novel for you Chapter 1030: Two-pronged Advancement (Part )
Chapter 1030: Two-pronged Advancement (Part )
"This prescription has a strong effect of warming the yang and promoting diuresis, and a large amount of aconite is used. It must be strictly decocted first to remove the toxins, and the patient's reaction must be closely observed."
"There are a lot of diuretics, so electrolytes, especially blood potassium, need to be monitored to prevent hypokalemia from inducing malignant arrhythmias. Should Western medicine's supportive treatments such as diuretics, vasodilation, cardiotonic treatment (low-dose diltiazem), and blood pressure and blood sugar control be combined with this?"
After listening to Xun Jiahong's plan, He Yonghua asked Chen Yang.
Chen Yang nodded: "The plan is very good. Although the aconite is strong, in this critical moment of life and death, only a strong dose can cure the serious illness."
"During medication, monitor vital signs, urine volume, weight, electrolytes, and liver and kidney function daily. Adjust the diuretic dosage as appropriate based on the resolution of edema and tolerance."
Chen Yang said to He Yonghua, "The cardiothoracic surgery department is responsible for this. Our goal is to get the patient back to a semi-recumbent position within a week, with the wheezing, coughing, and edema significantly alleviated, and heart function improved to around Grade III."
He Yonghua nodded.
"Director Xun, Director Lin, you are fully responsible for the Chinese medicine treatment. If you have any questions, feel free to contact me." Chen Yang said to Xun Jiahong.
"Don't worry, Director Chen." Xun Jiahong nodded.
"Then we'll discuss the surgery."
Chen Yang paused and said, "Originally, the surgical plan could have been discussed after the patient had recovered, but this operation is quite difficult. After today's discussion, we can strengthen the relevant aspects and try to avoid mistakes during the operation."
"Director Chen is right." He Yonghua nodded.
Chen Yang looked at the screen again, and his fingers drew the outline of calcification in the air.
"I've previously discussed the core challenges of this surgery with Director He: addressing calcification, reconstructing the annulus, relieving LVOT obstruction, and avoiding damage to critical structures—all are interconnected and essential. Conventional MVR (mitral valve replacement) approaches carry uncontrollable risks."
After a pause, Chen Yang's eyes swept over the crowd: "My idea is this, everyone listen first."
"First, approach and exposure. A standard median sternotomy was performed, and establishing cardiopulmonary bypass (CPB) required exceptional care. The patient's cardiac function was so poor that hemodynamic stability was crucial before transfer. During the procedure, a transatrial sulcus left atrium approach was performed to fully expose the mitral valve apparatus and calcified areas."
"Second, calcification treatment—'fine carving,' with the goal of 'reshaping' rather than 'eradicating.' High-speed burs, fine rongeurs, and bone curettes are used."
"The key is to flatten the anterior lordosis and focus on grinding and removing the calcified protrusion that presses forward on the LVOT. This is the key to relieving the obstruction! The operation must be extremely precise to avoid damaging the adjacent aortic valve and ventricular septum."
"Smooth the annular plane and remove any sharp, raised calcified nodules to create a relatively flat, stable 'platform' for suturing the prosthetic valve. For calcified bases deeply embedded in the myocardium, do not completely remove them. Retain a thin, secure calcified 'shell' as a foundation for suturing to avoid transmural myocardial defects. The procedure should be like carving jade, peeling off layer by layer, gently and again!"
"Avoidance of key areas is crucial. For calcifications near the circumflex coronary artery (usually near the P2-P3 region of the posterior mitral valve annulus) and the atrioventricular node/His bundle (near the anterior external limb), avoidance is the primary approach. Only minimal smoothing is performed, and no risk of deep removal is tolerated. It's better to make suturing more difficult to ensure safety."
"Third, artificial valve selection and implantation strategy, and special valve design."
"Given the limited LVOT space, a low-profile prosthetic valve must be selected. Furthermore, to minimize the risk of postoperative LVOT obstruction, I recommend using a valve with a trumpet-shaped sewing ring design or employing the 'everting suturing' technique, which hides the sewing ring as close to the atrial side of the calcified annulus as possible, minimizing the protrusion of the valve device on the ventricular side (i.e., the LVOT region)."
"Reinforced sutures. Because the calcified annular tissue is fragile, conventional sutures can easily cut the tissue and cause paravalvular leakage. Interrupted mattress sutures with pledgets are used to distribute suture tension and increase stability. Suture points are primarily selected in relatively 'safe' and 'flat' areas, avoiding dangerous areas. If necessary, artificial material (such as bovine pericardium strips) can be pre-placed on the calcified 'platform' to reinforce the sutures. The sutures can be sewn to the reinforcement bands to increase the holding force."
"Real-time LVOT monitoring: Before and after valve implantation, intraoperative transesophageal echocardiography (TEE) must be used to dynamically assess LVOT width and blood flow velocity in real time. If significant LVOT obstruction persists (accelerated blood flow and increased pressure gradient) after valve implantation, further valve position adjustment or further fine-tuning of calcifications may be necessary. Even the more radical but highly risky Morrow procedure (partial ventricular septal resection) to expand the aortomitral continuity area may be considered as a last resort."
"Fourth, a conduction system protection plan is needed. Because the calcified area is close to the conduction bundle, the risk of high-degree atrioventricular block (III-degree AVB) after surgery is extremely high. Pre-placement of a temporary epicardial pacing lead is essential! Be prepared for the possibility of a permanent pacemaker being installed after surgery."
Chen Yang spoke slowly, but each word was clear and powerful, like a precise scalpel, dissecting the complex, maze-like surgical difficulties layer by layer and providing a concrete and feasible solution. The entire plan was logically rigorous and rich in detail, taking not only the technical operation into consideration but also thoroughly assessing the risks and formulating contingency plans.
The consultation room was completely silent, and everyone was shocked by Chen Yang's in-depth professional analysis and highly creative solutions.
Many people in the cardiothoracic surgery team and Qiu Yunshan from the Haizhou Provincial Cardiothoracic Surgery Department had their mouths slightly open, their faces full of disbelief.
He Yonghua's eyes sparkled with excitement, and he nodded vigorously. "Excellent! Director Chen's plan hits the nail on the head. 'Meticulous craftsmanship,' 'special valve + inversion suturing,' and 'real-time TEE monitoring'—these three core strategies address the biggest risk points! I completely agree!"
Qiu Yunshan's face flushed with excitement. "Brilliant! Absolutely brilliant! Director Chen, your plan truly points the way forward for this type of complex MAC surgery. Our Haizhou team will fully cooperate."
Chen Yang's plan is simply... simply...
For a moment, Qiu Yunshan couldn't find the right words to describe it.
When He Yonghua asked just now, Qiu Yunshan guessed that Chen Yang should have some knowledge of cardiothoracic surgery. But after listening to Chen Yang's analysis and layout, Qiu Yunshan realized that this was not just a dabbling, this was proficiency, and this level was probably higher than He Yonghua's.
Wen Manlu looked at Chen Yang with a burning gaze. She knew that Chen Yang had been reading books on cardiothoracic surgery for some time, but she didn't know that Chen Yang had already mastered it to such an extent.
The man I like is truly a genius in medical field.