novel for you Chapter 1023 Confused He Yonghua
Chapter 1023 Confused He Yonghua
"Haizhou feels the risk is too great and the technical difficulty is beyond their current handling capabilities. They hope we can take over."
As Chen Yang examined the patient, He Yonghua was also speaking nearby: "The patient is a 58-year-old male with a long history of hypertension, diabetes, and renal insufficiency (CKD stage 3). His main complaints are progressively worsening chest tightness and shortness of breath after activity. For the past two months, he has experienced paroxysmal nocturnal dyspnea, and even orthopnea."
In He Yonghua's opinion, Chen Yang didn't know much about cardiothoracic surgery, so he explained it patiently.
Since the establishment of the medical center, the hepatobiliary surgery and traditional Chinese medicine surgery departments have already opened, but the cardiothoracic surgery department has no patients yet. He Yonghua is a little anxious and eager to show himself.
As a cardiothoracic surgery expert at Peking Union Medical College Hospital, He Yonghua is also quite proud.
He is only fifty years old this year. The reason he agreed to come to the medical center is to make a breakthrough and become an authority in domestic cardiothoracic surgery.
In the past few days, He Yonghua has been looking for related patients. He thinks this patient is very suitable.
Chen Yang took the information and quickly scanned the admission record and preliminary diagnosis on the first page.
"The initial diagnosis...severe mitral regurgitation, significant left ventricular enlargement (LVEDD 75mm), and an EF value of only 38%... Well, heart function class IV (NYHA classification), this is indeed a big problem."
As Chen Yang spoke, he turned to the imaging report and carefully looked at the results of the cardiac ultrasound and cardiac CT.
"Here lies the key issue. Both color Doppler ultrasound and CT scans clearly show that the root cause of severe mitral regurgitation is not just leaflet prolapse or chordae tendineae rupture, but the more problematic issue is the presence of severe mitral annular calcification (MAC)."
"Moreover, the calcification is large and ring-shaped, and... the calcified plaque has extended backward, invading the myocardium of the posterior wall of the left ventricle, while protruding forward, partially compressing the left ventricular outflow tract (LVOT)."
"This operation is very difficult." Chen Yang raised his head and looked at He Yonghua.
He Yonghua was stunned. He was stunned.
Although Chen Yang only said a few simple words, it also showed that Chen Yang understood cardiothoracic surgery and was an expert, otherwise he would not have said such words.
"Does Dr. Chen also understand cardiac surgery?" He Yonghua asked.
"I know a little bit." Chen Yang said.
He Yonghua opened his mouth and was speechless for a moment.
"Director Chen, what you just said is indeed the core of the problem. This calcification not only causes the valve ring to become rigid and unable to effectively support the prosthetic valve, but more importantly, its location and extent are extremely critical. It's like a solid rock stuck in a critical position."
"Hard calcification makes it impossible to simply suture the prosthetic valve as in conventional surgery. If the suture is forced, the valve may become unstable (with an extremely high risk of paravalvular leakage), or the suture may fail to cut through the calcified tissue."
"Calcification protrudes forward, encroaching on the space of the left ventricular outflow tract. If a standard-sized prosthetic valve is implanted, the valve stent or sewing ring itself may further aggravate the stenosis of the LVOT, and the patient may suffer from catastrophic low cardiac output syndrome after surgery."
"Calcification is deep in the myocardium, and removing it can easily damage the left circumflex coronary artery (near the posterior annulus of the mitral valve) and the cardiac conduction system running near the annulus (especially the atrioventricular node and His bundle). The risk of high-grade atrioventricular block and permanent pacemaker insertion after surgery is also extremely high."
.......
He Yonghua said one by one.
"Haizhou has tried conservative medical treatment and optimized heart failure medication, but the effect was minimal and the patient's symptoms continued to worsen."
"Currently, surgery is the only option that could potentially improve quality of life and prolong life, but the risks... after evaluation, they felt were beyond their technical control. This degree of MAC combined with LVOT obstruction is a very challenging procedure, even in top centers."
Chen Yang didn't respond immediately. His fingers slid back and forth across the CT images and ultrasound reports, using his vast experience base to deduce.
After a moment, Chen Yang raised his head and said slowly, "Director He, the core of this case is how to safely and effectively treat the calcified annulus while avoiding LVOT obstruction and damage to critical structures. The conventional mitral valve replacement (MVR) approach is too risky. We need a comprehensive strategy."
Approach and Exposure: A standard median sternotomy is performed to fully expose the heart. Extreme caution is required when establishing cardiopulmonary bypass (CPB), as the left ventricle is significantly enlarged and cardiac function is extremely poor. Maintaining hemodynamic stability before transfer is crucial.
Chen Yang said slowly, "The first step is to deal with the calcification—'peak reduction and valley filling.'"
"It's not about completely removing all calcification, which is neither realistic nor extremely dangerous. Instead, it's about reshaping the annulus structure to create a relatively flat 'platform' that can firmly suture the prosthetic valve, while also relieving LVOT obstruction."
"Fine bone curettes, rongeurs, and even high-speed drills can be used (with continuous irrigation and cooling to prevent thermal damage and embolism). The key is to remove the calcified area that protrudes forward and compresses the LVOT. This is the key to relieving outflow tract obstruction."
Chen Yang had never performed cardiothoracic surgery, but he had been studying and understanding it recently. Because of the system, Chen Yang learned quickly.
At this moment, Chen Yang was analyzing the situation for He Yonghua with the intention of communicating. He was expressing his thoughts and hoped that He Yonghua would make the judgment.
People’s mentality is actually different depending on whether they have done it or not.
"There's also shaping, which involves removing overly sharp, raised calcified nodules on the annulus plane to create a relatively flat foundation for suturing. The operation must be extremely gentle, peeling off layer by layer like an archaeologist, avoiding violent pulling or prying."
"Retaining the base. For calcified bases deeply embedded in the myocardium, it is not necessary to completely remove them. Retaining a thin layer of calcified shell may be safer than forcibly removing them and causing transmural myocardial defects..."
Chen Yang spoke very seriously, and became more and more excited as he spoke, but He Yonghua on the opposite side was dumbfounded.
He Yonghua looked at Chen Yang with confusion in his eyes.
Is Chen Yang a monster?
It was already surprising that Chen Yang was involved in hepatobiliary surgery, but unexpectedly he was also involved in cardiothoracic surgery.
Originally, He Yonghua thought that he was the only authority on cardiothoracic surgery in the center, but after listening to Chen Yang's analysis, He Yonghua suddenly felt that in terms of knowledge, he seemed not much better than Chen Yang.
Moreover, Chen Yang is not a novice who has never performed surgery. Although Chen Yang performs hepatobiliary surgery, the basics of all surgical operations are actually similar, which are nothing more than incision, suturing, drainage, etc.
Once you have a certain level of basic knowledge, as long as you are proficient in the surgical procedures and understand certain aspects, you will be fully capable of performing surgery.
And Chen Yang is such a person.
"Director He, this operation is quite difficult. Are you confident?"
After Chen Yang finished speaking, he raised his head and asked He Yonghua.
"Uh..." He Yonghua opened his mouth and thought, haven't you finished your analysis?
You have analyzed the difficulties thoroughly just now.