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重癥冠心病的外科治療

Clinical Analysis of 1405 Patients Undergoing Coronary Artery Bypass Grafting and Transmyocardial Laser Revascularization

Objective To summarize the essential of perioperative therapy and improve the prognosis of coronary artery bypass grafting （CABG） and transmyocardial laser revascularization （TMLR） through analyzing 1405 patients with coronary atherosclerotic heart disease. Methods From May 1997 to January 2006, 1 405 patients were treated in our hospital. On-pump CABG were performed in 825 patients, single CABG were performed in 666 patients, CABG with cardiac valvular operation in 98 patients, CABG with cardiac ventricular aneurysm resection in 55 patients, CABG with ventricular septal defect repairment in 2 patients; CABG with left atrium gelatinous tumor resection in 2 patients, CABG with ascending aorta repairment in 1 patient, and mediastinal septum tumor resection in 1 patient. Off-pump coronary artery bypass grafting （OPCAB） were performed in 500 patients; single TMLR were performed in 30 patients, CABG＋TMLR were performed in 50 patients. Results The number of bridge vessel was 2.9±1.0. Forty-two patients（3.0%） died of bleeding, myocardial infarction, low cardiac output syndrome, renal failure, multiple organ failure（MOF） and so on. Various complications were occurred in 70 patients（5.0%）, including bleeding, low cardiac output syndrome, myocardial infarction, renal failure and so on. All of them were recovered after treatment. There were 1 177 patients of angina in grade Ⅲ-Ⅳ （CCS） before operation, 1 154 of them （98.0%） changed in grade 0-Ⅰ （CCS） postoperatively. There were 857 patients （62.9%） in follow-up for 8.3±2.9 months postoperatively. There was no angina in 788 patients（91.9%） 6 months after surgery. The ultrasonic graphic showed that left ventricular ejection fraction was 0.66±0.10 and raised 7.9% than that before operation. The quality of life was better than before. Conclusion CABG has become the most potent routine operation in the therapy of coronary artery disease. It can extend the applications of CABG and improve the operative prognosis, if the indications are correctly mastered and the perioperative management are enhanced.

體外循環冠狀動脈旁路移植術圍手術期血漿腦鈉肽的變化及其臨床意義

目的 觀察體外循環冠狀動脈旁路移植術(CABG)圍手術期血漿腦鈉肽（brain natriuretic peptide,BNP）的變化規律。 方法 2005年7～10月我院收治20例CABG患者，分別于麻醉誘導后，主動脈開放前，開放后20 min，進入ICU，術后12 h，24 h和48 h測量血漿BNP濃度，分析圍手術期BNP的變化規律，以及BNP與心功能、血流動力學指標及術后血漿肌酸激酶同工酶(CKMB)、肌鈣蛋白(TNT)等的相關關系。 結果 麻醉誘導后BNP與左心室射血分數（LVEF）呈明顯負相關（r=-0.912，P=0.000），與左心室舒張期末內徑（r=0.714，P=0.000），肺毛細血管楔壓(PCWP，r=0.809，P=0.000），中心靜脈壓(r=0.787，P=0.000）呈明顯正相關。手術前后BNP濃度的差異有統計學意義（F=42.259,Plt;0.01），從主動脈鉗開放后逐步上升，并在術后24 h達峰值。進入ICU，術后12 h，24 h的BNP濃度與PCWP呈明顯正相關（r=0.602，P=0.005；r=0.554，P=0.011；r=0.631，P=0.003），與CK-MB濃度呈明顯正相關(r=0.528，P=0.017；r=0.638，P=0.002；r=0.882，P=0.000)；但與TNT濃度的相關性不明顯。 結論 冠心病患者術前血漿BNP濃度能正確反映術前的心功能狀態；心肌缺血再灌注損傷是術后BNP大量釋放的原因；術后BNP監測能正確及時地反映患者的心功能狀態，特別是前負荷狀態。

三房心外科治療六例

Combined Coronary Artery Bypass Grafting and Valve Replacement: Report of 80 Cases

Abstract: Objective To summarize the experience of combined coronary artery bypass grafting(CABG) and valve replacement. Methods From May 1997 to March 2006, the results of 80 consecutive patients undergone valve replacement (MVR) and CABG were analyzed. CABG were performed withtotal grafts in 159 grafts (mean 1.99 grafts), with mitral valve replacement (MVR) in 49 patients, with aortic valve replacement (AVR) in 18 patients, with MVR+AVR in 13 patients(mechanical valve replacement in 68 and biological valve replacement in 12). Results The hospital time after operation was 19.2±13.4d. The hospital mortality rate was 12.5% (10/80). The primary cause of death included low cardiac output yndrome, acute renal failure, nervous system complications ,ventricular fibrillation and cardiac arrest. Multivariate testing of preoperative and operative description identified that preoperative myocardial infarction, worse cardiac function, radiographic cardiac enlargement and low ejection fraction were associated with an increase of hospital mortality (P＜0.05). There were postoperative complications including bleeding, severe ventricular arrhythmia, nervous system complications and incision infection. Followup of 58 patients (82.86%, range 6 to 60 months) showed the symptoms of angina pectoris and heart failure were significantly relieved. There were 2 longterm deaths (cerebral infarction and lung infection). Conclusion Combined CABG and valve replacement is an effective way for treatment of coronary artery and valvular heart disease. Improving the heart function preoperatively, strengthening myocardial protection, shortening operation and myocardial ischemia time, and complete revascularization are the key factors for success operation.

