术后呼吸功能障碍临床治疗效果观察

术后病人常发生不同程度的呼吸功能障碍 ,尤以剖胸手术和上腹部手术最为严重。本研究采用麻醉医师特有的专业技术与方法 ,对剖胸术后病人进行呼吸功能治疗 ,以期改善术后病人的呼吸功能 ,现报道如下。1　临床资料1 1　一般资料　选择择期剖胸手术病人 4 0例 ,男性 2 8例 ,女性 12例 ,平均年龄 (5 6.8± 1.9)岁。其中食管癌切除食管胃弓上或弓下吻合术 34例 ,纵隔手术 6例。手术切口均为左后外侧肋间切口。术前经查体和各项辅助检查证实无严重心肺疾患 ,ＡＳＡ分级Ⅰ～Ⅱ级。随机将病人分为治疗组 (2 0例 )与对照组 (2 0例 ) ,两组病人一般情…     

右胸前外侧小切口微创再次和多次二尖瓣置换术的手术配合

目的 总结右胸前外侧小切口微创技术在心脏术后患者再次或多次施行二尖瓣置换手术的手术配合.方法 对15例心脏外科术后再次出现二尖瓣病变患者施行右胸小切口微创二尖瓣置换术.术前做好心理护理和手术准备,术中密切配合,术后做好器械保养.结果 15例患者手术过程顺利,术后未发生出血及其他并发症.结论 加强微创小切口手术配合是手术成功的保证.     

右胸前外侧切口在成人心脏直视手术中的应用

目的总结经右胸前外侧切口在成人心脏直视手术中的应用。方法经右胸前外侧切口对192例成人患者进行心脏直视手术，其中男74例，女118例，年龄18—59岁。房间隔缺损76例，室间隔缺损52例，风湿性二尖瓣病变45例，其它19例。结果全组无手术死亡。术中出血量（190±88．9）ml，术后拔除气管时间0．5—23（中位时间3）h，放置胸管时间（38±15）h，胸腔引流总量（240±195）ml。主要并发症：再次开胸止血2例，胸腔积液7例，肺不张3例。术后住院时间（7．6±1．7）d。结论若选择病例合适、手术操作技术成熟，应用右胸前外侧切口进行成人心脏直视手术可安全顺利实施，且切口美观、创伤小、恢复快。     

普胸外科术后再次剖胸止血32例临床分析

目的 探讨普胸外科术后胸内活动性出血的原因及外科治疗经验.方法对1995年1月～2006年1月32例普胸外科术后再次开胸止血患者的出血部位、出血原因及诊治经过等资料进行回顾性总结并分析.结果 32例患者剖胸止血术后均未再次出现胸内出血,无严重并发症发生,全部治愈出院.结论术中仔细操作、关胸前认真检查可预防大部分普胸外科术后出血的发生,对普胸外科术后发生的活动性出血应积极再次剖胸止血,以免延误病情,危及生命.     

剖胸未切除的肺癌经肺动脉介入治疗后再手术的体会

在选择性肺动脉介入治疗肺癌有明显疗效的基础上，对１８例经剖胸探查由于肿瘤侵犯肺门大血管、腔静脉、主动脉及心脏等而未能切除的巨大肺癌，在手术后进行选择性肺动脉插管，用抗癌药物对肺癌直接灌注治疗，使肺癌缩小后再次手术均获切除，且康复顺利。     

改良LPD肺动脉灌注对体外循环术后全身炎症反应的影响

目的 研究体外循环（CPB）期间改良低钾右旋糖酐（LPD）溶液肺动脉灌注对CPB术后全身炎症反应的影响。方法 30例行二尖瓣置换术病人随机分为肺灌注组15例，对照组15例。肺灌注组病人CPB术中一次性肺动脉灌注低温改良LPD液，对照组常规行二尖瓣置换术。分别手术前、术后0h,6h抽取病人静脉血，采用双抗体夹心ABC-ELISA法测算TNF-α、IL-8血浆浓度。结果 同组术后与术前比较均有明显升高（P〈0．05）；改良LPD灌注组与对照组比较，术后0h、术后6h TNF-α与IL-8血浆浓度有显著降低（P〈0．05）。结论 CPB心脏手术可引起术后细胞因子TNF-α、IL-8水平的升高，CPB中改良LPD肺动脉灌注可降低术后TNF-α、IL-8水平，具有抑制CPB所致全身炎症反应的效果。     

