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分段改良De Vega三尖瓣成形術治療功能性三尖瓣關閉不全

目的 評價分段改良De Vega三尖瓣成形術治療功能性三尖瓣關閉不全（FTR）的臨床療效，總結治療經驗。 方法 選擇2006年10月至2007年12月在我院手術治療的風濕性二尖瓣病變合并FTR患者共58例，根據三尖瓣成形手術方式的不同分為兩組，改良組：26例，男8例，女18例；年齡49.6±11.8歲；接受分段改良De Vega三尖瓣成形術。傳統組：32例，男6例，女26例；年齡47.9±12.8歲；接受傳統改良De Vega三尖瓣成形術。于圍手術期用超聲心動圖測量兩組患者三尖瓣瞬時反流量、三尖瓣瓣環周徑，并隨訪術后三尖瓣反流情況。 結果 兩組術后三尖瓣瞬時反流量均較術前減少（Plt;0.05），組間比較差異無統計學意義（F=1.969，Pgt;0.05）；三尖瓣瓣環周徑均較術前明顯縮小（Plt;0.01），組間比較差異無統計學意義（F=2.336，Pgt;0.05）；兩組均無因三尖瓣反流再次手術者。隨訪6~12個月時，兩組患者三尖瓣反流情況較出院前明顯改善，組間比較差異無統計學意義（Pgt;0.05）。 結論 分段改良De Vega三尖瓣成形術，能較為有效地糾正FTR，并可取得滿意的近期療效。

心瓣膜置換術后早期心肌頓抑致低心排血量綜合征的診治經驗

目的 探討心瓣膜置換術后早期心肌頓抑的識別、診斷，以及由此導致嚴重低心排血量綜合征（LCOS）的治療方法，以提高診斷、治療水平。 方法 回顧分析我科2004年9月至2006年9月期間4例心瓣膜置換術后早期出現心肌頓抑導致LCOS患者的臨床資料，4例均為女性，年齡35～54歲，平均年齡46-75歲。術前左心室大小、收縮功能均基本正常，左心室舒張期末內徑（LVEDD)3.5～6.3 cm，射血分數(EF)49%～61%；2例行二尖瓣、主動脈瓣置換術，1例行二尖瓣置換術，1例行主動脈瓣置換術。 結果 4例患者均在術后早期（14～40 h、平均26 h）出現無明確原因的LCOS，給予大劑量腎上腺素［0.10～0.15 μg/(min·kg）］治療無效而改行主動脈內球囊反搏（IABP）治療，4例患者IABP支持時間為7～12 d（平均8.5 d），3例痊愈，1例因肺部感染于術后28 d死于多器官功能衰竭。2例出現急性腎功能不全，1例7 d后腎功能恢復正常，1例經腹膜透析治療2周后痊愈。 結論 心肌頓抑可出現在術前心功能良好，手術經過順利的心瓣膜置換術患者，由心肌頓抑導致的術后早期LCOS，及時應用IABP可以減輕心臟負荷，增加冠狀動脈灌注，改善重要臟器循環，有助于左心室渡過心肌頓抑期，恢復收縮功能，是成功救治的重要手段。

白塞氏病合并主動脈瓣置換術后瓣周漏的臨床分析

摘要： 目的 總結白塞氏病所致主動脈瓣置換術后發生瓣周漏的外科治療經驗，探討相關手術方式和解決方法。 方法 回顧性分析第二軍醫大學附屬長海醫院收治的4例白塞氏病所致主動脈瓣置換術后瓣周漏患者的臨床資料，均為男性，年齡24～50歲(36±7歲)。其中3例為主動脈瓣重度關閉不全行主動脈瓣置換術后出現瓣周漏行改良Bentall手術，另1例為升主動脈瘤、主動脈瓣重度關閉不全行Wheat術后出現瓣周漏行改良Bentall手術。 結果 4例患者術后恢復順利，無并發癥發生。均痊愈出院。術后隨訪1～24個月，心功能恢復至Ⅰ～Ⅱ級。3～6個月定期行超聲心動圖和全主動脈血管造影檢查，未發現主動脈瓣周漏復發，人工機械瓣膜功能良好，人工主動脈血管通暢。 結論 白塞氏病合并主動脈瓣或升主動脈病變如單純行心瓣膜置換術，術后人工瓣膜脫落的發生率較高，改良Bentall手術方式是解決問題的良好方法。

