解剖外人工血管旁路移植术治疗复杂主动脉缩窄

目的 总结解剖外人工血管旁路移植术治疗复杂主动脉缩窄48例的手术治疗经验.方法 1997年7月至2008年7月,采用解剖外人工血管旁路移植术治疗复杂主动脉缩窄48例.男34例、女14例.年龄10～58岁,平均(30±12)岁.病因有:主动脉缩窄合并心内畸形28例,主动脉缩窄合并升主动脉瘤1例,成人主动脉缩窄合并局部动脉壁钙化7例,主动脉缩窄合并弓发育不良4例,降主动脉长段或多发缩窄4例(各2例),主动脉缩窄合并局部动脉瘤形成1例,主动脉缩窄术后再狭窄合并心内畸形2例,主动脉缩窄介入术后再狭窄1例.手术方式有:升主动脉-腹主动脉旁路移植术37例,升主动脉.心包后胸降主动脉旁路移植术9例,左锁骨下动脉-降主动脉旁路移植术2例.旁路移植术应用直径8～18 mm(平均直径16 mm)人工血管.同期手术包括主动脉瓣置换术16例,二尖瓣成形或置换术9例,主动脉根部置换术6例,动脉导管未闭缝合术5例,升主动脉成形或置换术4例,室间隔缺损修补术3例,冠状动脉旁路移植术2例.31例于低温体外循环下完成手术.结果 住院死亡1例(2.1%),死于术后感染中毒性休克.术后机械性肠梗阻2例,均为升主动脉-腹主动脉旁路移植术后,予开腹探查后痊愈.二次开胸止血3例.术后上下肢平均收缩期压差较术前明显下降,术前(65±27)mm Hg,术后(14±11)mm Hg,差异有统计学意义(P<0.05).随访4～73个月,平均28.9个月,无晚期死亡,无人工血管相关并发症,无再次手术.5例患者残余高血压需药物治疗.结论 解剖外人工血管旁路移植术是治疗成人及青少年复杂主动脉缩窄的有效方法.升主动脉-腹主动脉旁路移植术可在非体外循环下进行,操作相对容易,应用最多.升主动脉-心包后降主动脉旁路移植术多需体外循环下完成,技术要求高.左锁骨下动脉-降主动脉旁路移植术经左后外切口,适用于无心内畸形的降主动脉缩窄.     

Treatment of in-stent coronary restenosis with excimer laser angioplasty

Objective To evaluate the efficacy and safety of excimer laser coronary angioplasty (ELCA) with adjunctive balloon angioplasty in patient with in-stent restenosis.Methods ELCA was performed in 20 patients of in-stent restenosis.All patients were symptomatic and had class Ⅲ-Ⅳ angina. ELCA was performed with the Spectranetics CVX-300 System. The laser catheter of Vittesse C (concentric) and E (eccentric) with diameter of 1.4-2.0 mm was used.Results Laser catheter crossed all stenotic stents without difficulty. The lesion length was 4.6-51.2 mm,mean 20.7±13.7 mm, including 14 lesions &gt;10 mm. Laser treatment alone increased minimal lumen diameter (MLD) from 0.3±0.3 mm to 1.4±0.3 mm (P&lt;0.0001) and improved the diameter stenosis from 88.8%±10.0% to 46.0%±8.0% (P&lt;0.0001). Adjunctive balloon angioplasty further increased minimal lumen diameter to 2.3±0.7 mm and reduced diameter stenosis to 14.2%±8.2% (P&lt;0.0001). At follow-up (1-17 months, mean 8.9±5.7 months), 17 (85%) patients had remained asymptomatic, 3 (15%) patients had mild to moderate exertional angina, 1 (5%) patient received CABG. Conclusion ELCA with adjunctive percutaneous transluminal coronary angioplasty (PTCA) is an efficient and safe technique to debulk tissue in the patient with in-stent restenosis. The incidence of procedural related complication was low and ELCA may be used as a good method for in-stent restenosis treatment.     

