房室隔缺损的外科治疗

目的总结手术治疗房室间隔缺损的经验.方法回顾1991年5月至2002年9月接受手术修补的30例房室隔缺损患者的病例资料,其中部分型23例,完全型5例,过渡型2例,分别行房、室间隔缺损补片修补术,二尖瓣和/或三尖瓣缝合矫治术.结果术后死亡2例,1例为肺动脉高压,死于重度低心排血量综合征；另1例术后7天死于颅内出血.安置永久性心脏起搏器1例,长期存活28例,随访9个月～12年,临床效果良好.结论充分认识房室隔缺损的传导组织解剖特点,是防止心脏传导阻滞的基础,根据瓣膜畸形的特点决定手术方法是提高手术效果的关键.     

牛心包在心血管外科手术中的应用

目的总结应用牛心包作为心血管外科手术修补材料的初步经验。方法1985年8月～20004年8月，我科应用复合鞣制的牛心包片作为心血管外科手术的修补材料348例，其中男226例，女122例，年龄最大73岁，最小6个月，体重5～82kg。其中，先天性心脏病法洛四联症右心室流出道狭窄加宽补片术147例，法洛三联症房缺修补术18例，巨大房间隔缺损修补术66例，大室间隔缺损修补51例，完全性房室通道修补术8例，部分型房室通道修补术19例，右心室双出口4例，肺静脉异位引流矫治术7例，三尖瓣闭锁及单心室行全腔一肺动脉连接术5例，先天性二尖瓣关闭小全行成形及修补术4例，先天性三尖瓣关闭不全成形及修补术5例，细小主动脉瓣环加宽换瓣术3例，主动脉缩窄加宽补片术4例，肺动脉狭窄加宽补片术7例。结果348例牛心包片在使用过程中技术后早期未发现漏血、溶血、血栓、感染、排斥反应等并发症。术后存活336例，死亡12例，死亡率3．45％，死亡率与牛心包片的使用无明显关系。经过2个月～19年的随访，术发现有牛心包片撕裂、瘤样扩张、钙化、血栓及晚期感染等不良反应，效果满意。结论牛心包片取材方便，来源充足，具有良好的张力强度，且价格低廉。因此，牛心包片作为心血管外科手术中的修补材料，比其它人工修补材料及自体心包补片更具有方便、经济、安全、可靠、来源充足、效果好等特点，而且其耐久性良好，有较好的临床应用价值。     

法洛四联症合并完全性房室隔缺损的外科治疗

目的探讨法洛四联症合并完全性房室隔缺损外科治疗经验。方法回顾性分析9例患者的临床资料,其中完全性房室隔缺损A型3例,C型6例;均有右心室流出道漏斗部狭窄,6例伴明显的肺动脉瓣及瓣环狭窄。术前共同瓣轻度反流7例,中度反流2例。1例行中央体肺分流术,1例行心外管道全腔静脉-肺动脉吻合术,其余7例均行一期根治手术,其中跨肺动脉瓣环5例。结果9例患者死亡3例;1例婴儿术后2d脱机,后因低氧再次插管呼吸机辅助呼吸40d脱机,5例在术后1d脱机,呼吸循环功能良好,顺利康复出院。随访1个月-4年,4例有轻度二尖瓣反流,无残留心脏畸形。结论法洛四联症合并完全性房室隔缺损手术的关键在于确切修补室间隔缺损、完善修复二尖瓣、防止左心室流出道狭窄及Ⅲ°房室传导阻滞。     

完全性房室通道的外科治疗

目的总结94例完全性房室通道(com p lete atrioven tricu lar cana l defect,CAVCD)的外科治疗经验。方法一期手术矫治CAVCD 94例,房、室间隔缺损修补用双片法(涤纶片+心包片)65例,单片法29例,术中行房室瓣成形,并同期修补合并畸形。结果全组死亡10例(10.6%),其中<6个月者4例。4例术后出现二尖瓣中至大量反流,心肺功能衰竭死亡,3例因肺动脉高压危象死亡,3例分别死于低心排血量、脑并发症和气胸。随访84例,随访时间3~6个月,超声心动图复查二尖瓣轻度反流18例,轻至中度反流12例。结论严重二尖瓣关闭不全和肺动脉高压危象是CAVCD矫治术后主要的死亡原因,早期手术矫治和确切的房室瓣成形可获得较好的手术效果,术中常规使用食管超声心动图对提高手术疗效具有重要的作用。     

