中国心外科发展现状的幻灯

nullCardiac Surgery in China Current status and Some CharacteristicsCardiac Surgery in China Current status and Some CharacteristicsZhu Xiaodong Fuwai Cardiovascular Institute 2004.10CHINA: A developing country with a huge population of 1.3 billions*CHINA: A developing country with a huge population of 1.3 billions*Even the growing pace of the population has gradually slowed down Increasing rate: still as high as 0.7% per year Out of 16.6millions of newborns >100,000 babies with CHD (6.7 ‰) are added each year * Report of the Ministry of Public Health. 2001 Potential Patients who may need cardiac surgery:Potential Patients who may need cardiac surgery:Myocardial infarction 2.967 millions* Rheumatic valvular disease 2.235 millions Congenital heart disease 1.80-1.95 millions （6.7‰ in newborns) Idiopathic cardiomyopathy 1.60 millions** Others Total >8millions *Gu Dongfeng. Prevalence of cardiovascular diseases in China 42nd conference on cardiovascular disease epidemiology and prevention 2002.04 Hawaii **Yubao Zou et al. Am J Medicine 2004,116:14-8Distribution of different kinds of heart operationsDistribution of different kinds of heart operationsIn general : Number one:Congenital (60%-65%) Second: Valve surgery (20%-25%); Third:Coronary surgery (10%-20%） *CABG >50% in few units Fuwai Hospital： (1977~2003) 25,279 cases CongenitalCABGValvesCABG has gradually surpassed valve operationsCABG has gradually surpassed valve operationsFu-Wai HospitalLimited Medical resources The capacity of cardiac surgeryLimited Medical resources The capacity of cardiac surgeryThere are about 900 cardiothoracic units (including about 500 heart units) Nearly 80,000 heart operations in 2003 13 big heart centers (>1000 open hearts/year) (阜外, 安贞, 新华, 上海中山, 长海, 武汉协和, 亚心, 霍英东, 湘雅, 沈军区, 华西, 四医大, 三医大…) Our mission: Millions of heart operations /yOur mission: Millions of heart operations /y Another hundred of heart centers as big as Fu-wai heart hospital or as good as THI should be built up in China. A whole network of service and a reliable insurance system nationwide also should be established.1. Increasing number of baby-patients1. Increasing number of baby-patients苏肇伉：心血管病国际论坛2004.09 北京characteristic349 operations of complicated congenital heart diseases. 57％ under 6 months of age 徐志伟)*： *晚期心脏病外科治疗研讨会，上海 2004 Surgery of Congenital Heart Disease2. More complicated anomalies 2. More complicated anomalies About 25％ are complicated cases Overall operative mortality ------10% to 15％ Unlike western countries, most cyanotic cases are Tetralogy of Fallot ( mortality 1.1%-5%) Because of small percentage of neonates. In a series of 115 neonates of congenital heart disease nearly 50% of them were TGA* *苏肇伉：心血管病国际论坛2004.09 北京 Surgery of Congenital Heart DiseaseContinueImprovement of Coronary SurgeryImprovement of Coronary SurgeryFirst CABG 1974 Guo Jiaqiangnull 10%-20% of total number of heart operations in general (in few heart centers, the percentage of CABG has been as high as 50%) Operative mortality: 2%-3% in big centersThe number of CABGFWHnullOff-pump Coronary bypass Number of OPCAB has been increasing Out of total number of CABG, 20%-30% are off-pump in general. A series of 1198cases (79.5% of total CABG) Mortality 1.2% Early results were satisfactoryIt was 46% at FWH 2003Promotion & competition from PTCAPromotion & competition from PTCA PTCA has been increasing much faster in recent years Especially since drug-eluting stent came into use.  Sirolimus eluting stent has been widely used in China. PTCA was one and a half times more than CABG at FWH  PTCA is still facing “re-stenosis”  Guideline update: severe proximal LAD stenosis and/or 3-vessel disease may achieve improved survival with CABG. So, Surgeons will have more complicated or restenosis cases.Etiology of Valve Disease Etiology of Valve Disease The majority of heart valve disease was rheumaticCongenitaldegenerative(Fu Wai Hospital 1997~2003)Heart Valve Surgery:nullTechnically popularized MVR >AVR Valve prosthesis: Mechanical >90% : G-K,Lanzhou,St.Jude, MAFW 97-03Valve Replacement First case -- 1965 Cai Yongzhi, Tissue valves: much less (because of younger age and re-operation..)Home made Pericardial Since 1976, The longest:AVR-21y;MVR-21y Valve Repair Valve RepairAmong the mitral valve operations Only around 10%----repair A variety of plastic rings are used Alfieri edge to edge technique: for ischemic mitral regurgitation TV： Exclusively --- reconstruction technique De Vega or Ring AV repair: Only limited indications AS, Prolapse of leaflets, AV-ring dilatation Minimally Invasive Procedures for heart valve surgeryMinimally Invasive Procedures for heart valve surgeryRight thoracotomy Partial sternotomy Beating heart with ECC Endoscopy assisted 11%Fu Wai Hospital Data:1997~2000)null Surgery of Aortic AneurysmThe aortic arch replacement was started ----1960th The operative mortality of dissecting aneurysm has come down to 6.8%-10.1% recently. Surgery + Intra-vascular intervention Elephant procedure 60 cases (FWH 1997-2003) Ascending aorta and total arch replacement combined with stented graft implantation into the descending aorta Surgical Treatment for End stage Heart Failure Surgical Treatment for End stage Heart FailureBasically there are 3 approaches: 1. Heart, heart-lung transplantation ※ Very effective and important ※ Very limited number so far. Heart and heart-lung transplants are less than 200cases ※ More heart centers have started heart transplant in many provinces recently.null A new design at FWH The 3rd Generation of VAD Megnetic activated subaortic pump Surgical Treatment for End stage Heart Failure continue2. Ventricular assist device(VAD) Novacor, BAS, Meados, Berlin Heart It is too expensive and complex technically Surgical Treatment for End stage Heart FailureSurgical Treatment for End stage Heart Failure3. Cell transplantation  It is now only in the stage of basic research, and very few primary clinical trial.  Mostly: Using marrow stem cells (put stem cells into coronary artery)ContinueSummarySummaryChina, as a developing country, there are some characteristics in cardiac surgery. 1. huge and continue growing patient population. 2. Increasing coronary heart disease, CABG is moving to the second largest group in cardiac surgery. 3. Rheumatic is the main cause of heart valve disease. Very small percentage of tissue valves are used. 4. The majority of cyanotic congenital heart disease is Tetralogy of Fallot Summary continueSummary continueCardiac surgery in China is now at its full speed of development. From the point of technology in the field of coronary and valvular surgery, there is no significant gap compared with developed countries. As to neonate heart surgery and aortic surgery, we have a rather long way to go. nullLastly, I hope the information I provided here may encourage you to extend your practice or collaboration in the near future.nullThank you