冠状动脉畸形15例临床分析

目的 总结先天性冠状动脉畸形的外科治疗经验.方法 15例冠状动脉畸形患者中冠状动脉瘘11例,冠状动脉起源异常4例.合并风湿性心瓣膜病1例,法洛四联症1例.非体外循环下手术6例,其中5例行孤立瘘支动脉结扎术,1例行冠状动脉切线缝扎术;体外循环下经心腔修补内瘘口手术4例;体外循环心脏停跳下切开冠状动脉修补外瘘口1例;左冠状动脉回旋支异常起源于左肺动脉行回旋支左肺动脉开口处结扎术1例,左锁骨下动脉与左冠状动脉吻合、肺动脉端开口处结扎术1例,左冠状动脉主干移植术2例,合并的心脏疾病均同时纠治.结果 1例因术后低心排血量综合征死亡,余14例术后心悸、胸闷、心脏杂音消失,均痊愈出院.结论 冠状动脉畸形一旦确诊,应及时采用适宜的矫治技术治疗.     

冠状动脉瘘23例手术治疗

目的：观察冠状动脉瘘手术治疗效果。方法：对23例冠状动脉瘘患者畸形情况及手术治疗回顾性分析，结果：瘘口发生于右冠状动脉13人，左冠状动脉9人，双冠状动脉1人，瘘入右心室9人，右心房6人，肺动脉3人，冠状静脉窦2人，左心房2人，左心室2人，多瘘口患者3人，所有患者均经手术纠正畸形，除1例多个瘘口患者，术后残留一小瘘口外，余效果良好，结论：外科手术是目前冠状动脉瘘最佳治疗方法。     

64排螺旋CT在诊断成人冠状动脉-肺动脉瘘中的应用价值

目的：探讨64排螺旋CT在诊断成人冠状动脉-肺动脉瘘中的应用价值。方法回顾性分析我院28例成人冠状动脉-肺动脉瘘的CT图像。结果28例冠状动脉-肺动脉瘘患者中,单侧分支血管参与者10例,双侧分支血管参与者18例。动脉瘘血管直径较起始冠状动脉直径小的患者有24例,占85.71%;动脉瘘血管直径较起始冠状动脉直径大的患者有4例,占14.29%。结论64排螺旋CT可清晰地显示血管的起源、走行和终止等情况,对冠状动脉-肺动脉瘘的诊断具有重要的临床应用价值。     

先天性冠状动脉瘘83例临床分析

目的　总结83例先天性冠状动脉瘘的临床特点及治疗体会。方法　1984年3月～2003年12月共收治冠状动脉瘘83例,介入栓堵治疗9例;手术治疗48例;其余26例未做治疗。结果　死亡1例,为手术治疗后室颤所致。43例随访1个月～8年,平均3 5年,效果良好。结论　先天性冠状动脉瘘大部分经心脏B超可得到诊断。选择性冠脉造影可明确诊断,手术治疗或介入治疗均安全、有效,远期效果良好。     

Coronary surgery at the Cardiovascular Surgical Clinic (1976-1990)]

In the Cardiovascular Surgical Clinic of the Semmelweis Medical University of Budapest the first coronary artery bypass grafting (CABG) procedure was performed in 1975. Since that time coronary artery surgery has become a routine everyday practice representing more than half of the total workload of adult cardiac surgery. The analysis of 1347 operations performed between 1976-1990 on patients with coronary heart disease showed the followings: the first few years--so called learning curve of CABG operations is characterised by high mortality. With passing time the number of cases performed each year increased rapidly and the surgical technique has improved too. At the same time the operative mortality figures showed decreasing tendency--it was 2.1% for the last 609 cases. All observed parameters showed some progress: in 1990 the average number of grafts per patient was 3.09, internal mammary artery usage 15 percent and the mean aortic cross clamp time per anastomosis 24.5 minutes. Complete myocardial revascularisation is the key point of coronary artery surgery. In order to achieve this target in all operated cases further technical improvement is necessary.     

Coronary artery abnormalities in Puerto Rico

A retrospective study was done to determine the frequency of coronary artery anomalies in terms of their origin, course, and structure. The clinical history, catheterization data and surgical reports of patients undergoing coronary angiography at the Cardiovascular Center of Puerto Rico and the Caribbean, from 1999 to 2004, were analyzed. Thirty-eight patients were identified with a coronary artery anomaly in this population. These anomalies were classified according to their clinical consequences and the need for surgical intervention.     