NuMED CHEATHAM-PLATINUM STENT AND BALLOON IN BALLOON DELIVERY CATHETER FOR TREATMENT OF NATIVE COARCTATION OF THE AORTA

COARCTATIONoftheaorta(CoA)isacongeni talheartdefectinvolvinganarrowingoftheaor ta.Thenarrowedsegmentcalledcoarctationismostlikelytohappeninthesegmentjustaftertheaorticarch.Thenarrowingcanberemovedbysurgeryorsome timesbyanonsurgicalballoondilation.However,…     

Percutaneous Balloon Angioplasty for Severe Native Aortic Coarctation in Young Infants Less Than 6 Months: Medium- to Long-term Follow-up

Background:

Although balloon angioplasty (BA) has been performed for more than 20 years, its use as a treatment for native coarctation of the aorta (CoA) during childhood, especially in young infants, remains controversial. This study aimed to assess the effects and potential role of percutaneous transcatheter BA for native CoA as an alternative therapy to surgical repair in young infants.

Methods:

The 37 patients aged from 6 days to 6 months with severe CoA in congestive heart failure or circulatory shock were admitted for BA. Patient''s weight ranged from 2.4 to 6.1 kg. All 37 patients were experiencing cardiac dysfunction, and eight patients were in cardiac shock with severe metabolic acidosis. Eleven patients had an isolated CoA, whereas the others had a CoA associated with other cardiac malformations. Cardiac catheterization and aortic angiography were performed under general anesthesia with intubation. Transfemoral arterial approaches were used for the BA. The size of the balloon ranged from 3 mm × 20 mm to 8 mm × 20 mm, and a coronary artery balloon catheter was preferred over a regular peripheral vascular balloon catheter.

Results:

The femoral artery was successfully punctured in all but one patient, with that patient undergoing a carotid artery puncture. The systolic peak pressure gradient (PG) across the coarctation was 41.0 ± 16.0 mmHg (range 13–76 mmHg). The mean diameter of the narrowest coarctation site was 1.7 ± 0.6 mm (range 0.5–2.8 mm). All patients had successful dilation; the PG significantly decreased to 13.0 ± 11.0 mmHg (range 0–40 mmHg), and the diameter of coarctation significantly improved to 3.8 ± 0.9 mm (range 2.5–5.3 mm). No intraoperative complications occurred for any patients. However, in one case that underwent a carotid artery puncture, a giant aneurysm formed at the puncture site and required surgical repair. The following observations were made during the follow-up period from 6-month to 7-year: (1) The PG across the coarctation measured by echocardiography further decreased or remained stable in 31 cases. The remaining six patients, whose PGs gradually increased, required a second dilation. No patient required further surgery because of a CoA; (2) in two cases, an aortic aneurysm was found with an angiogram performed immediately postdilatation and disappeared at 18 and 12 months of age, respectively; (3) tricuspid regurgitation and pulmonary hypertension improved in all patients; (4) all patients were doing well and were asymptomatic.

Conclusions:

Percutaneous BA is a relatively safe and effective treatment for severe native CoA in young infants, and should be considered a valid alternative to surgery because of its good outcome and less trauma and fewer complications than surgery.     

主动脉瓣病变合并升主动脉扩张的"背心式"人工血管包裹术及其应用效果

目的:总结一种"背心式"升主动脉和根部成形术对于防止主动脉瓣病变同时合并轻、中度升主动脉扩张的患者术后中、远期发生旷置的升主动脉进行性扩张或急性主动脉夹层的效果及应用该术式的体会.方法:对2002年10月至2006年6月间采用主动脉置换或成形、升主动脉缩小成形、升主和根部背心式人工血管包裹术("背心式"手术)治疗的30例主动脉瓣病变和升主动脉扩张的临床病例进行回顾性分析和随访,平均随访时间(18±10.5)个月.结果:30例"背心式"手术并同期其他部位手术病例的总体外循环平均时间(103.4±21.7)min(80～151 min),主动脉阻断平均时间(73.0±21.6)min(48～120 min),其中19例单纯行"背心式"手术的患者体外循环平均时间仅为(91.3±8.9)min(80～118 min),主动脉阻断平均时间(61.6±11.3)min(48～82 min),无住院死亡.平均随访18个月,无复发性主动脉扩张和夹层形成,升主动脉平均直径由术前的(46.7±3.1)mm(40～53mm)降为(33.7±2.5)mm(30～43mm).在本组30例患者中16例为先天性主动脉二瓣化畸形,23例主动脉瘤壁病理结果显示主动脉壁弹力纤维断裂(6例)、稀少(1例)和中、重度黏液性变(16例).结论:由于主动脉壁本身存在病理改变和血液动力学冲击,为防止远期升主动脉进一步瘤变或夹层形成,对以主动脉瓣病变为主的轻、中度主动脉根部扩张采用Robicsek术更为合理.相比Bentall和David术,此术式不仅可以缩短手术时间和减小手术风险,而且能够达到同样甚至更好的手术效果.     

