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右心房橫紋肌肉瘤手術治療一例

聯合右心房-肺動脈切口手術一期根治嬰幼兒法洛四聯癥

目的　探討聯合右心房-肺動脈切口徑路手術一期根治嬰幼兒法洛四聯癥（TOF） 的療效，總結其臨床經驗。 方法 回顧性分析 2006年1月至2012年1月解放軍第91中心醫院采用聯合右心房-肺動脈切口徑路行一期根治術治療69例嬰幼兒TOF的臨床經驗，其中男47例，女22例；年齡5個月至2歲7個月；體重5～16 kg。心臟超聲心動圖提示：左心室舒張期末容積指數（LVEDVI） 24.5～36.9 ml/m2，Nakata指數＞120 mm2/m2，McGoon比值1.15～2.20。 結果 圍術期死亡2例，死亡率2.9%，其中術后死于肺部感染1例，滲漏綜合征1例。術后患者血流動力學平穩，不需使用大劑量的血管活性藥物。呼吸機輔助呼吸時間（11.7±9.3） h，住ICU時間（38.2±20.7） h。生存的67例患者均順利出院，動脈血氧飽和度由術前平均85%上升至99%，臨床癥狀改善，活動耐量增加，心功能（NYHA分級）恢復至Ⅰ～Ⅱ級。隨訪67例，隨訪率100%，隨訪時間11～70個月。隨訪期間無死亡，1例于術后3個月因大量心包積液行心包穿刺引流，1例于術后8個月因肺動脈瓣狹窄再次行手術矯治，其余患者恢復良好，心功能（NYHA分級）Ⅰ～Ⅱ級。 結論 聯合右心房-肺動脈切口徑路手術一期根治嬰幼兒TOF安全、可行，較常規手術縮短了體外循環時間，減少了右心室創傷，避免患者遠期右心室功能衰竭、室性心律失常導致的猝死，有利于患者遠期生存，效果滿意。

Continuous Half-thickness Suture Outside of the Pectinate Muscles in the Right Atrium Incision in Adult Patients Undergoing Cardiac Surgery

ObjectiveTo evaluate the continuous half-thickness suture outside of the pectinate muscles in the right atrium incision in adult patients undergoing cardiac surgery. MethodsA total of 1 040 consecutive adult patients undergoing cardiac surgery by the right atrium incision with cardiopulmonary bypass (CPB) were randomly divided into a control group (n=518 with 236 males and 282 females at mean age of 44.55 years) and a trial group (n=522 with 242 males and 280 females at mean age 45.75 years) between January 2010 and June 2014. The right atrium incision was sutured by continuous full-thickness suture in the control group and sutured by continuous half-thickness suture in the trial group. After the suture, the bleeding in the right atrium incision was recorded. ResultsAll patients underwent the open-heart operation. Seven patients died of postoperative low cardiac syndrome including four patients in the control group and 3 patients in the trial group. The heart incision was inspected before suturing the pericardium. A total of 203 patients of local active bleeding were stitched again in the right atrium incision in the control group. Only 26 patients were stitched again in the trial group (P<0.001). In the cases of re-exploration for bleeding or tamponade after cardiac operation, 3 patients of bleeding due to the right atrium incision were confirmed in the control group, and no one was confirmed in the trial group. ConclusionThe continuous half-thickness suture in the right atrium incision can prevent the incision bleeding, and avoid locally stitching again in adult patients undergoing cardiac surgery.

“一鞘兩傘” Hybrid 技術封堵室間隔缺損殘余漏及左心室右心房通道一例

經皮椎體成形術后右心和下腔靜脈骨水泥占位一例

The Study on the Relationship between Daily Activity and Patent Foramen Ovale

ObjectiveTo study the relation between daily activity that can make right atrium pressure rise (such as abdominal belt, sighs, weight lifting) and patent foramen ovale (PFO). MethodsA total of 122 cases of positive patients by the routine transcranial Doppler (TCD) foaming test between 2014 and 2015 were collected. Forty-one patients underwent TCD foaming test in the case of abdominal belt, 41 in the case of sighs, and 40 in the case of weight lifting. We recorded the right to left shunting of the above three cases, and compared them with the normal TCD foam test. ResultsThere was a significant difference in the positive rate between the sigh group and abdominal belt group, and between the sigh group and weight lifting group (χ2=10.5, 7.40; P<0.01). The positive rate in the abdominal belt group was not significantly different from that of the weight lifting group (χ2=0.314, P>0.05). In the sigh group, the sigh shunting volume was significantly higher than that when the patients were at rest. The shunting volume was the biggest when the patients had Valsalva movement, followed by sighing and resting. ConclusionThe daily activity that can make right atrium pressure rise (such as abdominal belt, sighs, weight lifting) can increase the shunting flow from the right to the left. The highest positive rate occurs when patients sigh. This study can provide a certain theoretical basis for the pathogenesis of patent foramen ovale and cryptogenic stroke.

經食管超聲心動圖引導右心房巨大粘液瘤切除一例

延伸入右心房內腫瘤的外科治療

目的　總結膈下腫瘤蔓延至右心房的外科治療經驗。　方法　自 1991年 5月～ 2 0 0 2年 11月外科治療膈下腫瘤蔓延至右心房 6例 ,病變來源于子宮平滑肌瘤 3例 ,子宮間質肉瘤 1例 ,下腔靜脈粘液肉瘤 1例 ,腎平滑肌肉瘤 1例。 5例完整切除右心房和下腔靜脈內腫瘤 ,1例部分切除。　結果　無手術死亡 ,1例粘液肉瘤患者部分切除腫瘤術后 5個月死亡 ,其余患者隨診 5個月～ 3年 ,下腔靜脈內無腫瘤復發 ,無明顯癥狀。　結論　膈下腫瘤蔓延至右心房應積極手術治療 ,手術盡量完整切除腫瘤 ,中期療效良好。

經右心房切口行右心室流出道疏通術

目的　總結右心室流出道梗阻經右心房切口、三尖瓣口行右心室流出道疏通術的經驗。　方法　自2007年6月至2010年12月，安徽醫科大學第一附屬醫院對21例右室雙腔心、單純右心室流出道狹窄及法洛四聯癥患者［（14例右室雙腔心、4例單純右心室流出道狹窄和3例法洛四聯癥，流出道壓差為（52.56±17.31） mm Hg］，經右心房切口、三尖瓣口行右心室流出道疏通術，切除異常纖維環和增生肥厚肌束，疏通右心室流出道，對并發肺動脈瓣或瓣下狹窄的患者，再經肺動脈根部切口協助顯露，同時矯正其他并發畸形。　結果　所有患者手術順利，術后心功能均恢復滿意，術后超聲心動圖復查提示：右心室流出道疏通效果滿意，壓差＜20 mm Hg，7例術后有輕度收縮期雜音。術后隨訪至6個月，隨訪期間所有患者體力活動完全恢復；復查心臟彩色超聲心動圖提示:無明顯右心室流出道室壁肥厚增生和再梗阻，右心室流出道壓差進一步縮小或消失。　結論　經右心房切口行右心室流出道疏通術適用于右室雙腔心、單純右心室流出道狹窄及部分法洛四聯癥患者，可避免直接切開右室壁引起的心肌、冠狀動脈損傷，減輕了術后瘢痕纖維增生，有利于術后心功能恢復。