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主动脉窦瘤破裂的外科治疗

摘要 目的　总结1973～1999年85例主动脉窦瘤破裂的外科治疗经验。　方法　主动脉窦瘤破裂85例，合并室间隔缺损40例(47.1%)，主动脉瓣关闭不全15例(17.6%)，均以补片行主动脉窦瘤修补，其中40例以同一补片修补主动脉窦瘤和室间隔缺损，5例同期行主动脉瓣置换术，3例行主动脉瓣成形术。　结果　全组死亡3例，死亡率3.5%，无残余分流等并发症，71例随访2个月～24年，心功能恢复良好。　结论　主动脉窦瘤破裂一经确诊，应尽早手术，采用补片修补主动脉窦瘤及用同一乒乓球拍形补片修补窦瘤和室间隔缺损，效果较好。对于严重的主动脉瓣关闭不全，应同期行主动脉瓣置换术，而轻度主动脉瓣关闭不全可不用特殊处理。

Outcome of Short and Middle Term of Right Ventricular Outlet Tract Reconstruction with Gore-Tex Monocusp Valve

Abstract: Objective To evaluate the outcome of reconstruction of right ventricular outlet tract (RVOT) with 0.1 mm Gore-Tex monocusp valve for short and middle term. Methods Between June 2002 to July 2006, 48 patients underwent reconstruction of RVOT with Gore-Tex monocusp valve to correct cardiac anomalies, including 33 patients with tetralogy of Fallot (TOF) and pulmonary stenosis, 8 patients with TOF and pulmonary atresia, 3 patients with TOF and absent pulmonary valve, 2 patients with double outlet of right ventricle and pulmonary stenosis, 1 patient with truncus arterious and 1 patient with complete transposition of great artery, ventricular septal defect and pulmonary stenosis. Results There was no operative death. The postoperative blood oxygen saturation was up to 1.00. The ratioes of right ventricular systolic pressure and left ventricular systolic pressure were between 0.22 to 0.65.The gradient between right ventricle and left or right pulmonary artery was less than 10 mmHg. All patients were followed up including echocardiography ranged from 3 to 48 months. There were no late death and complication. Trivial and mild pulmonary insufficiency was detected in 18 patients and valvular motion remained competent in 40 patients. Conclusion The results suggest that the reconstruction of RVOT with Gore-Tex monocusp valve can achieve excellent outcome for short and middle term.

冠状动脉瘘27例

Surgical treatment for double outlet of ventricle with atrioventricular discordance

Objective To report the surgical treatment for double outlet of ventricle with atrioventricular discordance. Methods 11 patients aged from 3 to 25 years underwent surgical treatment for double outlet of ventricle with atrioventricular discordance. 10 of them were double outlet right ventricle and the other one was double outlet left ventricle. The surgical treatment included biventricular repair (n=9) and single ventricular repair (n=2). The biventricular repair was performed by intraventricular patch repair and extracardiac valved conduit or homograft valved conduit. The single ventricular repair included bidirected Glenn operation and total cavopulmonary connect. Results There were two early deaths in biventricular repair and no death in single ventricular repair. The cause of death was severe low cardiac output syndrome. Four survivors in biventricular repair were followed up from 1 to 11.5 years, three of them were in NYHA class Ⅰ or Ⅱ and one in NYHA class Ⅲ. Conclusions Double outlet of ventricle with atrioventricular discordance can be treated by biventricular repair or single ventricular repair according to the development of ventricle and pulmonary arteries. Closure of ventricular septal defect , no obstruction from ventricle to great artery and no harm of conduction system are the keys of conventional management to achieve good results.

