经食管超声心动图引导下两种术式治疗房间隔缺损的临床对照研究

目的:比较经右胸小切口和经皮行房间隔缺损(atrial septal defect, ASD)封堵的手术效果。方法:回顾性分析2008年2月至2020年4月复旦大学附属中山医院心脏外科完成的经食管超声心动图(transesophageal echocardiographic, TEE)引导下ASD封堵手术310例患者的临床资料,男性80例,女性230例,年龄2～76岁,平均年龄(40±14)岁。根据手术入路分为右胸小切口组(右胸组)112例和经皮组(经皮组)198例,采用t检验和χ~2检验比较2组患者的手术效果。结果:全组无手术死亡。右胸组和经皮组分别有108例和189例封堵顺利(96.4%vs 95.5%),术后出现封堵器脱落分别为3例和2例(2.7%vs 1.0%),2组差异无统计学意义。经皮组手术室拔除气管插管率明显高于右胸组(76.8%vs 7.1%),术后住院时间短于右胸组[(2.1±0.9) d vs(3.8±1.6) d],术后并发症发生率低于右胸组(0 vs 5.4%),差异均有统计学意义(P0.05)。结论:TEE引导下ASD封堵手术安全、有效,相对于经右胸小切口ASD封堵,经皮ASD封堵手术创伤更小,患者住院时间更短,恢复更快,可作为ASD封堵的首选方法。     

单纯超声心动图引导下经皮房间隔缺损封堵术的临床研究

对比分析单纯超声心动图引导下经皮房间隔缺损(ASD)封堵术与经胸房间隔缺损封堵术的有效性和安全性。回顾分析2015年6月~2016年8月在郑州市儿童医院心脏外科住院并行超声引导经皮房间隔缺损封堵术的患儿26例(n=26),同期行超声引导经胸封堵术的患儿22例(n=22),记录比较两组患者一般情况、手术时间、住院时间、术后并发症等发生情况。经皮封堵组26例均封堵成功,2例患者在清醒状态下完成手术,手术时间(35.3±13.2)min,住院时间(3.7±1.0)d。术后早期出现少量残余分流2例,术后1个月随访消失。经胸封堵组21例均封堵成功,1例因残余分流2mm术中转外科修补术,手术时间(54.7±12.5)分钟,住院时间(6.4±0.8)天,术后出现各类并发症13例。两组患儿术后6个月内口服肠溶阿司匹林3mg/(kg.d)抗凝。经皮组和经胸组封堵器置入成功率分别为100.0%和97.6.0%,两组比较差异无统计学意义(P=0.58);手术时间分别为(35.3±13.2)min和(54.7±12.5)min,两组比较差异有统计学意义(P=0.20);住院时间分别为(3.7±1.0)天和(6.4±0.8)天,两组比较差异有统计学意义(P=0.20)。至随访结束两组患者均未发生外周血管损伤、心脏穿孔、封堵器移位、脱落等严重并发症。单纯超声心动图引导下经皮ASD介入封堵术是创伤更小、花费更少、更安全的治疗方法,值得在临床推广。     

心导管及经胸小切口两种路径房间隔缺损封堵比较及超声心动图监测的价值

目的　比较心导管法和经胸小切口法房间隔缺损 (ASD)封堵术的异同和超声心动图监测的价值。方法　心导管法ASD封堵术 111例 ,经胸小切口直接由右房置入封堵器 71例。经食管超声心动图 (TEE)或经胸超声心动图 (TTE)检测缺损大小及边缘状况 ,并指导封堵。结果　心导管法和经胸小切口法封堵的缺损大小、ASD/(ASD +残留间隔 )及封堵器大小分别为 (18.7± 7.5 )mmvs (19.1± 6.1)mm (P >0 .0 5 ) ,0 .44± 0 .13vs0 .5 0± 0 .14 (P <0 .0 5 )和 (2 4.3± 8.0 )mmvs (2 6.4± 8.4)mm (P >0 .0 5 )。心导管法和经胸小切口法缺损一侧缘≤ 5mm和两侧缘之和≤ 10mm者分别为 18.0 %vs 3 2 .4% (P <0 .0 5 )和 5 .4%vs 12 .7% (P >0 .0 5 )。两种方法共封堵双孔及多孔ASD 7例 ,均于较小孔缺损边缘留有少量分流。结论　心导管法可顺利闭合中、小型ASD ,对缺损较大、边缘较短者有一定技术难度 ;经胸小切口法适应证更广 ,可作为补充     