完全性房室隔缺损的外科治疗

目的 总结完全性房室隔缺损的手术方法和临床经验，以提高手术疗效。方法 27例完全性房室隔缺损患者，年龄88天～24岁。合并右心室双出口、肺动脉瓣狭窄和镜像右位心1例，动脉导管未闭1例，继发孔型房间隔缺损1例，左上腔静脉残留2例，重度肺动脉高压13例，中度肺动脉高压14例。手术均采用双补片法修补，室间隔缺损采用Gore—Tex补片修补，房间隔缺损采用自体心包补片修补。结果 术后早期死亡2例，其中1例死于脑出血，1例死于右侧心力衰竭。所有患者术后均为窦性心律，无完全性房室传导阻滞。随访23例，随访时间2个月～10年，均为窦性心律，无死亡。复查心脏彩色超声心动图提示：二尖瓣轻度反流6例，中度反流2例，心功能均较术前增强。结论 完全性房室隔缺损患者早期行手术治疗，防止肺血管阻塞性病变的发生、发展，术中注意防止左心室流出道狭窄，矫治二尖瓣反流是提高手术疗效的关键。     

婴幼儿二尖瓣关闭不全的成形术

总结１９９０年４月至１９９５年１２月收治婴幼儿二尖瓣关闭不全（ＭＩ）成形术的临床经验。本组７１例中男３５例、女３６例，年龄５个月～３岁、平均２．１岁，体重６～１４ｋｇ、平均１０．２ｋｇ，４１例（５７．８％）＜１０ｋｇ。重度二尖瓣关闭不全１６例，中度４４例，轻度１１例。主要病种包括：单纯ＭＩ３例，ＭＩ＋室间隔缺损和（或）动脉导管未闭３５例，ＭＩ＋房间隔缺损或单心房２２例（Ｉ孔型１６例，Ｉ孔型６例；单心房４例），ＭＩ＋Ｉ孔房间隔缺损和室间隔缺损１１例。手术根据二尖瓣的病理采用瓣交界缝缩、瓣环环缩、修补前瓣叶裂、腱索短缩及转移和后瓣叶成形及共同房室瓣修补等方法修复二尖瓣。同期矫治其它心内畸形。结果术后早期死亡４例（术后感染和低心排综合征各２例），死亡率５．６％。６７例出院病儿中４２例（６２．７％）随诊２个月～５年，平均１．１年。轻度二尖瓣关闭不全５例，中度４例，无重度者；心脏明显缩小。作者认为婴幼儿二尖瓣关闭不全可采用瓣膜成形术治疗，并能取得良好的术后早期和晚期结果。     

未闭合膜部室间隔缺损的外科处理

为了探明位于三尖瓣边缘上的小室间隔缺损（ＶＳＤ）术后易发生心内残余分流的原因，１９９１年１月至１９９２年６月，我们于术中观察了３０例这一类型的ＶＳＤ。发现有以下特点：（１）三尖瓣隔瓣及其腱索与室间隔粘连；（２）隔瓣下隐蔽着一个较大的膜部室间隔缺损（ＭＶＳＤ）；（３）隔瓣边缘上的１个或多个缺损间及与隔瓣下的ＭＶＳＤ相互交通。我们认为，隔瓣边缘上的小“ＶＳＤ”可能是ＭＶＳＤ未完全闭合的一种形式。采用切开隔瓣，修补ＭＶＳＤ，再缝合隔瓣切口的手术方法，成功地避免了术后心内残余分流。     

完全性房室间隔缺损合并法乐四联症的手术矫正

目的　报告完全性房室间隔缺损合并法乐四联症的外科治疗。　方法　 6例患者 ,年龄 3～ 9岁 ,均施行手术根治 ,经右房 右室切口修补VSD ,房室间隔缺损采用两块补片技术修复 ,左房室瓣裂隙的修复均采用间断缝合 ,右室流出道均用带单瓣的补片跨瓣加宽。　结果　全组 6例术后出现低心排综合征、多器官衰竭、灌注肺并发症各 1例 ,早期死亡 1例为多器官衰竭者 ,5例长期存活。术后随访 6个月～ 5 5年 ,1例有轻度左房室瓣关闭不全。心功能Ⅰ级 4例 ,Ⅱ级 1例。　结论　完全性房室间隔缺损合并法乐四联症可应用 2块补片法行手术根治 ,左房室瓣瓣裂的常规修补可降低其关闭不全的发生率 ,大部分患者术后心功能可获得良好的改善。     

矫正型大动脉转位伴心脏畸形外科治疗

自１９８５年９月至１９９４年３月手术治疗３３例矫正型大动脉转位伴心脏畸形病人，其中男２１例，女１２例，年龄１～３５岁（平均１１岁）。其中ＳＬＬ型３１例，ＩＤＤ型２例，手术修复室间隔缺损２８例，肺动脉狭窄２９例（１４例应用外带瓣管道，其中９例同种主动脉带瓣管道，５例为带戊二醛处理的猪肺动脉瓣的人工管道），修补房间隔缺损１５例，左侧房室瓣关闭不全成形２例，动脉导管未闭缝合和改良Ｆｏｎｔａｎ手术各１例。     