Therapeutic efficacy of extracardiac conduit total cavopulmonary connection

Objective To summary the experience of extracardiac conduit total cavopulmonary connection (TCPC) and study the operative indication, design, method, and therapeutic efficacy. Methods 29 patients of extracardiac conduit TCPC were reviewed:the average age was 10 years. Of them, there were 9 cases of tricuspid atresia, 9 double inlet ventricle with left ventricular type, 3 mitral atresia, 3 corrected transposition of the great arteries with anatomically right ventricular hypoplasia and 5 double outlet of right ventricle with left ventricular hypoplasia. All patients underwent cardiopulmonary bypass, 12 cases with heart arrested, and 17 without heart arrested. In them, 20 cases’ superior vena cava were anastomosed directly to the upper margin of right pulmonary artery, 9 cases deviated to the left side of right pulmonary artery to enlarge the stoma. For the inferior vena cava stoma, 22 cases’ anterior walls of right atrium were partially incised, and sutured to the posterior wall, then anastomosed with Gore-Tex blood vessel prostheses and connected to pulmonary trunk, and the other 7 cases’ bottom of right atrium was totally incised, the proximal was closed, and the distal was anastomosised with Gore-Tex blood vessel prostheses and connected to the lower margin of right pulmonary artery, deviated to the right sidedness. Results 5 died in the first 22 cases, and the next 7 cases all survive. All patients were followed up for 3 months to 10 years with no late death. Of them, 12 cases had low cardiac output syndrome, and 11 cases of chylothorax. Conclusions Compared with other types of Fontan operation, the extracardiac conduit TCPC has better long-term effects in older or grown-up children. Nevertheless, strict operative adoption, reasonable operative design, refined procedures, carefully observation and treatment are the key points of improving therapeutic efficacy.

慢性缩窄性心包炎的外科治疗

目的 总结慢性缩窄性心包炎的外科治疗经验。方法 78例患者术前均被明确诊断为慢性缩窄性心包炎，均在全身麻醉下经胸部正中切口行心包剥脱术。结果 术后中心静脉压6.5～14.0mmHg（1kPa=7.5mmHg），平均8mmHg。死亡1例，再次开胸止血2例，发生低心排血量综合征3例。术后病理检查：心包纤维结缔组织增生、玻璃样变性60例，呈于酪样结核病变18例（伴结核肉芽肿形成7例）。随访65例，随访时间3个月～10年，心功能（NYHA）均为I级，无心包缩窄复发和死亡。结论 手术是治疗慢性缩窄性心包炎惟一有效的方法，胸部正中切口是较佳的手术径路，心包切除范围应根据具体病情而定，力争将心包彻底松解切除。

Surgical correction of complete atrioventricular septal defect associated with tetralogy of Fallot

Objective To summarize the experience of surgical correction of complete atrioventricular septal defect associated with tetralogy of Fallot(CAVSD-TOF). Methods Twelve patients aged 6-16(11.1±2.8) years underwent correction of CAVSD-TOF. The atrioventricular septal defect was closed through a right atriotomy and longitudinal right ventriculotomy in each case. The three-patch technique was used for the first 7 cases and two-patch technique for the later 5 cases. The commissure between the superior and inferior bridging leaflets of the left portion of the common atrioventricular valve was closed in each patient. Right ventricular outflow tract obstruction was relieved by a transannular patch. Results There were 4 deaths in the early postoperative period, 3 deaths in the first 7 cases compared to 1 death in the later 5 cases. The causes of death included severe low cardiac output syndrome(3 cases) and perfusion pulmonary edema(1 case). Six survivors were followed up from 3 months to 13.5 years. Heart function (NYHA) was class I or Ⅱ in all cases. Conclusion CAVSD-TOF can be corrected by using the two-patch technique and closure of atrioventricular septal defect through a combined approach through right atriotomy and right ventriculotomy. Routine closure of the commissure of the left portion of the atrioventricular valve achieves a low incidence of regurgitation.

The Long Effect of Nonpulsatile Flow on Changes of Structure and Function in Pulmonary Microcirculation

Objective To investigate the long effect of nonpulsatile flow on changes of structure and function in pulmonary microcirculation and to identify the pulmonary reconstruction under this blood perfusion. Methods Canine models with nonpulsatile flow in the right lung was established, and sacrificed 6 months later. Compare endothelial nitric oxide synthase (eNOS) in vascular endothelium, apoptosis in smooth muscle cell with immunohistochemistry by streptavidinbioepidermmultienzyme complex methodes, and observe structural changes in pulmonary arterioles with optical microscope. Results The expression of eNOS in the right nonpulsatile flow perfusing lung was weaker as compared to the left lung （10 846.7±177.8 vs. 13 136.1±189.6;t＝2.240, P=0.040）, the fas was ber as compared to the left lung（14 254.1±217.1 vs. 11 976.7±195.7; t＝2.160, P=0.040）. The ratio of wall thichness/vessel diameter in the right lung（13.64%±12.80% vs. 14.96%±13.10%） and wall area/vessel area(46.40%±11.70% vs. 47.80%±12.20%) was lower as compared to the left lung(Plt;0.05). Conclusion Longterm nonpulsatile flow can decrease the expression of eNOS, contract the muscles in capillary net, and increase pulmonary vascular resistance. Moreover it canincrease the arteriole apoptosis, leading to vascular structure remodeling.