右外侧小切口剖胸在小儿先天性心脏畸形矫治术的体会

目的总结采用右胸小切口进行心内直视术的治疗体会。方法本组 54例患者中房间隔缺损 (ASD) 17例 ,室间隔缺损 (VSD) 2 4例 ,法乐四联症 (TOF) 9例 ,心内膜缺损 (PECD) 4例 ,单心房 2例 ,均经右侧小切口剖胸治疗。结果全组无手术死亡。体外循环 30～ 12 0分钟 ,平均 ( 6 5.2± 3.5)分钟。主动脉阻断 10～ 12 1分钟 ,平均 ( 32 .3± 1.91)分钟。术后住院 6～ 15天 ,平均 ( 7.5± 1.50 )天。结论右外侧小切口剖胸应用于心内直视手术具有进胸、关胸快 ,手术时间短 ,胸液少等特点 ,且切口位置隐蔽 ,符合患者的美观要求 ,又不破坏骨性支架 ,无鸡胸或胸骨感染     

心脏彩色多普勒超声心动图监测右胸小切口房缺封堵术与右心导管房缺封堵术对比研究

目的探讨评价右胸小切口房缺封堵术与右心导管房缺封堵术的优缺点。 方法43例房间隔缺损（ASD）患者中，21例行介入手术ASD封堵术，22例行右胸小切口ASD封堵术。介入手术ASD封堵术是在大型数字减影血管造影机（DSA）下进行，经胸超声心动图监测封堵器的位置，观察有无残余分流，是否影响二尖瓣及主动脉瓣的功能。右胸小切口ASD封堵术是在手术室进行，无体外循环，完全由超声心动图监测整个过程。 结果21例行介入手术ASD封堵术者成功19例，22例行右胸小切口ASD封堵术全部封堵成功，其中包括腔静脉型房缺3例。 结论房间隔缺损封堵术有2种方式，一是右胸小切口经超声心动图全过程指导放置封堵器，二是经右心导管在DSA下放置ASD封堵器。两者比较介入疗法放置封堵器对患者创伤小，但对30mm以上大房缺及腔静脉型房缺封堵器放置不易成功。而外科微创手术对这些难治型ASD封堵更有优势。     

经胸超声与经食管超声引导下经皮房间隔缺损封堵术的应用比较

目的比较单纯经胸超声(TTE)与单纯经食管超声(TEE)在房间隔缺损(ASD)封堵术中的应用效果。方法回顾本院收治的36例中央型ASD患者,按照手术引导方式不同,将患者分为两组。其中21例患者运用TTE引导(TTE组),15例患者运用TEE引导(TEE组),比较两组间临床治疗效果。结果两组均无死亡及并发症发生。TEE组成功13例(成功率87%);失败2例,为封堵器未能成功卡位,改为体外循环下ASD修补术;TTE组成功18例(成功率86%);失败3例,1例为缺损较小,TTE图像质量差,未能引导导丝通过ASD改为TEE引导下封堵成功,2例因缺损较大,封堵器卡位不牢,改为体外循环下ASD修补术。术后随访3～48个月,无残余分流及封堵伞移位。两组患者间ASD最大径、封堵伞型号及住院时间差异无统计学意义(P0.05);TTE组手术室滞留时间(68.7±10.8)min及总费用(2.58±0.36)万元均小于TEE组(125.3±19.2)min和(2.94±0.77)万元,P0.05。结论单纯TTE及TTE引导下经皮ASD封堵术同样安全、有效。TTE组比TEE组更有效的缩短患者手术室滞留时间、减少患者住院总费用。     

超声心动图在房缺介入治疗中的应用价值

目的 探讨经胸(TTE)及经食道(TEE)超声心动图在房缺(ASD)介入治疗中的应用价值。方法 TTE或TEE在36例ASD患者中进行选择并指导完成Amplatzer堵闭器的封堵及术后随访。结果 31例封堵术成功,5例(经TTE选择的病例)不适合行封堵或封堵失败;TTE(16.8±6.8)mm、TTE(20.0±4.41)mm所测ASD大小与球囊伸展直径(25.42±5.0)mm之间的关系分别显示为无相关(r=0.231,P>0.05)及有一定的相关性(r=0.357,P<0.05),而TTE在去除部分ASD残缘的软边后重新测量得到的缺损直径(22.8±4.9)mm与球囊伸展直径之间相关性良好(r=0.955,P=0.0000);5例ASD残缘较长而硬(18.0±2.0)mm的患者在TTE指导下完成封堵;在术后短、中期的随访中,TTE显示所有患者堵闭器位置固定,短期内残余分流(2例)消失及右室容量负荷降低(26例)。结论 ASD堵闭术前应常规行TEE检查以正确筛选病例并指导堵闭器型号的选择,对于残缘较长(最好>1cm)而硬质的ASD、可在TTE指导下完成手术,而TTE在术后随访期中能对封堵疗效作出全面的评价。     

