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二尖瓣置换术后三尖瓣关闭不全的外科治疗

目的总结二尖瓣置换术后三尖瓣关闭不全患者的外科治疗经验。方法14例心脏瓣膜疾病患者行二尖瓣置换术后发生中度或重度三尖瓣关闭不全,其中相对性关闭不全12例,器质性关闭不全2例。行三尖瓣成形术4例,均使用人工瓣环成形;行三尖瓣置换术10例,其中置换生物瓣6例,双叶机械瓣4例。在心脏不停跳下手术4例,常规心脏停搏手术10例。结果全组无手术死亡,术后发生低心排血量综合征3例,用升压药维持循环,患者均顺利出院。术后复查超声心动图,右心房、室均明显缩小,右心室前后径(22.5±5.6mm)较术前(31.9±5.9mm)明显减小(Plt;0.001)。随访14例,随访时间1.8±1.3年,心功能级2例、级9例,级2例,1例于术后4年因心力衰竭死亡。结论二尖瓣置换术后远期三尖瓣关闭不全的患者经外科矫治后疗效满意,合理掌握手术指征、手术时机和良好的围术期治疗是手术成功的关键。

主动脉瓣下狭窄老年患者一例

升主动脉隔离装置在升主动脉近端钙化患者非体外循环冠状动脉旁路移植术中的应用

摘要： 目的 评价升主动脉近端隔离装置（Heartstring和Enclose近端吻合装置）在非体外循环冠状动脉旁路移植术（OPCAB）中的应用效果。 方法 2006年1月至2008年2月收治了150例合并升主动脉近端钙化的冠心病患者，其中男102例，女48例；年龄55～78岁，平均年龄69岁。所有患者在冠状动脉旁路移植术中应用升主动脉近端隔离装置，大隐静脉与升主动脉近端共完成251个吻合口，升主动脉近端吻合口1～3个/例，大隐静脉桥血管完成后应用流量仪进行流量测定。术后观察神经系统并发症的发生情况。 结果 术后死于低心排血量综合征1例（067%）；二次开胸止血2例，其中1例为乳内动脉床渗血，1例为胸骨后出血；其余患者术后24 ｈ胸腔引流量为100～200 ml。所有患者均于术后24～48 ｈ内顺利拔除气管内插管；术后均未出现明确的昏迷、肢体偏瘫、语言障碍及运动不协调等神经系统并发症；大隐静脉桥血流量为28.5～70.1 L/min（53.7± 23.9 L/min）。术后随访145例，随访率97.32%，随访时间3个月～1年；4例失访。随访期间患者未发生迟发性脑出血或脑梗死等神经系统并发症。结论 在OPCAB术中应用Heartstring和Enclose升主动脉近端隔离装置，安全、有效，能有效地降低脑卒中的发生率。

冠状动脉CT血管造影诊断冠状动脉左前降支左心室瘘一例

Bilateral Pectoralis Major Muscle Flaps for the Treatment of Sternal Dehiscence after Cardiac Surgery

Objective To investigate surgical strategies using bilateral pectoralis major muscle flaps for the treatment of sternal dehiscence after cardiac surgery. Methods From May 2005 to October 2010，21 patients with sternal dehiscence, sternal osteomyelitis and mediastinitis after cardiac surgery were admitted to Beijing An Zhen Hospital of　Capital Medical University. There were 13 male patients and 8 female patients with their age of 53-72 （64.5±7.8） years. There were 19 patients after coronary artery bypass grafting （CABG） and 2 patients after heart valve replacement. The non-viable　and necrotic bones were debrided and sternal wires partially or completely removed. The sternal origins of pectoralis major were released on both sides. The pectoralis major muscle flaps were tensionlessly sutured across medially over the sternal defect. Multiple suction drains were placed and removed in due time. The skin was intermittently closed. Results All the pectoralis major muscle flaps lived well after surgery，and all the patients were discharged in 2 weeks after surgery. Twenty patients were discharged with complete wound closure，and 1 patient had wound fistula and infection after removal of suction drains that was healed after another surgery to resect the wound fistula. During 6 month follow-up，sternal wound healed well in all the patients with normal thoracic appearance，and none of the patients had abnormal respiratory movement, infection recurrence or persistent infection. Conclusion Bilateral pectoralis major muscle flap technique is a positive and efficient surgical strategy for the treatment of refractory sternal dehiscence after cardiac surgery.