Surgical Treatment for Patients with Stanford Type A Aortic Dissection

ObjectiveTo summarize our clinical experience of surgical treatment for 51 patients with Stanford type A aortic dissection (AD). MethodsClinical data of 51 patients with Stanford type A AD who received surgical treatment in Shanghai Yuanda Heart Hospital between February 2009 and January 2013 were retrospectively analyzed. There were 29 males and 22 females with their age of 35-63 (47.2±11.1)years. The diagnosis of all the patients was confirmed by enhanced CT scan and Doppler echocardiography. Surgical procedures included Bentall procedure and Sun's procedure in 29 patients, Bentall procedure, mitral valve replacement and Sun's procedure in 2 patients, ascending aorta replacement and Sun's procedure in 17 patients, valsalva sinus plasty, ascending aorta replacement and Sun's procedure in 2 patients, ascending aorta replacement (stage 1), Sun's procedure (stage 2)and endovascular exclusion of the thoracic aorta (stage 3)in 1 patient. ResultsMean operation time was 320.6±77.3 minutes, cardiopulmonary bypass time was 190.4±63.4 minutes, aortic cross-clamp time was 123.2±45.1 minutes, duration of circulatory arrest with hypothermia was 28.2±11.1 minutes, and mean length of hospital stay was 13.4±4.2 days. Two patients (3.9%)died perioperatively including 1 patient with intraoperative bleeding and another patient with delayed bleeding after operation. Postoperative complications included bleeding, paraplegia, perivalvular leak and sternal dehiscence in 1 patient respectively, and endoleak in 2 patients. Forty-nine patients were followed up for 3-48 (25.3±10.5)months and no late death occurred. ConclusionSurgical treatment is effective for patients with Stanford type A AD.

小腸黏膜下層-骨髓間充質干細胞移植-治療陳舊性心肌梗死

摘要: 目的 探討自體骨髓間充質干細胞(MSCs)小腸黏膜下層(SIS)支架復合物移植于陳舊性心肌梗死區域后細胞的存活、支架的降解情況及其對心功能的影響。 方法 將16只黑山羊按隨機數字表法分為兩組，每組8只。實驗組：建立心肌梗死模型，抽取自體骨髓,經體外分離MSCs,進行培養、傳代、BrdU標記、與SIS支架復合，并于心肌梗死6周時將MSCs-SIS復合物補片移植至陳舊性心肌梗死區；對照組：建立心肌梗死模型。于移植后6周行超聲心動圖、HE染色及免疫組織化學檢測。 結果 MSCs-SIS植入心肌梗死區2周時在補片區可見大量炎性細胞浸潤；6周時淋巴細胞浸潤消失，SIS部分降解，移植區見大量移植細胞存活。MSCs-SIS植入體內后6周時，實驗組每搏輸出量(42.81±4.91 ml vs. 37.06±4.75 ml)、射血分數(59.20%±5.41% vs. 44.56%±4.23%)、室壁增厚率（54.51%±8.60% vs. 43.36%±8.91%）、舒張期E峰 (54.85±6.35 cm/s vs. 43.14±4.81 cm/s)顯著高于對照組(Plt;0.05)，左心室收縮期末容積(29.75±5.98 ml vs. 46.25±6.68 ml)、舒張期末容積(72.55±8.13 ml vs. 83.31±8.61 ml)顯著低于對照組(Plt;0.05)。 結論 SIS作為支架移植MSCs有利于移植細胞存活，對陳舊性心肌梗死后心功能有明顯的改善作用。

Uniportal Procedure for the Correction of Pectus Excavatum in 203 Patients

ObjectiveTo summarize the clinical experience and investigate the safety and reliability of uniportal procedure for the correction of pectus excavatum (PE). MethodsFrom November 2010 to November 2015, 203 PE patients (164 males, 39 femalzs average age of 5.7±3.0 years, ranging from 2 to 19 years) underwent the correction operation with only single 2 cm incision on right lateral chest. There were 188 patients under 12 years of age and 15 patients above 12 years. According to Park classification, 176 patients were symmetric and 27 were asymmetric. ResultsAll operations were performed successfully. The average operating time was 16.1±5.2 min with a range of 4-65 min and the average postoperative hospital stay was 6.4±1.3 d, ranging from 4-14 d. A single incision was made on the right chest and only one bar was inserted in the patients. Postoperative follow-up was 1-56 months (mean, 27.6 months). There was no complication occurred such as bar turnover, displacement and redepressed sternum. Totally, 84 patients received bar removal procedure. ConclusionIn terms of operation time and surgical trauma, uniportal procedure for PE is superior to Nuss procedure. And there is no significant difference in the safety and effectiveness between two procedures. Uniportal procedure is especially suitable for the treatment of PE children under 12 years of age.