右腋下直切口手术治疗先天性心脏病

目的 通过右腋下直切口治疗先天性心脏病可以达到创伤小、疼痛轻、美观的目的.方法 本组40例患者中,进行单纯型继发孔房间隔缺损修复18例,房间隔缺损并二尖瓣关闭不全修复3例,室间隔缺损修复15例,法洛四联症心内根治术2例,心内型完全性肺静脉异位引流和部分房室管畸形修复各1例.结果 全组无手术死亡.体外循环时间18～66分30秒,主动脉阻断时间为3～52分;术后6～12天出院.结论 微创伤切口先天性心脏病手术能达到完全修复的效果.

The Effect of Ischemic Preconditioning on Myocardial Ischemic Reperfusion of Elderly Rats

Objective To investigate the effect of ischemic preconditioning(IPC) on myocardial ischemic reperfusion injury(I/R) of elderly rats. Methods Fiftysix Wistar rats, of which there were 28 aged from 21-23months(elderly rat) and 28 aged from 4-5months(young rat), were used to build isolated heart perfusion Langendorff model. The rats were divided into 7 groups with random number table（8 in each group）: adult control group, adult I/R group, adult IPC group, elderly control group, elderly I/R group, elderly IPC group and elderly enhanced IPC group. The control group underwent a 90-min perfusion without any intervention; the I/R group underwent a 30-min equilibration period, then a 30-min ischemia and a 30-min reperfusion; the IPC group underwent a 10-min equilibration period, then a 5-min ischemia for twice and a 5-min reperfusion, after that a 30-min ischemia and [CM(158-3mm]a 30-min reperfusion; the enhanced IPC group underwent a 10-min equilibration period, then a 5-min ischemia for 4-times and a 5-min reperfusion, after that a 30-min ischemia and a 30-min reperfusion. The recovery rates of cardiac output(CO), left ventricular developed pressure (LVDP), the maximum rising and descending rate of left ventricular pressure (±dp/dtmax) after a 30-min reperfusion were compared among groups. The activity of creatine kinase (CK) in coronary outflow, the level of malonyldialdehyde (MDA) and superoxide dismutase (SOD) before ischemia and after a 30min reperfusion were detected. The myocardial infarction areas were compared among groups. Results After a 30min reperfusion, compared with adult I/R group, in adult IPC group CK reduced significantly(89.48±18.72 U/L vs. 115.76±16.72 U/L，q=6.061，Plt;0.01)，the level of MDA decreased significantly（9.53±3.44 nmol/ml vs. 16.84±2.29 nmol/ml，q=7.732，Plt;0.01)，the level of SOD increased significantly（584.7±122.62 U/ml vs. 429.46±85.24 U/ml，q=4.754，Plt;0.01)，the recovery rates of CO,LVDP,+dp/dtmax and -dp/dtmax increased ignificantly(78.69%±9.68% vs. 65.10%±8.63%，83.61%±8.46% vs. 67.23±8.68%，81.68±8.68% vs. 67.89%±6.89%，89.79%±7.78% vs. 66.79%±8.46%，Plt;0.01), the myocardial infarction areas reduced significantly (5.25%±4.33% vs. 14.75%±8.02%,q=7.458，Plt;0.01)。There was no statistical significance between elderly IPC group and elderly I/R group in the above indexes（Pgt;0.05）.However, There was statistical significances between elderly enhanced IPC group and I/R group. CK reduced significantly (88.60±28.32 U/L vs. 105.76±9.64 U/L，q=5.620，Plt;0.01)，the level of MDA decreased significantly（8.38±3.36 nmol/ml vs. 16.80±3.06 nmol/ml，q=7.500，Plt;0.01)，the level of SOD increased significantly（558.87±78.66 U/ml vs. 433.75±86.65 U/ml，q=7.335，Plt;0.01)，the recovery rates of CO,LVDP,+dp/dtmax and -dp/dtmax increased significantly (77.99%±10.02% vs. 66.26%±9.78%，85.59%±6.67% vs. 73.90%±6.66%，83.87%±9.98% vs. 68.90%±8.68%，86.01%±766% vs. 70.39%±7.98%，Plt;0.01)， the myocardial infarction areas reduced significantly (795%±6.32% vs. 1568%±10.36%,q=8.680， Plt;0.01). 〖WTHZ〗Conclusion The protective effect of IPC on I/R elderly rat hearts has weakened. The enhanced IPC is able to regain the protective effect of IPC on elderly rat hearts.