体外循环与非体外循环冠状动脉旁路移植术临床分析

目的 比较体外循环冠状动脉旁路移植术（on—pump CABG，on—pump）和非体外循环冠状动脉旁路移植术（off—pump CABG，off—pump）的临床应用效果。方法 回顾2003年12月-2005年1月间我院行冠状动脉旁路移植术（CABG）195例的临床资料，依据术中采用不同的手术方式分为on—pump组和off—pump组。并对两组患者的术前、术后临床资料、术后并发症发生情况进行分析。结果 两组患者术前一般临床资料比较差别无统计学意义；术后off—pump组发生并发症17例，on—pump组26例（P=0．000）；off-pump组住院死亡2例，on—pump组死亡6例（P=0．025）。结论 在多支左主干病变中，off—pump和on—pump在再血管化的应用上无差别；off—pump后的心电图改变、死亡率和并发症发生率比on—pump患者低，但是合并瓣膜病或严重的3支血管病变、左主干病变、室壁瘤形成的患者更适宜采用on—pump，off—pump不能取代on—pump。

Comparison Analysis Between Chordal Transposition and Chordal Shortening in Repairing Anterior Leaflet Prolapse

Objective To compare chordal transposition and chordal shortening in repairing anterior leaflet prolapse (ALP)， and explore the surgical indications as well as merits and demerits of these two techniques. 〖WTHZ〗Methods We retrospectively reviewed the data of 90 ALP patients recruited into Anzhen Hospital between March 1986 and March 2008, and classified them into chordal shortening group (n=23) and chordal transposition group (n=67). KaplanMeier survival curve and freedom from reoperation curve were established to compare the two groups. Univariate analysis and multivariate logistic analysis regression were used to identify independent risk factors for early death and late cardiac events. 〖WTHZ〗Results There were three perioperative deaths in chordal shortening group（13.0%）, and three deaths in chordal transposition group (4.4%), and the difference was not significant (χ2=2.019，P=0.155). The follow-up time ranged from 1 month to 18 yrs（7.70±5.41 yrs）. There were 5 late deaths, of which 3 were in chordal shortening group and 2 in chordal transposition group. The KaplanMeier survival curve showed that 5-year survival rate of chordal shortening group was significantly lower than chordal transposition group (70.00%±18.24% vs.98.00%±1.98%,χ2=12.50, P=0.000); And the KaplanMeier freedom from reoperation curve showed [CM(159mm]that 5-year reoperation rate of chordal shortening group was also significantly lower than chordal transposition group (83.30%±15.20% vs.96.10%±2.71%,χ2=10.27，P≤0.001). By the univariate analysis, we found that age＞55 yrs old, concomitant CABG procedure, New York Heart Association (NYHA) function class Ⅲ-Ⅳ, preoperative heart failure history, aortic clamping time＞90 min, and preoperative lefe ventricular ejection fraction (LVEF)＜45% were the risk factors for perioperative death and risk factors for late cardiac events included postoperative mitral regurgitation＞2+, chordal shortening technique, preoperative heart failure history, and aortic clamping time＞90 min. The multivariate logistic analysis regression showed that aortic clamping time＞90 min, concomitant CABG procedure, preoperative LVEF＜45% were the independent predictors for perioperative death, and NYHA class ⅢⅣ, chordalshortening technique and residual mitral regurgitation＞2+ were the independent predictors for the late cardiac events. Conclusion （1） There is no statistically difference between chordal transposition and chordal shortening in the perioperative survival rate. (2) Chordal transposition has a relative superiority to chordal shortening in terms of 5-year survival rate. (3) Chordal transposition has a higher mid and longterm rate of freedom from reoperation than chordal shortening. （4） Although chordal transposition has a lower incidence of reoperation and ahigher mid and longterm survival rate, the indication for it is restricted to less extensive ALP and patients with transferrable chord in the posterior leaflet. Chordal shortening is an independent risk factor for late events.