经皮球囊瓣膜成形术治疗先天性主动脉瓣狭窄

为研究评价先天性主动脉瓣狭窄 (AS)球囊瓣膜成形术 (PBAV)的效果。方法　于 1986年 12月 - 1999年 8月应用PBAV术治疗了 2 7例AS病人 ,年龄 2 .5- 12岁 (平均 6 .0 9± 2 .2 6岁 )。PBAV术球 瓣比值 :发育良好型者 (19例 )为 0 .95± 0 .0 8;发育不良型 (8例 )则为 1.0 0± 0 .11。术前后测定左室和升主动脉压力及跨主动脉瓣压力阶差 (ΔP)。出院后多普勒超声心动图随访以监测跨主动脉瓣ΔP。结果　发育良好型者 15例 (占 78.9% )即刻效果良好 ,随访中有 4例 (2 6 .7% )ΔP回复至 50mmHg以上 ;发育不良型 4例 (占 50 % )效果良好 ,其中随访中有 3例回升 (占 75.0 % )。 2 7例PBAV后无一例有轻度以上主动脉瓣返流及其它并发症结论　PBAV术是一种对AS有效、安全的替代外科瓣膜切开的介入性治疗方法 ,而且发育良好型AS较发育不良型效果好     

TRANSCATHETER CLOSURE OF PATENT DUCTUS ARTERIOSUS

Ｒ啨ｓｕｍ啨　　 Ｏｂｊｅｃｔｉｆ　Ｅｘｐｌｏｒｅｒｌ ｅｆｆｉｃａｃｉｔ啨ｄｅｌａｆｅｒｍｅｔｕｒｅｔｒａｎｓｃａｔｈ啨ｔ啨ｒｉｅｎｎｅｄｅｌａｐｅｒｓｉｓｔａｎｃｅｄｕｃａｎａｌａｒｔ啨ｒｉｅｌ (ＰＣＡ )ａｖｅｃｌａｓｐｉｒｅ (ｃｏｉｌ)ｄ啨ｔａｃｈａｂｌｅｅｔａｖｅｃｌｅｂｌｏｑｕｅｕｒＡｍｐｌａｔｚｅｒ (Ａｍｐｌａｔｚｅｒｄｕｃｔｏｃｃｌｕｄｅｒ,ＡＤＯ) ,ｄｉｓｃｕｔｅｒｌｅｓｆａｃｔｅｕｒｓｉｍｐｌｉｑｕ啨ｓ .　Ｍ啨ｔｈｏｄｅｓ　Ｌａｆｅｒｍｅｔｕｒｅｔｒａｎｓｃａｔｈ啨ｔ啨ｒｉｅｎｎｅ…     

降主动脉缩窄手术的麻醉处理

目的总结和探讨23例降主动脉缩窄手术的麻醉处理方法。方法23例降主动脉缩窄患者在控制性降压及降温麻醉下行主动脉缩窄矫正术。麻醉采用芬太尼为主的静吸复合全麻,麻醉中同时监测上下肢血压,并应用微量泵静注硝普钠控制血压。结果麻醉诱导及阻断主动脉前上肢收缩压维持在100-130mmHg,下肢收缩压80-100mmHg,阻断主动脉时间16-48（32）min。阻断主动脉期间上肢收缩压波动在100-130mmHg之间,下肢收缩压40-52 mmHg。开放主动脉后上肢血压无明显降低。全组未发生与麻醉相关的并发症。结论降主动脉缩窄手术的麻醉处理重点在于控制性降压和适当的降温,并应严防急性心衰、心跳骤停、截瘫、急性肾功能衰竭等并发症的发生。     