原發性左心房低度惡性纖維粘液瘤樣肉瘤一例

先天性心臟病合并肺動脈瓣感染性心內膜炎的外科治療

目的　探討先天性心臟病合并肺動脈瓣感染性心內膜炎的外科治療方法和效果。　方法　2009年1月至2012年1月第二軍醫大學長海醫院收治先天性心臟病合并肺動脈瓣感染性心內膜炎患者6例，男1例，女5例；年齡8～41 （24.8±11.8）歲。動脈導管未閉（PDA）4例，PDA合并先天性主動脈瓣狹窄1例，室間隔缺損（VSD）合并三尖瓣反流1例。3例行PDA結扎＋肺動脈內贅生物清除術，1例行PDA結扎＋肺動脈瓣贅生物切除術，1例行PDA結扎＋肺動脈瓣贅生物切除術＋主動脈瓣置換術（AVR，置換19 mm CarboMetics環上機械主動脈瓣），1例肺動脈瓣膜破壞嚴重，行VSD修補＋右心室流出道贅生物清除＋右心室流出道拓寬＋三尖瓣成形術＋肺動脈生物瓣置換術（置換27 mm HancockⅡ型生物瓣）。　結果　6例患者術后均恢復良好，無圍術期死亡和心內膜炎復發。所有患者復查超聲心動圖提示，未見贅生物、殘余漏、瓣周漏等并發癥。術后隨訪6個月～3年中，患者臨床癥狀完全消失，均無明顯不適。術后心功能恢復至Ⅰ級5例，Ⅱ級1例。　結論　對于先天性心臟病合并肺動脈瓣感染性心內膜炎患者，正確把握手術時機，積極行外科手術治療是最有效的治療方法。

Clinical Outcomes of Aortic valve Replacement for Surgical Treatment of Patients with Severe Aortic Stenosis and Left Ventricular Dysfunction

ObjectiveTo investigate clinical outcomes of aortic valve replacement (AVR)for surgical treatment of patients with severe aortic stenosis (AS)and left ventricular dysfunction (LVD). MethodsClinical data of 29 patients with severe AS and LVD (left ventricular ejection fraction (LVEF) < 0.50)who underwent AVR in Changhai Hospital between January 2000 and December 2011 were retrospectively analyzed. Patients with mitral stenosis were excluded from this study. There were 22 male and 7 female patients with their age of 14-76 (56.3±12.9)years. Preoperative and postoperative clinical and echocardiographic findings were compared to assess AVR effects. Possible risk factors affecting postoperative recovery of left ventricular function were analyzed according to postoperative LVEF changes. ResultsOne patient died within 30 days after AVR. In the other 28 patients, postoperative aortic pressure gradient (APG)decreased from 97.6±25.1 mm Hg to 25.0±9.7 mm Hg, while LVEF increased from 41%±6% to 56%±11%. Postoperative left ventricular end-diastolic/systolic diameter/volume all significantly improved (all P < 0.001). ConclusionsAVR is an effective treatment for patients with severe AS and LVD. Left ventricular function improves significantly in most patients after AVR. Patients with a less dilated left ventricle may have a better LVEF recovery.

Clinical Analysis of Repeated Heart Valve Surgery in 325 Patients

Abstract： Objective To summarize surgical experiences and explore risk factors of patients undergoing repeated heart valve surgery. Methods Clinical records of 325 consecutive patients who underwent repeated heart valve surgery from January 1998 to December 2008 in Changhai Hospital of Second Military Medical University were retrospectively　 analyzed. There were 149 male patients and 176 female patients with their average age of （47.1±11.8） years. Following　 variables were collected: preoperative morbidity， heart function， indications and surgical strategies of repeated heart valve surgery， postoperative mortality and morbidity， which were compared with those clinical data of patients who underwent their first heart valve surgery during the same period. Multivariate logistic regression was used to determine risk factors of perioperative death of patients undergoing repeated heart valve surgery. Results The main reasons for repeated heart valve surgery were mitral valve restenosis after closed mitral commissurotomy and new other valvular diseases. Postoperatively， 28 patients died in the early-stage with the overall mortality of 8.6% （28/325）. The main reasons of in-hospital death included low cardiac output syndrome （LCOS）and acute renal failure. Compared with patients undergoing their first heart valve surgery， patients who underwent repeated heart valve surgery were more likely to have chronic obstructive　 pulmonary disease （COPD)， New York Heart Association (NYHA） classⅢ-Ⅳ， and atrial fibrillation， preoperatively. Their cardiopulmonary bypass time and aortic cross clamp time were comparatively longer. They also had more postoperative　 morbidities such as LCOS， acute renal failure and acute respiratory distress syndrome （ARDS）. Multivariate logistic regression showed that preoperative critical state （OR=2.82， P=0.002）， cardiopulmonary bypass time longer than 120 minutes （OR=1.13， P=0.008）， concomitant coronary artery bypass grafting （OR=1.64， P=0.005）， postoperative LCOS（OR=4.52， P＜0.001）， ARDS （OR=3.11， P＜0.001） and acute renal failure （OR=4.13， P＜0.001）were independent risk factors of perioperative death of patients undergoing repeated heart valve surgery. Conclusion Repeated heart valve surgery is a difficult surgical procedure with comparatively higher risks. Full preoperative assessment of the valvular lesions，　 proper timing for surgery and perioperative management are helpful to reduce postoperative mortality and morbidity.