冠状动脉慢性完全阻塞性病变的分布特征及其与侧支循环间的相关性分析

目的 研究冠状动脉慢性完全阻塞性病变的分布特征及其与侧支循环间的相关关系。方法 用SPSS统计软件分析113例冠状动脉旁路术患者的临床基线资料和冠状动脉造影资料。结果 慢性完全阻塞性病变6l例(7l处)，分布于：左主干l例(0．9％)；前降支近段17例(15．0％)、中段9例(8．0％)、远段3例(2．7％)；回旋支近段5例(4．4％)、中段6例(5．3％)、远段3例(2．7％)；右冠状动脉近段9例(8．0％)、中段l0例(8．8％)、远段8例(7．1％)。侧支循环72例(63．7％)，慢性完全阻塞性病变与侧支循环间的直线相关系数r=0．707(P=0．000)。结论 冠状动脉慢性完全阻塞性病变多见于前降支、右冠状动脉的近、中段，与侧支循环间有高度正相关性。     

80例糖尿病合并冠心病患者冠脉介入治疗并发症的临床分析

[目的]探讨糖尿病合并冠心病患者行冠状动脉介入治疗的并发症发生情况。[方法]选择在我院行冠状动脉介入治疗的糖尿病合并冠心病患者80例设为实验组,同期在我院冠状动脉介入治疗的非糖尿病冠心病患者80例为对照组,比较两组患者的手术并发症的情况。[结果]两组患者在心源性休克、冠状动脉损伤、低血糖等的发生率方面差异有统计学意义(P﹤0.05);在局部血肿、出血、尿潴留、血栓形成等方面的发生情况中差异无统计学意义(P﹥0.05)。[结论]糖尿病合并冠心病患者行冠脉介入治疗时心源性休克、冠状动脉损伤、低血糖等的发生率较非糖尿病冠心病患者高,在围手术期间要注意预防,并做好病情的观察,做好对应的有效处理。     

The place and role of coronary endarterectomy in the management of ischemic heart disease]

Coronary endarterectomy is one of the oldest operation performed on the coronary arteries. In the case of multivessel coronary artery disease it is an alternative method to achieve complete myocardial revascularisation however it increases both perioperative infarction rate and mortality. Sometimes it is undoubtedly the only chance of the patient apart from heart transplantation. Since 1983 when the first coronary endarterectomy was performed in the Cardiovascular Surgical Clinic of Semmelweis Medical University of Budapest, until the end of 1990 the procedure has been used in 97 patients on 119 coronary artery segments. A new surgical technique of coronary endarterectomy is described, a detailed analysis of the cases is presented and the results are discussed.     

Prospective evaluation of a clinical and exercise-test model for the prediction of left main coronary artery disease

In a multivariate logistic regression analysis of data from 508 patients, only two clinical factors, age and typicality of pain, were independently significant predictors of left main coronary artery disease. The resulting multivariate equation was prospectively applied to another 370 patients to derive pre-exercise-test (ETT) probabilities of left main coronary artery disease, and these pre-ETT probabilities were combined with literature-derived likelihood ratios for various ETT findings to derive post-ETT probabilities. This model, which can be displayed in simple graphic form, accurately predicted the probability of left main coronary artery disease when prospectively evaluated in this independent validation set of patients. The likelihood of left main coronary artery disease was 16% when the ETT increased the probability, and 4% when it decreased the probability (p less than 0.001). While 48% of patients had mid-range (5-15%) probabilities of left main coronary artery disease before the ETT, only 24% fell into this range of probabilities after the ETT (p less than 0.0001), as ETT results moved patients into higher and lower probability ranges. Thus, probability of left main coronary artery disease can be calculated from clinical and ETT data with this model. These estimated pre- and post-ETT probabilities of left main coronary artery disease may aid in the selection of patients for noninvasive testing or for cardiac catheterization.     

Coronary arteriovenous fistula with vasospastic angina

A 50-year-old man was admitted to our hospital because of chest pain. Twenty-four-hour ECG recording demonstrated ST-segment depression and elevation at the time of spontaneous angina. During treadmill exercise test, the patient developed chest pain with ST-segment depression in leads V4 to V6. After the administration of nifedipine (10 mg), the patient was able to reach up to the maximum predicted heart rate without anginal symptoms and ST-T changes. Coronary arteriogram demonstrated 50% stenosis at the proximal portion of the left anterior descending artery (LAD) and two small fistulas originated from LAD to pulmonary artery. Spasm was induced at the proximal portion of LAD by the hyperventilation. If patients with coronary arteriovenous fistula (CAVF) have symptoms, elective CAVF ligation has been recommended. However, this case suggests that coronary spasm could be one of the cause of angina pectoris in patients with CAVF. Elective CAVF ligation must be carefully indicated in CAVF patients with angina pectoris.     