手术治疗婴幼儿主动脉缩窄32例分析

目的总结32例婴幼儿主动脉缩窄的外科治疗经验。方法手术治疗婴幼儿主动脉缩窄(CoA)32例。单纯主动脉缩窄7例,合并动脉导管未闭(PDA)17例,合并心内畸形的25例,合并主动脉弓发育不良1例。采用正中胸骨切口或左侧切口,手术方法包括缩窄段切除主动脉端端或端侧吻合24例;纵行切开缩窄段,心包片加宽成形7例;1例应用锁骨下动脉片翻转法。结果死亡3例,29例患儿顺利出院,上下肢压力差消失,其中25例随诊3个月～3年,2例出现主动脉轻度狭窄。无其他并发症。结论婴幼儿主动脉缩窄的外科治疗可获得良好的近中期疗效,合并心内畸形的患儿大部分可采取正中切口一期手术。     

Use of covered Cheatham-Platinum stent as the primary modality in the treatment for native coarctation of the aorta

Background  Bare stent implantation in the treatment for native and recurrent coarctation of the aorta (CoA) has become established as an alternative to surgery and balloon angioplasty. However, this modality still encounters significant complications during the procedure and/or follow-up. The covered Cheatham-Platinum (CP) stent commonly used to be chosen as a rescue treatment in these patients. The purpose of this study was to evaluate the use of covered CP stent as the primary modality in the treatment for native CoA.

Methods  Twenty-five covered CP stents and 2 bare CP stents were implanted in 25 patients with native CoA. All patients after the intervention were invited for follow-up examinations.

Results  The peak systolic gradient across the lesion decreased significantly from a median value of 67.5 mmHg (quartile range, 19.3 mmHg) to 2 mmHg (quartile range, 4.0 mmHg) (P <0.0001). Stenotic segment diameter increased from a median value of 5.0 mm (quartile range, 1.5 mm) to 17.9 mm (quartile range, 2.5 mm) (P <0.0001). The median ratio of diameter of the coarctation postprocedure to preprocedure was 4.2 (quartile range, 1.6). All of the CP stents were placed in the suitable position without any acute complications. During a follow-up period of up to 72 months, no complications were encountered. Most of the patients (21/25) were normotensive, apart from four patients requiring antihypertensive medication during the follow-up.

Conclusion  The implantation of covered CP stent as the primary modality is safe and effective in the treatment for native CoA in adolescents and adults.

     

主动脉缩窄合并动脉导管未闭的介入治疗

目的 探讨主动脉缩窄（COA）合并动脉导管未闭（PDA）介入治疗新方法。方法 在全麻下完成操作，经12F输送鞘管将一主动脉带膜支架送至COA处，经双球囊扩张定位并置入。结合文献报道，对COA的类型、诊断、治疗及COA合并PDA的介入治疗进行讨论。结果 （1）经双球囊扩张及主动脉带膜支架置入后COA被解除，跨主动脉缩窄处收缩期压力阶差术前为90-96mmHg（1mm Hg=0．133kPa），术后基本消失。（2）术前四肢血压分别为：右上肢165／110mmHg、左上肢160／110mmHg、右下肢未满意测出、左下肢55／35mmHg；术后第3天四肢血压分别为：右上肢100／75mmHg、左上肢105／80mmHg、右下肢110／70mmHg、左下肢115／75mmHg。（3）随访3个月，惠儿血压正常，无并发症发生。结论 先天性COA并PDA患者可用双球囊可扩张性主动脉带膜支架治疗，且安全、有效。     