冠状静脉窦逆行灌注在夹层动脉瘤手术中的应用

目的总结15例经冠状静脉窦逆行灌注心肌停搏液体外循环下胸主动脉夹层动脉瘤手术的临床经验，探讨改善心肌保护的方法。方法15例夹层动脉瘤手术中，9例升主动脉＋全弓置换＋降主动脉支架象鼻术，4例Bentall＋全弓置换＋降主动脉支架象鼻术，2例Bentall＋二尖瓣置换或成形。均经冠状静脉窦逆行灌注心肌停搏液体外循环下手术。结果无手术死亡，复跳顺利，脱机顺利，术后1例出现肾功能不全，1例出现低心排出量，经矫正后恢复，均顺利康复。结论对复杂胸主动脉夹层动脉瘤患者，采用经冠状静脉窦逆行灌注心肌停搏液进行心肌保护，具有较好的治疗效果。     

二尖瓣狭窄闭式分离术后再狭窄的手术治疗

目的：探讨二尖瓣狭窄闭式分离术后再狭窄的治疗。方法：报告了１９７８ 年至１９９６ 年施行二尖瓣狭窄闭式分离手术４２０ 例,术后再狭窄再次手术５２ 例,其中右径闭式分离术３４ 例（８ ％ ） ,二尖瓣置换术１８ 例（４３ ％ ） ,死亡１ 例（５５６ ％ ） ,并对手术方式及手术径路进行了讨论。指出二尖瓣狭窄术后再狭窄再次手术治疗,首选直视成形或瓣膜置换手术,对于瓣下结构良好,无瓣膜关闭不全及左房血栓者,右径闭式分离亦较满意。术中心包严重粘连不应过分分离,可在心包外行腔静脉插管,建立体外循环,可避免转流前因过分游离粘连造成大出血。     

275例主动脉瓣置换术应用连续缝合法的临床观察

目的探讨主动脉瓣置换中连续缝合方法的应用。方法275例病人主动脉瓣置换采用2/0Prolene线连续缝合法,用3根线265例、1根线10例。同期行二尖瓣置换232例,三尖瓣置换5例,三尖瓣成形112例,升主动脉置换9例,左房血栓清除术32例。结果全组均置入人工机械瓣膜,1例体外循环中发生抑肽酶过敏,需用阿拉明和大剂量激素;1例发生鱼精蛋白过敏再次转流,其他病例手术顺利。无1例住院死亡和严重并发症发生。结论采用连续缝合方法可简化手术操作,减少心肌缺血和转流时间,有利于心肌保护并减少术后并发症。     

右胸小切口微创二尖瓣置换术的手术配合

目的探讨右胸小切口微创二尖瓣置换术的手术配合。方法选取2018年2月-2019年2月天津市胸科医院收治的经右胸小切口微创二尖瓣置换术患者52例作为研究对象,对手术护理经验进行总结,做好术前准备、术中配合工作。结果患者的微创二尖瓣置换术术前准备完善、术中配合度优良,手术成功,无患者死亡,术后快速房颤1例,伤口延迟愈合1例,并发症发生率为3.85%,经相关治疗后均痊愈。结论在右胸小切口微创二尖瓣置换术中,完善相关手术管理制度,做好术前准备、术中配合等工作,在很大程度上能提高右胸小切口微创二尖瓣置换术的手术治疗护理的质量,得到了医务人员的好评,得到患者的认可,值得临床推广应用。     

Coronary reoperation through left thoracotomy without cardiopulmonary bypass: 3 case reports

With the increasing number of patients who have undergone coronary artery bypass grafting, the incidence of reoperative coronary grafting is also increasing. Reoperative coronary artery bypass grafting is associated with morbidity and mortality rates greater than those of primary coronary operations. Left thoracotomy can provide access for reoperation when repeat median sternotomy is extremely dangerous. Coronary artery grafting on a beating heart and via left thoracotomy can be a good alternative strategy when redo coronary surgery is necessary in the circumflex or left anterior descending territories.     