Experimental Research of Small Molecule Compound XAV939 Inducing Mouse Embryonic Stem Cell into Cardiac Myocyte

ObjectiveTo investigate the feasibility of small molecule compound XAV939 to induce mouse embryonic stem cells (mESC) to differentiate into cardiac myocytes. MethodsWe revived and cultured undifferentiated mESC growing confluently on trophoderm made of mouse embryonic inoblast cell. The mESCs were digested by trypsin to form embryoid bodies (EBs) by handing drop method. After plated, EBs were induced by XAV939 to differentiate into cardiac myocytes. We observed the cardiac myocytes with lightmicroscopy and identified it with immunofluorescence method. Result The XAV939 can effectively induce mESC into cardiac myocytes with the mean efficiency rate of 71.85%±1.05%. The differentiated cardiac myocytes shrinked spanteously and rhythmicly. The cardiac troponin T as the special marker of cardiac myocyte was positive. ConclusionThe small molecule compound XAV939 could effectively induce mES cells into cardiac myocytes.

主动脉瓣四叶畸形合并肾移植术后行主动脉瓣置换术一例

The Early and Middle- long Term Clinical Outcome of Surgical Treatment of Pulmonary Embolism

Abstract: 　Objective　To invest igate the early and m iddle2long term clinical outcome of surgical t reatment for pulmonary th romboembo lism (PTE). 　Methods　The data of 57 cases of surgical t reatment fo r pulmonary embolism from O ctober 1994 to O ctober 2007 in A nzhen Ho sp italw ere analyzed ret ro spect ively, of w h ich 47 casesw ere ch ronic PTE done w ith pulmonary th romboendarterectomy, and 10 w ere acute PTE done w ith pulmonary embo lectomy. 　Results　There w ere 6 (12. 8%) perioperat ive death s in ch ronic PTE and 4 (40. 0%) death s in acute PTE (P =0.030). F ifteen cases suffered w ith residual pulmonary hypertension and 25 casesw ith severe pulmonary reperfusion injury. The pulmonary artery systo lic p ressure (PA SP) and the pulmonary vascular resistance (PVR ) of 41 cases with ch ronic PTE at 72 hours after surgery w ere low ered significant ly than tho se befo re surgery (52. 9±26. 1 mmHg vs. 91. 2±37. 4 mmHg; 410. 3±345. 6 dyn?s/ cm5 vs. 921. 3±497. 8 dyn?s/ cm5). The arterial oxygen saturat ion (SaO 2) and the arterial part ial p ressure of oxygen (PaO 2 ) at 72 hours after surgery w ere h igher significant ly than tho se befo re surgery (94.8% ±2.7% vs. 86.7% ±4.3%; 84. 4±5. 4 mmHg vs. 51. 8±6. 4 mmHg, P lt; 0. 05). With the fo llow -up of 44. 6±39. 3 month s (cumulat ive fo llow -up w as 160. 1 pat ient-years) of the 47 perioperative survivo rs, there w ere 5 late death s, of w h ich 4 ch ronic PTE and 1 acute PTE. A cco rding to Kap lan-Meier survival curve, the 5 years survival rate w as 89. 43%±5. 80% fo r ch ronic PTE and 83. 33%±15. 21% fo r acute PTE (Log rank test= 1.57, P = 0. 2103). The lineal bleeding rate related to ant icoagulat ion w as 1. 25% pat ient-years, and the lineal th romboembo lic rate related to ant icoagulat ion w as 0. 62% pat ient-years. A nd of the 42 mid-long term survivo r, the heart funct ion in 29 cases w as N ew Yo rk Heart A ssociat ion (NYHA ) class I , 10 cases NYHA class II , 3 cases N YHA class III. A cco rding to logist ic regression, the risk facto rs fo r the early death w ere acute PTE (OR = 3.28, peripheral type of PTE (OR = 2. 45) , unadop t ive of deep hypertherm ia and circulato ry arrest (OR = 2.86) ; and the risk facto rs fo r late death w ere peripheral type of PTE (OR = 2. 69) , lower limb edema p rep rocedure (OR = 2.79). 　Conclus ion　The operat ive mo rtality in acute PTE is significant ly h igher than that in ch ronic PTE, and the mid-long term survival rate is agreeable in bo th acute and ch ronic PTE, and the comp licat ions rate related to ant icoagulat ion is relat ively accep table.