冠心病并发左室室壁瘤的心室壁重建

目的探讨冠心病患者心肌梗死后并发左室室壁瘤的心室壁重建方法及疗效。方法 2003年6月-2008年8月,收治冠心病心肌梗死后并发左室室壁瘤患者23例。其中男13例,女10例;年龄47～74岁,平均61.2岁。心功能根据纽约心脏病协会(NYHA)分级标准:Ⅰ级3例,Ⅱ级6例,Ⅲ级10例,Ⅳ级4例。冠状动脉造影示冠状动脉单支病变2例,2支5例,3支16例。部位:心尖部18例,前壁合并外侧壁4例,单纯下壁1例。左室射血分数为36.52%±12.15%,左室舒张期末内径为(62.30±6.52)mm。术中直接行标准线性修补术9例,心内膜环缩后线性修补术6例,心内膜环缩后补片修补术8例。结果围手术期死亡2例,二次开胸止血1例;其余患者切口均Ⅰ期愈合,无早期相关并发症发生。术后21例存活患者均获随访,随访时间7～48个月,中位随访时间19个月。术后6个月,患者左室射血分数为46.52%±9.41%,较术前明显改善(t=2.240,P=0.023);左室舒张期末内径为(52.23±5.11)mm,较术前显著减小(t=2.170,P=0.035)。6个月时患者心功能根据NYHA分级标准:Ⅰ级8例,Ⅱ级13例。1例患者于术后18个月因脑出血死亡,其余患者均恢复日常生活。结论对冠心病并发左室室壁瘤患者,应根据不同病情采取个体化治疗,选择合适的瘤切除及心室壁重建方法,同期处理合并二尖瓣关闭不全和行冠状动脉旁路移植术,可取得良好效果。     

Endovascular thoracic aortic aneurysm repair with concomitant myocardial and carotid revascularization

A 73-year-old woman presented with a large saccular aneurysm involving the distal aortic arch. Preoperative aortography and cardiac catheterization revealed left main coronary artery and left common carotid artery stenoses. Concomitant coronary artery bypass grafting to the left anterior descending and first diagonal arteries, ascending aorta-to-left common carotid artery bypass grafting, and endovascular thoracic aortic aneurysm repair with antegrade stent-graft deployment and intentional left subclavian artery coverage were performed.     

Thoracoabdominal aneurysm repair: results with 337 operations performed over a 15-year interval

OBJECTIVE: To review perioperative results and late survival after thoracoabdominal aneurysm repair (TAA), in particular to assess the impact over time of epidural cooling (EC) on spinal cord ischemic complications (SCI). SUMMARY BACKGROUND DATA: A variety of operative approaches and protective adjuncts have been used in TAA to minimize the major complications of perioperative death and SCI. There is no consensus with respect to the optimal approach. METHODS: From January 1987 to November 2001, 337 consecutive TAA repairs were performed by a single surgeon. Clinical features included prior aortic grafts in 97 (28.8%) and emergent operation in 82 (24.6%), including rupture in 46 (13.6%) and dissection in 63 (19%). Operative management consisted of a clamp/sew technique with adjuncts in 93%. EC (since July 1993) to prevent SCI was used in 194 (57.6%) repairs. Variables associated with the end points of operative mortality and postoperative SCI were assessed with the Fisher exact test and logistic regression; late survival was estimated with the Kaplan-Meier method. RESULTS: Operative mortality was 8.3% and was associated with nonelective operation, intraoperative hypotension, total transfusion requirement, and the postoperative complications of paraplegia, renal failure, and pulmonary insufficiency. Postoperative renal failure and transfusion requirement were independent correlates of mortality. SCI of any severity occurred in 38 of 334 (11.4%) operative survivors, with 22/38 (6.6% of cohort) sustaining total paraplegia. EC reduced the risk of SCI in patients with types I-III TAA (10.6% vs. 19.8%, =.04). Independent correlates of SCI over the entire study interval included types I/II TAA, rupture, cross-clamp duration, sacrifice of T9-L1 intercostal vessels, and intraoperative hypotension. Late survival rates at 2 and 5 years were 81.2 +/- 3% and 67.2 +/- 5%. CONCLUSIONS: EC has decreased the risk of SCI after TAA repair. Decreasing the substantial proportion (nearly 25%) of patients requiring nonelective operation will improve results. Late survival is equal to that after routine AAA repair, indicating that the considerable resource expenditure required for TAA repair is worthwhile.     