Right subaxillary and posterolateral thoracotomy for open repair of congenital heart defects

OBJECTIVE: Low-risk cardiac surgery approaches zero morbidity/mortality, therefore, cosmetic issues append. Right thoracotomy has been advocated as cosmetically attractive alternative to median sternotomy. Posterolateral thoracotomy involves chest wall musculature division that contributes to postoperative pain/morbidity; access to the heart may be difficult. Longitudinal subaxillary incision and muscle-sparing thoracotomy can overcome these disadvantages and provide better visibility. PATIENTS AND METHODS: Between April 2000 and April 2004 the authors performed open-heart repair from right thoracotomy in 161 patients. Diagnoses comprised perioval and sinus venosus ASDs (137), VSD (11), incomplete/intermediate AVD (8), miscellaneae (5). According to both patients' and surgeon's preference a longitudinal midaxillary incision and muscle-sparing lateral thoracotomy was utilised in 98 cases. Intracardiac repair was performed by extracorporal circulation, usual cannnulation, cardioplegia. Data of 79 ASD closures via midline sternotomy were used as controls. RESULTS: Sternotomy and thoracotomy groups did not differ in demographic characteristics albeit thoracotomies exhibited wider age and weight range. The skin incision could be easily stretched up by 60% providing excellent visibility/access. No mortality occurred. Phrenic nerve palsies (2), transient tetraparesis (1) fully recovered. A mitral valve replacement was necessary for valve pathology unrelated to access. No breast and/or upper limb vascular/neurologic problems were encountered. CONCLUSIONS: Right subaxillary muscle-sparing thoracotomy offers safe option for open-heart repair of selected anomalies. Despite the shorter skin incision subaxillary approach provides better visibility than conventional thoracotomy as mediastinal organs are closer to the operator. Intermediate cosmetic result are appealing. With no muscles divided less postoperative pain is anticipated. The authors recommend to expand the spectrum of anomalies repaired via this approach.     

自体心包材料二尖瓣环成形术的中期结果

目的 回顾性分析自体心包材料二尖瓣环成形术的中期效果.方法 采用自体心包材料行二尖瓣环成形术48例.Carpentier分型：Ⅰ型5例,Ⅱ型41例,Ⅲ型2例.瓣叶及瓣下结构成形包括后叶四边形切除30例,瓣叶修补7例,腱索转移4例,“缘对缘”技术2例,人工腱索3例.伴随手术包括主动脉瓣替换1例,三尖瓣成形11例,冠状动脉旁路移植术9例,冠状动脉肌桥松解1例,永久性起搏器植入1例.自体心包条的长度为（51.9 ±2.8）cm.术后随访15～96（62.2 ±21.3）个月.采用门诊随访及电话随访方式,随访内容包括临床症状、心功能、超声心动图检查等.结果 术后左心室舒张末期内径[（45.1±1.3） mm vs（58.6±1.7）mm,t=12.85,P＜0.01]、左心房内径[（38.0±1.4）mm vs （50.6±1.6） mm,t=9.58,P＜0.01]明显缩小.全组早期术后无明显反流.术后30 d内死亡1例.远期无死亡,术后发生脑梗死1例,远期出现中度反流1例.无溶血并发症,无再次手术.结论 自体心包材料二尖瓣环成形是一种抗凝并发症发生率低、耐久性可、心功能维护好、廉价的成形方法.     

Endovascular treatment of 2 patients with an aneurysm of the descending thoracic aorta]

Two men, aged 71 and 70, who had previously experienced an abdominal aneurysm were found to have thoracic aortal aneurysms of respectively 8 cm and 7.5 cm in length. For the first patient an endovascular operation was carried out due to a high operative risk: with the help of a radiograph, four endoprostheses were inserted into the thoracic descending aorta via the femoral artery, after which the aorta diameter became more normal. A month later, the patient died from persistent renal failure, which had developed as a result of the previously ruptured abdominal aneurysm. In the second patient with an aneurysm of the proximal descending aorta, a left decompensation arose following aortal clamping during open surgical repair. Ten weeks later an endoprosthesis was inserted via the femoral artery. A year later the aortal diameter had decreased to 6.5 cm; the patient functioned well. The insertion of an endoprosthesis in the thoracic aorta is a minimally invasive procedure in which the patient experiences little perioperative inconvenience.     