TEE引导微创膜周部室间隔缺损封堵术中封堵入路夹角与手术成功率及心内操作时间的关系

目的 探讨经食管超声心动图(TEE)引导经胸微创膜周部室间隔缺损( pmVSD)封堵术中封堵入路夹角与手术成功率及心内操作时间的关系。方法 回顾性分析73例TEE引导下经胸微创pmVSD封堵治疗患者的TEE影像及病例资料。分析封堵入路夹角与心内操作时间的相关性;依据封堵入路夹角及手术成功情况,将患者分为封堵入路夹角＜30°组和封堵入路夹角≥30°组,比较两组的手术成功率和心内操作时间。结果 封堵入路夹角与心内操作时间呈正相关(rs=0.786, P＜0.05);封堵入路夹角＜30°组的手术成功率高于≥30°组(100% VS 80.95%,c2=11.251, P＜0.05);封堵入路夹角＜30°组的心内操作时间小于封堵入路夹角≥30°组(24.50±5.39min VS 39.05±4.31min,t=11.090, P＜0.05),差异有统计学意义。结论 TEE引导经胸微创pmVSD封堵术中封堵入路夹角与心内操作时间呈正相关,选择较小的封堵入路夹角＜30°可以提高手术成功率,缩短心内操作时间。     

低位小切口甲状腺手术的疗效评价

目的:探讨低位小切口甲状腺手术的临床价值.方法:将100例结节性甲状腺肿手术病例分成两组,低位小切口为A组(n=50),传统切口为B组(n=50).观察两组切口长度(cm)、手术时间(min)、术中出血量(mL)、术后24、48 h引流量(mL)、术后美观效果(VAS评分)、术后住院时间(d)、住院费用(元).结果:切口长度A组小于B组(P=0.000);手术时间A组与B组相近(P=0.346);术中出血量A组少于B组(P=0.000);术后24、48 h引流量A组少于B组(P=0.000);术后美观效果A组好于B组(P=0.000);术后住院时间A组短于B组(P=0.008);住院费用A组B组相近(P=0.098).结论:低位小切口甲状腺手术较传统手术创伤小、恢复快,不增加费用,术后切口美观效果好,能提高生存质量,迎合患者心理,有广泛推广价值.     

1例儿童经颈静脉房间隔缺损封堵术的手术配合

正继发孔型房间隔缺损(atrial septal defect,ASD)是最常见的先天性心脏病之一,传统方法是在体外循环直视下行ASD修补术[1],目前心脏不停跳下ASD修补术[2]、小切口ASD修补术等一些新的手术方法相继应用于临床[3],在心肌保护、切口美观方面取得一些进步。介入中心常采用经皮封堵技术,但封堵过程中患者和医师均暴露在X线下。近年来经胸及右腋下微创封堵ASD相继运     

Morphological Distinction of Cyanodermatium (Hydrococcaceae) and Radaisia (Hyellaceae) of Chroococcales (Cyanoprokaryota)

Radaisia gomontiana Sauvageau has been studied for their morphology from the material collected from natural habitat and from cultures. The continuous collections of the organism from nature did not show any sign of baeocyte formation. However, in the seventeenth collection, after 2 months growth in a water body, it did reveal the formation of baeocytes only for 2 days, whereas under culture conditions, stages of baeocyte and monocyte formation were recorded as distinct features. The organism is identified as Radaisia (Hyellaceae) when baeocytes are observed. Its vegetative stage which is recognized as Cyanodermatium (Hydrococcaceae).     