Diamond-shaped anastomosis for duodenal atresia: an experience with 44 patients over 15 years

During the period between 1974 and 1988 44 patients were treated for congenital intrinsic duodenal obstruction using a diamond-shaped anastomosis (35 atresias, including two multiple atresias and nine stenoses). Neither gastrostomy nor transanastomotic tube was used. Postoperatively, oral feeding was started on days 2 to 6 (3.66 +/- 1.41 day). Intravenous fluid administration was discontinued on days 3 to 20 (7.54 +/- 3.58 day). Fourteen patients died, none related to the operative procedure. Of 30 survivors, 21 patients have been followed from 6 months to 15 years. Body weight was within the normal range at the latest visit. Current barium study performed in 19 patients showed no blind loop, megaduodenum, or anastomotic malfunction. The diamond-shaped anastomosis provides the following advantages: (1) early recovery of anastomotic function, and (2) avoidance of later complications, such as formation of a blind loop or anastomotic stenosis.     

Left ventricular true aneurysm with pseudo-aneurysm detected five years and nine months following repair for oozing type free wall rupture

A case of true aneurysm of the left ventricle associated with pseudoaneurysm was treated surgically. The condition was detected five years and nine months following repair of an oozing type left ventricular free wall rupture due to myocardial infarction. Over this period, chest radiographs showed gradual cardiomegaly with prominence of the left fourth arch.     

Predicting outcome after myocardial revascularization in patients with left ventricular dysfunction

In order to identify the risk factors which could predict outcome after coronary artery bypass grafting in patients with left ventricular dysfunction, 80 consecutive patients with an ejection fraction ≤30%, who underwent isolated coronary artery bypass grafting at the authors' centre between January 1994 and May 1996 were evaluated. Preoperatively, mean(s.d.) ejection fraction was 27.1(3.8)%, 56 patients (70%) had angina, and 56 (70%) were in New York Heart Association (NYHA) functional class III or IV. There were five operative deaths, with a hospital mortality rate of 6.3%. Significant risk factors for hospital death were NYHA class IV, preoperative ventricular arrhythmias and left ventricular end-diastolic volume index >110 ml/m². At mean follow-up of 15(7) (range 6–30) months, there were six late deaths, five of which were from cardiac causes. Actuarial survival rate at 2 years was 82(5)% and freedom from cardiac death 84(5)%. Risk factors for overall mortality from cardiac causes were preoperative grade 2 mitral regurgitation, associated with left ventricular dilatation, and renal dysfunction (creatininaemia ≥180 μmol/l). At follow-up, mean ejection fraction was 37.5(8.4)%, and the overall functional status had improved: 12 patients (18%) had angina and eight (12%) were in NYHA class III and IV. Myocardial revascularization in patients with left ventricular dysfunction can be performed with acceptably low operative risk, good survival rate at 2 years, and functional status improvement. Patients with extensive ventricular dilatation, associated with significant mitral regurgitation, have a lower life expectancy and less functional benefits from coronary artery bypass grafting. These patients are better treated by cardiac transplantation.     

Right ventricular function in patients with reduced left ventricular function undergoing myocardial revascularization.

Complex interrelationships exist between the right (RV) and the left ventricles (LV). Therefore, in 30 consecutive patients with reduced LV function (left ventricular ejection fraction [LVEF]) less than 40% undergoing myocardial revascularization, RV hemodynamics were studied from the beginning of anesthesia until the end of the operation. The data were compared with 30 consecutive patients with normal LVEF (greater than 70%). Ventricular function was assessed during left heart catheterization, which was carried out within 1 month of the operation. In addition to standard hemodynamic variables, RV ejection fraction (RVEF), RV end-diastolic volume (RVEDV), and RV end-systolic volume (RVESV) were monitored by the thermodilution technique. The two groups did not differ preoperatively with regard to RVEF, pressure (MAP, PAP, PCWP, RAP, RVPsyst, RVEDP), cardiac index (CI), and volume variables (RVESV, RVEDV). However, when the group with preoperatively reduced LVEF was subdivided into patients with severely reduced LVEF (less than 30%; n = 14; mean value 25.1%) and patients with moderately reduced LVEF (30%-40%; n = 16; mean value 37.3%), RVEF was significantly lower in the patients with a LVEF below 30% throughout the entire investigation period. RVEDV and RVESV were significantly higher in these patients. In conjunction with the lower RVEF and normal PAP, this suggests reduced RV function. It can be concluded that a severely reduced preoperative LVEF (less than 30%) may also be associated with impaired RV function.     