重度三尖瓣病变行三尖瓣置换术27例临床应用

目的 探讨三尖瓣置换术(TVR)手术指征及方式,总结三尖瓣病变的手术治疗经验.方法 2005年9月至2010年5月共施行TVR 27例,其中置换生物瓣膜23例,机械瓣膜4例;同期行二尖瓣置换术8例,二尖瓣、主动脉瓣双瓣膜置换术4例,房间隔缺损修补术4例.结果 手术病死率为11.1％(3/27),其中2例术后死于重度低心排血量综合征,1例术后第7天死于多器官功能衰竭.术后二次开胸止血1例,经积极治疗后顺利康复出院.随访率91.7％(22/24),1例术后3年死于生物瓣膜毁损,1例术后19个月死于脑栓塞.随访期间心功能NYHA分级恢复至Ⅰ级6例,Ⅱ级14例.结论 行TVR的患者中、远期病死率均较高,对于严重的三尖瓣病变患者,正确的手术方式、合理的围手术期处理是手术成功的关键.对于年龄大于50岁、随访不便以及未生育适龄女性患者来说,优先考虑置换生物瓣膜.     

肺动脉高压对结缔组织病患者左心室功能的影响

目的探讨肺动脉高压(PAH)对结缔组织病(CTD)患者左心室功能的影响。方法选取结缔组织病患者34例,合并肺动脉高压者(CTD-PAH组)18例,未合并肺动脉高压者(CTD组)16例。选取正常对照组18例。采集左室侧壁(left ventriculer lateral wall,LVLW)二尖瓣环位点组织多普勒频谱(tissue Doppler imaging,TDI)和二尖瓣、主动脉瓣口血流脉冲多普勒频谱(pulse wave Doppler imaging,PW),测量左室等容舒张期(IRT)、等容收缩期(ICT)、射血期(ET)并计算左心室Tei指数(LVLWTei,PWTei)。结果 CTD-PAH组与CTD组、正常对照组比较,CTD-PAH组左心室Tei延长(P<0.05);左心室LVLWIRT、PWIRT延长(P<0.05);LVLFET、PWET缩短(P<0.05);CTD组与正常对照组间比较,差异均无显著性。结论肺动脉高压明显损伤结缔组织病患者左心室整体功能。     

Late postinfarction rupture of the interventricular septum

Postinfarction ventricular septal rupture complicates 1 to 2% of cases of acute myocardial infarction and accounts for 5% of early mortality. This severe complication usually occurs within two weeks after acute myocardial infarction, and the elderly are more susceptible. We present a case of late rupture of the septum. Case report: In a 75-year-old man, a ventricular septal defect developed more than two months after an extensive inferoseptal myocardial infarction due to occlusion of the right coronary artery. After more than two months of no symptoms he was referred to hospital due to symptoms of right ventricle failure. The diagnosis was made by echocardiography, pulmonary artery catheterization and ventriculography. Coronarography was also performed. Intraaortic balloon pump was introduced and the patient was transferred to the operating room. The defect was repaired using a circular polytetrafluoroethylene patch supported by buttressed interrupted sutures from both sides. Due to significant mitral valve regurgitation mechanical bileaflet mitral valve was implanted with preservation of the entire mitral apparatus and the left descending artery was revascularized using a saphenous graft. Conclusion: This case is reported to emphasize that later postinfarction rupture of the ventricular septum may occur with symptoms of right ventricle failure dominating the clinical course.     

