nonreproducible results. The most frequently utilized modality for detecting amyloid in tissue is an apple-green birefringence on Congo red stained sections using a polarizing microscope. This technique requires cell block preparation of aspirated material. Unfortunately, patients presenting in early stage of amyloidosis have minimal amounts of amyloid which greatly reduces the sensitivity of Congo red stained cell block sections of fat pad aspirates. Therefore, ultrastructural evaluation of fat pad aspirates by electron microscopy should be utilized, given its increased sensitivity for amyloid detection. This article demonstrates a simple and reproducible procedure for performing anterior fat pad aspiration for the detection of amyloid utilizing both Congo red staining of cell block sections and electron microscopy for ultrastructural identification.

Fat pad aspiration is a preferred, minimally invasive, and low cost approach as compared to other methods to detect amyloid for diagnosis of systemic amyloidosis. This video article demonstrates a procedural outline for performing fat pad aspiration with appropriate processing of the specimen for the optimal diagnostic outcome.

表演和加工为淀粉样蛋白前脂肪垫活检

Historically, heart, liver, and kidney biopsies were performed to demonstrate amyloid deposits in amyloidosis.  Since the clinical presentation of this ...

科研

医学

Minimal Erythema Dose (MED) Testing

Ultraviolet radiation (UV) therapy is sometimes used as a treatment for various common skin conditions, including psoriasis, acne, and eczema. The dosage of UV light is prescribed according to an individual's skin sensitivity. Thus, to establish the proper dosage of UV light to administer to a patient, the patient is sometimes screened to determine a minimal erythema dose (MED), which is the amount of UV radiation that will produce minimal erythema (sunburn or redness caused by engorgement of capillaries) of an individual's skin within a few hours following exposure. This article describes how to conduct minimal erythema dose (MED) testing. There is currently no easy way to determine an appropriate UV dose for clinical or research purposes without conducting formal MED testing, requiring observation hours after testing, or informal trial and error testing with the risks of under- or over-dosing. However, some alternative methods are discussed.

Minimal Erythema Dose MED Testing

This article describes how to conduct minimal erythema dose (MED) testing in order to determine the lowest dose of ultraviolet radiation that will cause erythema (burning) when administered to an individual.

最小红斑剂量（MED）测试

Ultraviolet radiation (UV) therapy is  sometimes used as a treatment for various common skin conditions, including  psoriasis, acne, and eczema. The ...

Minimal Invasive Surgical Procedure of Inducing Myocardial Infarction in Mice

Myocardial infarction still remains the main cause of death in western countries, despite considerable progress in the stent development area in the last decades. For clarification of the underlying mechanisms and the development of new therapeutic strategies, the availability of valid animal models are mandatory. Since we need new insights into pathomechanisms of cardiovascular diseases under in vivo conditions to combat myocardial infarction, the validity of the animal model is a crucial aspect. However, protection of animals are highly relevant in this context. Therefore, we establish a minimally invasive and simple model of myocardial infarction in mice, which assures a high reproducibility and survival rate of animals. Thus, this models fulfils the requirements of the 3R principle (Replacement, Refinement and Reduction) for animal experiments and assure the scientific information needed for further developing of therapeutical strategies for cardiovascular diseases.

A highly reproducible model for myocardial infarction in mice with minimal invasive manipulations is described. The model can be easily performed, resulting in a high reproducibility and survival rate. Thus, the described model will reduce the number of required animals as requested by the 3R principle (Replacement, Refinement and Reduction).

在诱导小鼠心肌梗死的微创手术过程

Myocardial infarction still remains the main cause of death in western countries, despite considerable progress in the stent development area in the last ...