经桡动脉冠状动脉介入诊疗临床应用观察

目的：经桡动脉冠状动脉介入诊疗临床应用的价值。方法：对有心绞痛、急性冠脉综合征的病人或高度临床怀疑冠心病的病人,Allen试验阳性者给予冠脉造影检查,冠脉造影阳性病人给以支架植入术或者冠脉搭桥手术。研究经桡动脉手术病人的手术成功率以及并发症情况,手术后观测事件发生率等,评价经桡动脉介入手术的安全性、可行性。结果：180例病人有176例行桡动脉穿刺手术诊疗,174例病人造影成功,75例需行介入治疗,73例经桡动脉介入手术成功,仅1例出现术后穿刺点渗血。结论：经桡动脉途径造影创伤小,局部血管出血及并发症少,术后无体位限制。     

双源CTA与DSA评价冠状动脉钙化性斑块管腔狭窄对比研究

目的:探讨双源CT冠状动脉成像(DSCTA)评价钙化斑块引起血管腔狭窄的准确性。方法:62例患者DSCTA显示冠状动脉一处或多处钙化斑块,并行冠状动脉造影(CAG)检查。钙化斑块大小分为小、中和大。使用各种后处理技术,以确定钙化斑块引起血管阻塞(狭窄管腔直径≥50%),无血管阻塞(狭窄管腔直径<50%),并与CAG比较。结果:DSCTA显示小钙化斑块122处,中44处,大86处。122处小钙化斑块,5%CAG显示有梗阻;44处中钙化斑块,14%梗阻;86大钙化斑块,42%有梗阻。DSCTA与CAG一致95%(116/122)小钙化斑块、91%(40/44)中钙化斑块、67%(58/86)大钙化斑块。DSCTA低估2例小钙化斑块血管腔狭窄,高估4例小钙化斑块、4例中钙化斑块、28例大钙化斑块血管腔狭窄。86处大钙化斑块引起的血管腔梗阻,DSCTA敏感性100%、特异性44%、阳性预测值56%、阴性预测值100%、准确性67%。结论 DSCTA准确显示90%以上小和中等大小钙化斑块血管阻塞病变,正确诊断约2/3大钙化斑块血管阻塞病变。判断错误通常是高估狭窄程度。     

手术切口感染目标性监测分析

目的 研究外科手术部位感染控制措施.方法 采用前瞻性调查方法,选择外科手术患者(包括妇产科)进行手术切口感染率跟踪调查分析.结果 以手术创伤最大、手术时间最长、手术危险程度最高的冠状动脉搭桥术感染率最高,达2.67%;在所有发生手术部位感染的11例病例中,只有1例在术前麻醉诱导期应用抗菌药物,术后用药有10例均为抗菌药物使用>4 d;术前、术后抗菌药物围术期正确使用率仅为9.09%,感染率与手术创伤的大小、手术时间、手术危险程度、围术期抗菌药物正确使用时间相关.结论 采用手术切口目标性监测,不断调整干预措施,可将手术切口感染率降低.     

不停跳冠脉搭桥手术54例配合体会

目的:探讨非体外循环冠状动脉搭桥的手术配合。方法:选择某医院在非体外循环即心脏不停跳下行多支冠状动脉搭桥术54例,采用胸骨正中切口,应用心脏表面固定器、冠脉内分流器行不停跳搭桥术,术中控制血压、心率的变化,保证有效循环血量,充分利用局部心肌固定器及冠状动脉塞子,使吻合口局部心肌处于相对静止和冠状动脉吻合处于无血状态。结果:54例冠状动脉搭桥手术顺利,无并发症及手术意外的发生,有效缩短手术时间,无1例死亡,术后8～15天均痊愈出院。结论:护士术前访视病人、充分准备,熟悉手术步骤,配合技术娴熟,有利于手术的顺利进行。     