电视辅助胸腔镜外科

１概述 电视辅助胸腔镜外科（Ｖｉｄｅｏ—ａｓｓｉｓｔｅｄ ＴｈｏｒａｃｉｃＳｕｒｇｅｒｙ,ＶＡＴＳ）是内镜外科在设备和手术器械不断发展的基础上产生的“微侵入”外科技术。如腹腔镜技术在外科的应用一样,９０年代以来,ＶＡＴＳ在胸外科领域也得到蓬勃发展。 ＶＡＴＳ的出现改变了胸腔内镜技术的面貌。早在１９１０年,瑞士内科医师Ｊａｃｏｂｅｕｓ首先把膀胱镜技术移植到胸腔内,用于诊断胸膜病灶以及应用到治疗肺结核的胸膜粘连术和肺萎陷疗法。开辟了内镜诊断、治疗胸部疾病的先例［１］。以后,在２０世纪三四十年代,逐渐发…     

Alpha(4)beta(7)/alpha(4)beta(1) dual integrin antagonists block alpha(4)beta(7)-dependent adhesion under shear flow

The alpha(4) integrin, alpha(4)beta(7), plays an important role in recruiting circulating lymphocytes to the gastrointestinal tract, where its ligand mucosal addressin cell adhesion molecule-1 (MAdCAM-1) is preferentially expressed on high endothelial venules (HEVs). Dual antagonists of alpha(4)beta(1) and alpha(4)beta(7), N-(2,6-dichlorobenzoyl)-(L)-4-(2',6'-bis-methoxyphenyl)phenylalanine (TR14035) and N-(N-[(3,5-dichlorobenzene)sulfonyl]-2-(R)-methylpropyl)-(D)-phenylalanine (compound 1), were tested for their ability to block the binding of alpha(4)beta(7)-expressing cells to soluble ligand in suspension and under in vitro and in vivo shear flow. Compound 1 and TR14035 blocked the binding of human alpha(4)beta(7) to an (125)I-MAdCAM-Ig fusion protein with IC(50) values of 2.93 and 0.75 nM, respectively. Both compounds inhibited binding of soluble ligands to alpha(4)beta(1) or alpha(4)beta(7) on cells of human or rodent origin with similar potency. Under shear flow in vitro, TR14035 and compound 1 blocked binding of human alpha(4)beta(7)-expressing RPMI-8866 cells or murine mesenteric lymph node lymphocytes to MAdCAM-Ig with IC(50) values of 0.1 and 1 microM, respectively. Intravital microscopy was used to quantitate alpha(4)-dependent adhesion of fluorescent murine lymphocytes in Peyer's patch HEVs. When cells were prestimulated with 2 mM Mn(2+) to activate alpha(4)beta(7) binding to ligand, anti-alpha(4) monoclonal antibody (mAb) [10 mg/kg (mpk) i.v.] blocked adhesion by 95%, and anti-beta(1) mAb did not block adhesion, demonstrating that this interaction was dependent on alpha(4)beta(7). TR14035 blocked adhesion to HEVs [ED(50) of 0.01-0.1 mpk i.v.], and compound 1 blocked adhesion by 47% at 10 mpk i.v. Thus, alpha(4)beta(7)/alpha(4)beta(1) antagonists blocked alpha(4)beta(7)-dependent adhesion of lymphocytes to HEVs under both in vitro and in vivo shear flow.     

Tumor pH-responsive flower-like micelles of poly(l-lactic acid)-b-poly(ethylene glycol)-b-poly(l-histidine)

Polymeric micelles were constructed from poly(l-lactic acid) (PLA; M_n 3K)-b-poly(ethylene glycol) (PEG; M_n 2K)-b-poly(l-histidine) (polyHis; M_n 5K) as a tumor pH-specific anticancer drug carrier. Micelles (particle diameter: ∼ 80 nm; critical micelle concentration (CMC): 2 μg/ml) formed by dialysis of the polymer solution in dimethylsulfoxide (DMSO) against pH 8.0 aqueous solution, are assumed to have a flower-like assembly of PLA and polyHis blocks in the core and PEG block as the shell. The pH-sensitivity of the micelles originates from the deformation of the micellar core due to the ionization of polyHis at a slightly acidic pH. However, the co-presence of pH-insensitive lipophilic PLA block in the core prevented disintegration of the micelles and caused swelling/aggregation. A fluorescence probe study showed that the polarity of pyrene retained in the micelles increased as pH was decreased from 7.4 to 6.6, indicating a change to a more hydrophilic environment in the micelles. Considering that the size increased up to 580 nm at pH 6.6 from 80 nm at pH 7.4 and that the transmittance of micellar solution increased with decreasing pH, the micelles were not dissociated but rather swollen/aggregated. Interestingly, the subsequent decline of pyrene polarity below pH 6.6 suggested re-self-assembly of the block copolymers, most likely forming a PLA block core while polyHis block relocation to the surface. Consequently, these pH-dependent physical changes of the PLA-b-PEG-b-polyHis micelles provide a mechanism for triggered drug release from the micelles triggered by the small change in pH (pH 7.2–6.5).