Full-root Aortic Valve Replacement by Stentless Aortic Xenografts in Patients with Small Aortic Roots

In patients with small aortic roots who need an aortic valve replacement with biological valve substitutes, the implantation of the stented pericardial valve might not meet the functional needs. The implantation of a too-small stented pericardial valve, leading to an effective orifice area indexed to a body surface area less than 0.85 cm2/m2, is regarded as prosthesis-patient mismatch (PPM). A PPM negatively affects the regression of left ventricular hypertrophy and thus the normalization of left ventricular function and the alleviation of symptoms. Persistent left ventricular hypertrophy is associated with an increased risk of arrhythmias and sudden cardiac death. In the case of predictable PPM, there are three options: 1) accept the PPM resulting from the implantation of a stented pericardial valve when comorbidities of the patient forbid the more technically demanding operative technique of implanting a larger prosthesis, 2) enlarge the aortic root to accommodate a larger stented valve substitute, or 3) implant a stentless biological valve or a homograft. Compared to classical aortic valve replacement with stented pericardial valves, the full-root implantation of stentless aortic xenografts offers the possibility of implanting a 3-4 mm larger valve in a given patient, thus allowing significant reduction in transvalvular gradients. However, a number of cardiac surgeons are reluctant to transform a classical aortic valve replacement with stented pericardial valves into the more technically challenging full-root implantation of stentless aortic xenografts. Given the potential hemodynamic advantages of stentless aortic xenografts, we have adopted full-root implantation to avoid PPM in patients with small aortic roots necessitating an aortic valve replacement. Here, we describe in detail a technique for the full-root implantation of stentless aortic xenografts, with emphasis on the management of the proximal suture line and coronary anastomoses. Limitations of this technique and alternative options are discussed.

Full-root aortic valve replacement by stentless aortic xenograft is a viable option in patients with small aortic roots. We describe, a technique for the full-root implantation of stentless aortic xenografts, with emphasis on the management of the proximal suture line and coronary anastomoses, and discuss its limitations and alternative options.

全根主动脉瓣置换主动脉瓣狭窄主动脉异种移植患者小主动脉根

In patients with small aortic roots who need an aortic valve replacement with biological valve substitutes, the implantation of the stented pericardial ...

Technique of Minimally Invasive Transverse Aortic Constriction in Mice for Induction of Left Ventricular Hypertrophy

Transverse aortic constriction (TAC) in mice is one of the most commonly used surgical techniques for experimental investigation of pressure overload-induced left ventricular hypertrophy (LVH) and its progression to heart failure. In the majority of the reported investigations, this procedure is performed with intubation and ventilation of the animal which renders it demanding and time-consuming and adds to the surgical burden to the animal. The aim of this protocol is to describe a simplified technique of minimally invasive TAC without intubation and ventilation of mice. Critical steps of the technique are emphasized in order to achieve low mortality and high efficiency in inducing LVH.
Male C57BL/6 mice (10-week-old, 25-30 g, n=60) were anesthetized with a single intraperitoneal injection of a mixture of ketamine and xylazine. In a spontaneously breathing animal following a 3-4 mm upper partial sternotomy, a segment of 6/0 silk suture threaded through the eye of a ligation aid was passed under the aortic arch and tied over a blunted 27-gauge needle. Sham-operated animals underwent the same surgical preparation but without aortic constriction. The efficacy of the procedure in inducing LVH is attested by a significant increase in the heart/body weight ratio. This ratio is obtained at days 3, 7, 14 and 28 after surgery (n = 6 - 10 in each group and each time point). Using our technique, LVH is observed in TAC compared to sham animals from day 7 through day 28. Operative and late (over 28 days) mortalities are both very low at 1.7%.
In conclusion, our cost-effective technique of minimally invasive TAC in mice carries very low operative and post-operative mortalities and is highly efficient in inducing LVH. It simplifies the operative procedure and reduces the strain put on the animal. It can be easily performed by following the critical steps described in this protocol.

The aim of this protocol is to describe step-by-step the technique of minimally invasive transverse aortic constriction (TAC) in mice. By elimination of intubation and ventilation which are mandatory for the commonly used standard procedure, minimally invasive TAC simplifies the operative procedure and reduces the strain put on the animal.

小鼠横主动脉狭窄诱导左心室肥厚的技术研究

Transverse aortic constriction (TAC) in mice is one of the most commonly used surgical techniques for experimental investigation of pressure ...