自体肺动脉瓣移植术在主动脉瓣病变治疗中的应用

目的　总结我院自体肺动脉瓣移植术 (Ross手术 )在主动脉瓣病变治疗中的临床经验。方法　从 1994年 10月至 2 0 0 2年 9月 ,共完成Ross手术 15例 ,其中 ,男 12例 ,女 3例 ,年龄 30± 14岁 ;术前诊断 :主动脉瓣病变 13例 ,老年退行性病变 1例 ,为重度主动脉瓣狭窄。亚急性细菌性心内膜炎 (SBE)合并主动脉瓣关闭不全 1例 ,术前UCG示主动脉瓣病变 ,狭窄和 /或关闭不全 (中重度 ) ,主动脉瓣环径 (AVD) :2 4± 0 4cm ;肺动脉瓣发育正常 ,功能良好 ,肺动脉瓣环径 (MPAD) :2 3± 0 2cm ;术前心功能 (纽约心脏协会NYHA)Ⅱ级 11例 ,Ⅲ级 4例 ,平均 :2 3级 ;所有病例均在全麻中度低温体外循环下进行 ,手术分三步进行 :(1)采取自体肺动脉瓣 ;(2 )切除病变的主动脉瓣并移植自体肺动脉瓣于主动脉位 ,采用主动脉根部移植法 ;(3)利用同种动脉瓣重建右室流出道 ;结果全组患者无手术死亡 ;术后主动脉平均跨瓣压差在正常范围 (7 2 3± 0 14mmHg) ,左室舒张未径 (LVDD)明显缩小 (P <0 0 0 1) ,LVEF :0 4 8± 0 2 2 ,心功能Ⅰ～Ⅱ级。所有患者均接受随访 ,随访 1～ 9年 ,心功能Ⅰ级 ,主动脉瓣、肺动脉瓣均功能良好 ,末见瓣膜狭窄或关闭不全。结论　Ross是一种临床疗效好的治疗主动脉瓣病变的手术方法。     

主动脉峡部环扎构建猪导管前型主动脉缩窄模型

目的建立主动脉峡部环扎构建猪导管前型主动脉缩窄模型。方法将10头猪麻醉后,经左侧第三肋间开胸,使用聚对二氧环己酮单丝可吸收缝线环绕主动脉峡部,固定其直径,测定主动脉峡部直径及跨主动脉峡部的收缩压差值（△P）。8周后,行心导管介入术,再次测定主动脉峡部直径及△P,用球囊导管对主动脉峡部进行扩张。结果8周后,2头动物主动脉峡部直径增大,未测得△P;建模成功率为80％。建模成功的8头动物,在心导管介入术时的体质量明显高于建模前,差异有统计学意义（P〈0．01）;球囊扩张术后的△P显著高于建模前,差异有统计学意义（P〈0．01）;但球囊扩张术后主动脉峡部内径无明显增大,差异无统计学意义（P〉0．05）。结论成功建立了主动脉峡部环扎构建猪导管前型主动脉缩窄模型的方法。     

主动脉缩窄合并心内畸形的外科治疗的临床研究

目的探讨主动脉缩窄合并心内畸形的外科治疗方法.方法 2003年1月至2010年3月共手术治疗CoA合并其他心内畸形11例,其中合并VSD5例,PDA2例,VSD＋PDA4例.合并主动脉弓发育不良1例.全组均行一期矫治.9例采用胸骨正中切口加左后外侧切口进行矫治,行人造血管旁路植入术.2例行胸骨正中单一切口,动脉缩窄段切除端-端或端侧吻合术.结果全组无手术死亡,均顺利出院.随访3月至4a,术后恢复良好.复查心脏超声,无吻合口狭窄,无吻合口处动脉瘤形成.结论根据患者年龄选择适合的手术方式,主动脉缩窄合并心内畸形有良好的疗效。     

双源CT对主动脉缩窄的诊断价值

目的评价双源CT（DSCT）对主动脉缩窄的诊断价值。方法采用西门子DSCT扫描机,连续容积增强扫描,对8例以心悸、气短就诊的患者进行DSCT检查并诊断为主动脉缩窄的病例进行分析。结果8例主动脉缩窄中,主动脉弓缩窄4例,胸主动脉缩窄4例。对所有扫描图像行多平面重组（MPR）及容积再现（VR）、最大密度投影（MIP）、表面阴影成像（SSD）、薄层VR重组。DSCT不仅全部显示缩窄的程度、形态,而且还显示了缩窄处与左锁骨下动脉和未闭动脉导管的关系。结论DSCT是评价主动脉缩窄快捷而有效的影像学技术,具有检查方便、迅速、无创伤、诊断正确率高等优点。     