Left ventricular aneurysm repair in rats: structural, functional, and molecular consequences

OBJECTIVES: This study examined the effects of aneurysm repair in a rat model of myocardial infarction on functional indices and on the spatiotemporal distribution of cardiac contractile protein and natriuretic peptide messenger RNA. METHODS: In a rat infarct model, expanded left ventricular aneurysms were plicated 4 weeks after infarction. At 30 weeks, transverse heart sections were taken at 4 levels (apex [level 1] through base [level 4]) and assessed by in situ hybridization histochemistry to determine regional messenger RNA levels of pre-pro-atrial natriuretic peptide, cardiac alpha-actin, skeletal alpha-actin, myosin light chain-2v, and beta-myosin heavy chain. RESULTS: Rats with plicated left ventricular aneurysms had reduced left ventricular endocardial circumference (19%, P <.005), lower heart weight ratio (31%, P <.05), left ventricular end-diastolic pressures (51%, P <.05), and increased +/-dP/dt (34%-38%, P <.05). Cardiac messenger RNA levels of pre-pro-atrial natriuretic peptide were reduced in the septum (levels 2 and 3), and skeletal alpha-actin levels were reduced in the septum and left ventricular free wall of plicated rats (level 3). beta-Myosin heavy chain levels were markedly reduced in peri-infarct regions of the left ventricular free wall, septum, and right ventricle in plicated rats at level 4, whereas myosin light chain-2v levels were reduced at levels 2 and 4 in the left ventricular free wall and at level 4 in the right ventricle. CONCLUSIONS: Plication of left ventricular aneurysm after infarction in the rat significantly reduced cardiac hypertrophy, improved cardiac function, and reduced the upregulation of pre-pro-atrial natriuretic peptide and both fetal and adult contractile protein isoforms associated with cardiac hypertrophy.     

Improved functional results following myocardial revascularization in patients with left ventricular dysfunction

Between February 1978 and October 1982, 40 patients with preoperative ejection fraction (EF) of 0.35 or less underwent aortocoronary bypass. An average of 3.1 saphenous vein grafts per patient were inserted and revascularization was considered complete in 33 (82%) of the subjects in the group. Mean follow-up period was 29 months (range 12-65 months). Early mortality was 5% (2 patients) and there were seven late deaths (3 cardiac and 4 non-cardiac). The five-year cardiac actuarial survival rate was 74% +/- 13% (+/- SEM). Angina has improved in 29 (94%) of the 31 long-term survivors with 23 (74%) being totally asymptomatic. Twenty-two of the long-term survivors performed an exercise test at the end of their follow-up period. These tests revealed that bypass surgery in such patients results in significantly enhanced myocardial oxygen consumption with concomitant increase in effort level and duration. The exercise ability is probably directly related to the degree of revascularization.     

Quantitative analysis of myocardial revascularization on left ventricular diastolic function

To evaluate the effects of myocardial revascularization on left ventricular diastolic function, we studied three groups of subjects. Group I consisted of 10 patients without any previous myocardial infarction. Group II consisted of 10 patients with previous myocardial infarction. The control group consisted of 8 normal subjects, all with no evidence of cardiac disease as determined by cardiac catheterization. Left ventricular diastolic function was assessed by maximum negative dp/dt, constant T, diastolic compliance and 1/3 fractional filling before and after surgical revascularization. (1) Constant T, maximum negative dp/dt and diastolic compliance: There was no significant difference among groups I, II and the control group preoperatively, and the variables were not improved postoperatively. (2) 1/3 fractional filling: 1/3 fractional fillings in groups I and II were significantly lower (p less than 0.05, p less than 0.01) than the control group preoperatively, and it was significantly improved in group I, but unchanged in group II postoperatively. In conclusion, myocardial revascularization improves left ventricular diastolic function in the patients without previous myocardial infarction. The effects of myocardial revascularization, however, in the patients with prior myocardial infarction do not bring about an enhancement of left ventricular diastolic function.     