Standardized Technique of Aortic Valve Re-implantation for Valve-sparing Aortic Root Replacement

Despite the obvious advantages of the preservation of a normal aortic valve during aortic root replacement, the complexity of valve sparing procedures prevents a number of cardiac surgeons from incorporating them into their practice. The aim of this protocol is to describe a simplified and user-friendly technique of an aortic valve-sparing root replacement (VSRR) procedure by re-implantation of the aortic valve. Proper selection of patients and limitations of the technique are discussed.
In 54 consecutive patients, normal appearing aortic valves were re-implanted in a commercially available polyester prosthesis with pre-shaped sinuses by a simplified and standardized technique. Placement of the first row of the proximal suture line, choice of the prosthesis size, and adjustment of the height of the commissures of the patient to the fixed height of the sinus portion of the prosthesis were slightly modified from the reference techniques with the aim of increasing its feasibility for use by other cardiac surgeons. Early mortality and morbidity as well as 5-year survival, freedom from aortic valve reoperation, and freedom from recurrent moderate regurgitation were collected in all patients.
Thirty-day mortality, re-sternotomy for bleeding, re-sternotomy for mediastinitis, and the incidence of stroke were very low, 1.8% for each (1 of 54). No patient required permanent pace-maker implantation. At 5 years, survival, freedom from aortic valve reoperation, and freedom from recurrent moderate regurgitation were 97.5%, 95.2%, and 91.6%, respectively.
Mid-term results of our standardized technique of re-implantation of the aortic valve for valve-sparing aortic root replacement are very good and compare with more complex techniques reported by experienced surgeons. By following the present protocol of the standardized re-implantation technique, a greater number of cardiac surgeons can perform this procedure with comparable good results.

Valve-sparing aortic root replacement has the advantage of preserving the patient&#39;s own aortic valve. The complexity of the reported techniques to date restricts their use to a limited number of cardiac surgeons. This protocol describes step-by-step a standardized technique reproducible by a greater number of cardiac surgeons.

主动脉瓣重置术治疗瓣膜备用主动脉根置换的规范化技术

Despite the obvious advantages of the preservation of a normal aortic valve during aortic root replacement, the complexity of valve sparing procedures ...

Improved Registration of 3D CT Angiography with X-ray Fluoroscopy for Image Fusion During Transcatheter Aortic Valve Implantation

The fusion of 3D anatomical models derived from high-fidelity pre-interventional computed tomography angiography (CTA), and x-ray (XR) fluoroscopy to facilitate anatomical guidance is of huge interest for complex cardiac interventions like TAVI procedures with cerebral protection. Co-registration of CTA and XR has been introduced either based on additional intraoperative non-/contrast-enhanced cone-beam computed tomography (CBCT) or two separate aortograms. With the related increase of radiation exposure and/or contrast agent (CA) dose, a potential additional risk for the patient is introduced. Here, we propose a modified co-registration approach making use of arteriograms of the iliofemoral arteries, routinely performed during the femoral puncture and sheath introduction. On-the-fly refinement of the co-registration during the on-going procedure enables accurate co-registration without any additional angiograms, thus reducing CA, XR dose and procedure time, while simultaneously improving operator confidence and procedure safety.

The aim of this study was to improve the co-registration for image fusion (IF) of pre-interventional CT data with real-time x-ray (XR) fluoroscopy during transfemoral transcatheter aortic valve implantation (TAVI).

经导管主动脉瓣植入术中 X 线透视 3D CT 血管造影的改进与影像融合

The fusion of 3D anatomical models derived from high-fidelity pre-interventional computed tomography angiography (CTA), and x-ray (XR) fluoroscopy to ...

Implantation of Human-Sized Coronary Stents into Rat Abdominal Aorta Using a Trans-Femoral Access

Percutaneous coronary intervention (PCI), combined with the deployment of a coronary stent, represents the gold standard in interventional treatment of coronary artery disease. In-stent restenosis (ISR) is determined by an excessive proliferation of neointimal tissue within the stent and limits the long-term success of stents. A variety of animal models have been used to elucidate pathophysiological processes underlying in-stent restenosis (ISR), with the porcine coronary and the rabbit iliac artery models being the most frequently used. Murine models provide the advantages of high throughput, ease of handling and housing, reproducibility, and a broad availability of molecular markers. The apolipoprotein E deficient (apoE-/- ) mouse model has been widely used to study cardiovascular diseases. However, stents must be miniaturized to be implanted into mice, involving important changes of their mechanical and (potentially) biological properties. The use of apoE-/- rats can overcome these shortcomings as apoE-/- rats allow for the evaluation of human-sized coronary stents while at the same time providing an atherogenic phenotype. This makes them an excellent and reliable model to investigate ISR after stent implantation. Here, we describe, in detail, the implantation of commercially available human coronary stents into the abdominal aorta of rats with an apoE-/- background using a trans-femoral access.