先天性房间隔缺损对新生儿心脏结构和血流动力学的影响

目的:通过检测先天性房间隔缺损(atrial septal defect,ASD)新生儿心脏结构和血流动力学的变化,探讨其对新生儿的潜在危害。方法:利用彩色多普勒超声心动图检测68例先天性房间隔缺损患儿与82例正常新生儿心脏各腔室的大小、肺动脉内压力、三尖瓣反流等。结果:进行心脏彩超检查的原因以心脏杂音、紫绀、宫内窘迫或新生儿窒息、呼吸急促、肺动脉瓣第二心音亢进最常见。房间隔缺损有房间隔水平存在异常分流但探测不到回声失落的无缺损型34例,回声失落直径<5mm的小缺损型21例,回声失落直径≥5mm的大缺损型13例。三种类型对室间隔、左心室、主动脉、左室后壁的影响差异无显著性,但对右心房、右心室、肺动脉的影响程度与缺损直径有显著正相关;只有大型房间隔缺损型导致左心房扩张;缺损和分流束的直径与肺动脉压力增高、三尖瓣反流率、反流面积也有显著正相关;但分流方向与缺损直径无关。结论:新生儿先天性ASD以轻型最多见,可导致新生儿心脏结构和血流动力学的异常改变。     

A hazardous finding of a rare anomalous left main coronary artery in a patient with a secundum atrial septal defect

A 23-year-old male referred for evaluation of a "choking" sensation with exertion and a murmur. A transthoracic echocardiogram demonstrated right atrial and ventricular dilatation, right ventricular volume overload, and a large secundum atrial septal defect (ASD) with left to right shunt and a calculated pulmonary-to-systemic blood flow ratio (Qp/Qs) estimated at 2.3 to 1. Cardiac catheterization also demonstrated evidence of the ASD with Qp/Qs of 4.6 to 1 with a significant step-up in oxygen saturation at the right atrial level. Additionally, an anomalous left main coronary artery (ALMCA) origin from the anterior right coronary cusp was suspected. Using 64-slice multidetector computed tomography coronary angiography (CCTA) the left main coronary artery was seen to arise from the right coronary cusp then traverse between the pulmonary trunk and the proximal ascending aorta before bifurcating into the left anterior descending and circumflex arteries that followed their normal courses distally. Based on the high risk nature of associated sudden death from an anomalous left main coronary artery (ALMCA) coursing between the aorta and the pulmonary trunk, the patient underwent surgical re-implantation of the ALMCA to the left coronary cusp and repair of the ASD. This case highlights a rare finding of a hazardous ALMCA in a patient with a secundum ASD and the utility of CCTA in evaluating the course of coronary anomalies along with other cardiac pathology.     

Surgical management with mitral valve replacement in young infants with congenital mitral valve diseases and complete atrioventricular septal defect

Objectives: The mechanical valve replacement may be the only option if the failing mitral valve cannot be repaired in complete AV septal defect (CAVSD), or congenital mitral valve stenosis and regurgitation in infants. In young infants the small mitral annulus - prothesis mismatch is a big problem. Aim: To assess the possibility of the left AV orifice repair and the necessity of mechanical valve replacement in CAVSD in young infants. Methods: Single center, retrospective study of 82 infants (13 pts under 3 months) who underwent complete repair of CAVSD between 2001 and 2007. Mechanical (bileaflet) valve replacement was required in 7 pts (5 weeks-7 months, 3.5-5 kg). The time interval between the two operations was 0-7 days, but the smallest baby spent 38 days in the intensive care unit waiting for increasing of his mitral annulus size from 11 to 15 mm. (Types of implanted valves: 2 Carbomedics 16 mm, 3 ATS 16 mm, 1 Sorin 17 mm, 1 Sorin 19 mm.) ATS 16 mm valves were implanted in 2 infants each with congenital mitral valve stenosis and regurgutation. Results: Early mortality (30 days) was 0, but 2 pts died in sepsis on the 46th and 71st postoperative day, respectively. In the follow-up period of 1-6 (mean 3) years 1 child (18 months later) needed reoperation (pannus removal), now all pts are doing well. Anticoagulation therapy was difficult in some cases without complication. Conclusions: The surgical repair of congenital mitral valve diseases and CAVSD can be performed successfully in very young infants. If the anatomic characteristics of the mitral valve is not suitable for repair, only mechanical mitral valve replacement can be performed successfully even in sometimes hopeless situation (one of our pts of 3.5 kg weight, is the smallest baby mentioned in the literature). Our early and mid-time results are good, but the re-replacement will be an unavoidable problem in the future.