Resection of postinfarction left ventricular aneurysm with and without revascularization

Twenty-four patients had resection of their ventricular aneurysm and 29 had resection plus revascularization. Sixty percent of the patients received no blood in the heart lung machine during surgery or at any time during hospitalization. One of 24 patients with ventricular resection and two of 29 patients with resection plus revascularization died during hospitalization, for an overall mortality of 5.7%. Fifty of the 53 patients had an ejection fraction of 0.4 or less and 23 of these had an ejection fraction of 0.2 or less. Survival rate was 75.5% at four years for all 53 patients compared to only 12% of patients alive at five years with medical treatment. For the patient with a large ventricular aneurysm, resection and myocardial revascularization can be performed with a low risk even for the patient with poorly functioning residual myocardium.     

Left ventricular pseudo-false aneurysm after a myocardial infarction; application of heart positioner

We herein present the case of a pseudo-false aneurysm which developed in a patient after a myocardial infarction in the posterior left ventricular wall. A 71-year-old man experienced an acute myocardial infarction due to occlusion in the left circumflex artery. Five weeks after the myocardial infarction, echocardiography and magnetic resonance imaging (MRI) disclosed a pseudo-false aneurysm at the posterior left ventricular wall. A patch closure of the aneurysm and coronary artery bypass grafting (CABG) to both the left anterior descending artery and the left circumflex arteries were successfully performed. At surgery, the Starfish Heart Positioner, a commercially available device that is designed to lift the heart during off-pump CABG, was found to be very useful for exposing the posterior left ventricular wall by lifting and fixing the apex of the left ventricle.     

The ePTFE patch in inguinal hernia repair: one surgeon's experience with 246 consecutive cases

Summary The aim of the study was to analyse the results of a single surgeon with a consecutive series of patients operated on for inguinal hernia with an ePTFE prosthesis. 246 inguinal hernias in 203 patients were operated on by Lichtenstein's technique using ePTFE prostheses. All patients were males aged between 27 and 92 who, barring one who was emergency-operated, were on an elective surgery list. Lichtenstein's technique with an ePTFE (77 Soft-Tissue Patch? and 169 MycroMesh?) prosthesis was used. General anesthesia was used in 122 patients, spinal in 79 and local in one. There were 27 type II hernias of the Nyhus classification, 96 type IIIa, 88 type IIIb and 35 type IV. There were no deaths or wound infections. The most frequent complication was inguino-scrotal hematoma on eight occasions and subcutaneous hematoma in nine, cutaneous paresthesiae in 13, pain in 7, seroma in 1 and testicular atrophy and orchitis in 1. After a mean follow-up of 35 months only one recurrence was detected after 17 months in one patient. Lichtenstein's technique is a simple and safe procedure for the repair of any type of inguinal hernia. The MycroMesh? prosthesis is easy to handle and has shown perfect tolerance and manageability.     

Direct arrhythmia surgery in ventricular tachycardia: an experience with 18 consecutive patients

18 patients with ventricular tachycardia (VT) underwent direct arrhythmia surgery between 1984 and 1988. There were 8 patients with ischemic VT, and 10 with nonischemic VT. Operative technique consisted of ablative procedures of the arrhythmogenic area determined by pre- and intraoperative mapping. Induced VT was usually unstable and transient during operation, so that instantaneous multi-point mapping was necessary in almost cases. For VT originated in the left ventricle or interventricular septum, the earliest excitation point determined by the epicardial mapping did not always predict the endocardial arrhythmogenic focus. Pre- and/or intraoperative endocardial mapping was important in this regard. Cryocoagulation (-150 degrees C, 120 sec) was mainly used as an ablative procedure; for ischemic VT, endocardial resection was added, and in nonischemic VT originated in the right ventricular outflow tract, transmural resection was combined with the cryoablation. In performing surgery for nonischemic VT, care must have been taken to make transmural cryocoagulation because the arrhythmogenic focus could exist intramurally. There were no operative deaths. In one patient with nonischemic VT, reoperation was required. After a mean follow-up of 17 month, all the patients are free from sustained VT.