This protocol describes the implantation of human coronary stents into the abdominal aorta of rats with an apoE-/- background using a trans-femoral access. Compared with other animal models, murine models carry the advantages of high throughput, reproducibility, ease of handling and housing, and a broad availability of molecular markers.

使用跨女性访问将人类大小的冠状动脉支架植入大鼠腹主动脉

Percutaneous coronary intervention (PCI), combined with the deployment of a coronary stent, represents the gold standard in interventional treatment of ...

The Intra-Aortic Balloon Pump

Cardiogenic shock remains one of the most challenging clinical syndromes in modern medicine. Mechanical support is being increasingly used in the management of cardiogenic shock. Intra-aortic balloon pump (IABP) is one of the earliest and most widely used types of mechanical circulatory support. The device acts by external counterpulsation and uses systolic unloading and diastolic augmentation of aortic pressure to improve hemodynamics. Although IABP provides less hemodynamic support when compared with newer mechanical circulatory support devices, it can still be the mechanical support device of choice in appropriate situations because of its relative simplicity of insertion and removal, need for smaller size vascular access and better safety profile. In this review, we discuss the equipment, procedural and technical aspects, hemodynamic effects, indications, evidence, current status and recent advances in the use of IABP in cardiogenic shock.

We describe the steps for the percutaneous implantation of the intra-aortic balloon pump (IABP), a mechanical circulatory support device. It acts by counterpulsation, inflating at the onset of diastole, augmenting diastolic aortic pressure and improving coronary blood flow and systemic perfusion, and deflating before systole, reducing left ventricular afterload.

主动脉内球囊泵

Cardiogenic shock remains one of the most challenging clinical syndromes in modern medicine. Mechanical support is being increasingly used in the ...

Four-Dimensional Computed Tomography-Guided Valve Sizing for Transcatheter Pulmonary Valve Replacement

The measurements of the right ventricle (RV) and pulmonary artery (PA), for selecting the optimal prosthesis size for transcatheter pulmonary valve replacement (TPVR), vary considerably. Three-dimensional (3D) computed tomography (CT) imaging for device size prediction is insufficient to assess the displacement of the right ventricular outflow tract (RVOT) and PA, which could increase the risk of stent misplacement and paravalvular leak. The aim of this study is to provide a dynamic model to visualize and quantify the anatomy of the RVOT to PA over the entire cardiac cycle by four-dimensional (4D) cardiac CT reconstruction to obtain an accurate quantitative evaluation of the required valve size. In this pilot study, cardiac CT from sheep J was chosen to illustrate the procedures. 3D cardiac CT was imported into 3D reconstruction software to build a 4D sequence which was divided into eleven frames over the cardiac cycle to visualize the deformation of the heart. Diameter, cross-sectional area, and circumference of five imaging planes at the main PA, sinotubular junction, sinus, basal plane of the pulmonary valve (BPV), and RVOT were measured at each frame in 4D straightened models prior to valve implantation to predict the valve size. Meanwhile, dynamic changes in the RV volume were also measured to evaluate right ventricular ejection fraction (RVEF). 3D measurements at the end of the diastole were obtained for comparison with the 4D measurements. In sheep J, 4D CT measurements from the straightened model resulted in the same choice of valve size for TPVR (30 mm) as 3D measurements. The RVEF of sheep J from pre-CT was 62.1 %. In contrast with 3D CT, the straightened 4D reconstruction model not only enabled accurate prediction for valve size selection for TPVR but also provided an ideal virtual reality, thus presenting a promising method for TPVR and the innovation of TPVR devices.

This study assessed a new methodology with a straightened model generated from the four-dimensional cardiac computed tomography sequence to obtain the desired measurements for valve sizing in the application of transcatheter pulmonary valve replacement.

用于经导管肺动脉瓣置换术的四维计算机断层扫描引导的瓣膜尺寸

The measurements of the right ventricle (RV) and pulmonary artery (PA), for selecting the optimal prosthesis size for transcatheter pulmonary valve ...