主动脉弓部瘤及降部瘤的外科治疗

目的：总结主动脉弓部瘤及降部瘤的外科治疗经验。方法：4例主动脉弓部瘤及降部瘤患者,左心转流(LAV)3例,深低温停循环和选择性脑灌注(HCA SCP)1例。3例降主动脉瘤中,2例急诊在LAV下血管置换,1例择期在LAV下血管置换。1例弓部瘤急诊在HCA SCP下行半弓置换。结果：4例均无手术死亡及脊髓、肾脏损害,1例主动脉弓部瘤术后出现脑梗塞。结论：主动脉弓部瘤及降部瘤外科治疗中,选择正确的体外循环方法和适当的外科吻合技术对手术成功有重要的意义。     

幼猪主动脉缩窄模型的术式探讨

目的比较环扎法和横切纵缝法建立主动脉缩窄模型的长期效果。方法分别采用环扎法（环扎组,n=20）和横切纵缝法（横切纵缝组,n=20）建立幼猪主动脉缩窄模型,建模后第1、3、6个月分别进行血管造影检查和病理学检查。另选取10只幼猪作为假手术组。结果建模后1个月,环扎组和横切纵缝组狭窄段血管直径均显著小于假手术组（P〈0．01）,狭窄段存在一定的压力阶差。建模后3、6个月,环扎组狭窄段血管直径逐渐增加,与假手术组差异无统计学意义,压力阶差为0;横切纵缝组狭窄段血管直径均显著小于假手术组（P〈0．01）,压力阶差相对稳定。结论横切纵缝法可建立长期稳定的主动脉缩窄模型,可作为心血管支架研究的可靠动物模型。     

Coronary perfusion pressure and the return of spontaneous circulation in human cardiopulmonary resuscitation

Coronary perfusion pressure (CPP), the aortic-to-right atrial pressure gradient during the relaxation phase of cardiopulmonary resuscitation, was measured in 100 patients with cardiac arrest. Coronary perfusion pressure and other variables were compared in patients with and without return of spontaneous circulation (ROSC). Twenty-four patients had ROSC. Initial CPP (mean +/- SD) was 1.6 +/- 8.5 mm Hg in patients without ROSC and 13.4 +/- 8.5 mm Hg in those with ROSC. The maximal CPP measured was 8.4 +/- 10.0 mm Hg in those without ROSC and 25.6 +/- 7.7 mm Hg in those with ROSC. Differences were also found for the maximal aortic relaxation pressure, the compression-phase aortic-to-right atrial gradient, and the arterial PO2. No patient with an initial CPP less than 0 mm Hg had ROSC. Only patients with maximal CPPs of 15 mm Hg or more had ROSC, and the fraction of patients with ROSC increased as the maximal CPP increased. A CPP above 15 mm Hg did not guarantee ROSC, however, as 18 patients whose CPPs were 15 mm Hg or greater did not resuscitate. Of variables measured, maximal CPP was most predictive of ROSC, and all CPP measurements were more predictive than was aortic pressure alone. The study substantiates animal data that indicate the importance of CPP during cardiopulmonary resuscitation.     

Coarctation of the aorta in adults.

Thirty-six patients, 19 men and 17 women, presented at age 18 or older between 1952 and 1974 with coarctation of the aorta. Of the 14 (39%) who had associated cardiovascular disease, 12 had aortic stenosis or insufficiency or both. Three patients had infections-two, endocarditis (aortic valve) and one, endarteritis. Three of the seven patients who did not undergo an operation are alive, two at more than 50 years of age. Five patients had myocardial infarctions, two at 35 years of age. Twenty-nine (80%) had operations; in eight instances the patient was over age 40. All 18 patients undergoing repair of isolated coarctation survived, while only 7 of the 11 patients with associated cardiovascular lesions who underwent repair recovered. Aortic valvular disease and myocardial infarction are serious complicating factors in coarctation of the aorta.     

Giant aortic arch aneurysm

To the editor:A 44-year-old man presented to our department with intermittent chest and back pain.He had a past medical history of having undergone aortic valve replacement and ascending aortic aneurysm repair (Bentall) in the same operation 12 years ago.The Bentall operation was performed due to the diagnosis of severe aortic valve regurgitation together with an aneurysm of the ascending aorta measuring 70 mm in diameter.The diameter of the remaining aortic arch had previously been measured as 40 mm at the time.