严重冠状动脉痉挛患者的临床特点分析及治疗随访

目的总结严重冠状动脉痉挛患者的临床特点,治疗方法及随访预后情况。方法选择确诊为冠状动脉痉挛的患者21例。了解患者的一般情况,包括年龄、性别、基础疾病、吸烟史及用药等,分析其临床特点、心电图、冠状动脉造影资料、诊断治疗及随访预后情况。结果严重冠状动脉痉挛患者以男性多见,占86％（18／21）;吸烟是主要的危险因素,占62％（13／21）;痉挛多发生于有固定狭窄的部位,占57％（12／21）,临床经过凶险,及时冠状动脉造影对早期明确诊断至关重要。钙离子拮抗剂是有效治疗的核心,其使用强调持续、足量,介入治疗不是有效的方法。冠状动脉痉挛急性发作期具有极高的危险性,但长期预后良好。结论冠状动脉痉挛临床常见,但易被忽视,及时诊断是防止致命事件的关键,钙离子拮抗剂是冠状动脉痉挛的核心用药,远期预后良好。     

危重冠心病冠状动脉搭桥术164例手术治疗临床分析

目的总结分析危重冠心病患者行冠状动脉搭桥术的围术期管理经验。方法共分析164例行冠状动脉搭桥术患者的临床资料,其中危重冠心病患者151例,占92.05%。均具备重要危险因素≥2条,或者具备次要危险因素≥3条。结果全组共搭动脉桥144支,静脉桥353支,同期行室壁瘤切除11例,瓣膜置换5例,瓣膜成形5例,室间隔穿孔修补术1例。围术期发生低心排2例、呼吸衰竭1例、肾功能不全1例,脑梗死1例。死亡2例,死亡率1.22%。结论搭桥手术治疗危重冠心病患者效果满意。周密的术前准备、术中充分恢复心肌血运及正确的围术期处理是确保手术成功,减少死亡率的关键。     

Revascularizing the Myocardium: The Saphenous Vein Bypass

A case is presented in which this most recent approach to the surgical treatment of coronary artery disease was successfully utilized. The authors discuss the procedure in the context of its advantages and of the limitations of previous techniques. The criteria they employ in the selection of appropriate patients from among the vast reservoir of patients with crippling disease are described.     

64层螺旋CT判定冠状动脉中重度狭窄的研究

目的 评价64层螺旋CT(64 SCT)冠状动脉成像判定冠状动脉中重度狭窄的准确度.方法 选择72例临床疑诊冠心病的患者先后行64 SCT冠状动脉成像和选择性冠状动脉造影(SCAG).对两种方法判定冠状动脉中重度狭窄的结果进行对照研究.结果 72例SCAG显示的720节段冠状动脉图像中,64 SCT提供可供分析为684节段,可评估率为95.0%.与SCAG对照分析,64SCT判定冠状动脉中重度狭窄(狭窄度≥50%)的敏感度、特异度、阳性预测值、阴性预测值以及准确度分别为67.4%、92.9%、69.5%、92.3%和88.0%.结论 64 SCT冠状动脉成像作为非侵入性检查方法对检出冠状动脉中重度狭窄有较高的准确度,可用于冠心病的初步筛查.     

冠状动脉钙化积分评估冠心病的临床价值研究

目的 探讨冠状动脉钙化积分（CCS）评估冠心病的临床价值.方法 采用16排螺旋CT测定96例入选冠心病患者CCS;同时使用导管法冠脉造影评估其冠状动脉,依据造影显示冠状动脉狭窄是否大于90%进行分组.分析患者性别、年龄、高血压病史、糖尿病史、吸烟史、血脂紊乱以及阳性家族史等各危险因素与CCS的相关性.结果 1.行导管法冠脉造影的96例患者中,冠脉狭窄 90%的冠心病患者CCS与狭窄介于50%～90%的冠心病患者CCS相比较有显著性差异（P〈0.05）;在该96例患者中,通过描绘ROC曲线,获得CCS诊断冠脉狭窄≥90%的标准,即ROC曲线截断点为187.5（灵敏度为85.7%,特异度为64.3%）.2.利用所获得的截断点以及二分类Logistic回归统计方法得出：冠脉狭窄程度与CCS、血脂紊乱、合并高血压和糖尿病史、吸烟史以及性别等呈正相关,OR分别为10.833、5.000、3.400、1.735、1.333（P〈0.05）;而高CCS与血脂素乱、合并高血压和糖尿病、糖尿病、高血压病、家族史、吸烟史、性别等呈显著正相关,OR分别为14.880、13.008、8.750、5.250、3.315、2.200、1.998（P〈0.05）,特别是血脂紊乱以及合并高血压和糖尿病的患者,与高CCS相关性明显强于其它传统危险因素.结论 高CCS与冠脉重度狭窄存在较强的相关性,故钙化积分的测定不仅对冠心痛的早期诊断有重要意义,对于冠脉狭窄程度的预判亦有重要的临床价值.