房室间隔缺损矫治术后左侧房室瓣反流的外科治疗

目的为提高房室间隔缺损修补术后左侧房室瓣反流的外科治疗效果,探讨其瓣膜的病理改变、手术方法的选择,总结围手术期处理经验。方法回顾分析上海交通大学医学院附属新华医院1995年1月至2009年12月收治29例房室间隔缺损矫治术后左侧房室瓣反流患者的临床资料,其中男16例,女13例;年龄4~62岁,平均年龄26.5岁;术前心功能分级（NYHA）Ⅱ级10例,Ⅲ级17例,Ⅳ级2例;曾行部分性房室间隔缺损矫治术18例,完全性房室间隔缺损矫治术11例;再次手术行心瓣膜修复术17例,心瓣膜置换术12例。结果手术后早期因多器官功能衰竭死亡1例;1例患者行心瓣膜置换术后发生永久性Ⅲ°房室传导阻滞而安装永久心脏起搏器,1例4岁患者行心瓣膜置换术后不能撤离体外循环而行左心辅助56 h后痊愈出院。术后随访25例,失访3例,均为行瓣膜修复患者;术后随访6个月~14年,平均8.2年;随访14例心瓣膜修复患者,左侧房室瓣前向血流均无明显加快,10例左侧房室瓣轻微或轻度反流,1例中度反流,3例分别于再次手术后10 d、3年和6年再发左侧房室瓣重度反流,最终行心瓣膜置换术;25例患者术后心功能明显改善,Ⅰ级17例、Ⅱ级6例、Ⅲ级2例;胸部X线片示：心影较术前明显缩小,心胸比率0.53~0.67（0.60±0.11）;未发现远期死亡。结论对房室间隔缺损矫治术后再发生的左侧房室瓣反流,进行及时的手术治疗,选择恰当的手术方式,能取得满意的近期和远期疗效。     

Oblique septal crossbar graft for anterior septal angle reconstruction

Nasal septal deformity is a central feature of the crooked nose, contributing to functional and aesthetic problems. Straightening of the septum often requires resection, scoring, or incision of the septum--maneuvers that inevitably weaken the cartilaginous dorsal and caudal L-shaped struts, which together are known as the L-strut. Compromise of this L-strut predisposes to septal buckling, recurrent deviation, and saddle nose deformity. We describe our experience with the oblique septal crossbar, a structural graft that allows biomechanically sound anterior septal angle reconstruction during septorhinoplasty. The technique improves dorsal septal support and facilitates correction of the crooked nose. The open septorhinoplasty approach and swinging door maneuver are followed by placement of a diagonally oriented crossbar graft, obtained from cartilage or the perpendicular plate. The approach allows consistent midline correction and buttressing of the nasal dorsum, with no complications to date.     

Entire septal patch technique for postinfarction ventricular septal rupture

Postinfarction ventricular septal rupture is still a surgically challenging situation with high operative mortality. We report a case of ventricular septal rupture in a 75-year-old woman successfully treated with our newly devised technique, in which a pliable large septal path is fixed with transmural sutures placed in posterior left ventricular free wall and anterior ventriculotomy closing sutures, thus covering the septal wall almost entirely. Our method may simplify the operation and reduce the risk of residual leakage.     

Interventricular septal hematoma in ventricular septal defect patch closure

We report a case of interventricular septal hematoma after patch closure of a perimembranous ventricular septal defect in a 4-month-old infant. On postoperative day 1, echocardiography showed a voluminous intramural hematoma causing severe thickening of the ventricular septum. Surgical revision was necessary immediately to drain the hematoma.     

Repair of multiple muscular ventricular septal defects: septal obliteration technique

BACKGROUND: The management of the apical multiple muscular ventricular septal defects (VSDs) remains still controversial. There are various surgical techniques and approaches for closure of "Swiss-cheese" VSDs. In this study, we report the outcome of multiple muscular VSDs repair, using the septal obliteration technique. METHODS: We used the septal obliteration technique in five "Swiss-cheese" ventricular septal defects cases through right atriotomy. Four of the cases had isolated multiple VSDs. One case also had an aortic arch interruption type A, which was repaired prior to cardiopulmonary bypass. Their ages varied between 43 days and 6 years. RESULTS: We did not experience any mortality or serious morbidity. Tracheostomy was required in one patient. There was no important residual shunt in postoperative period, except a minimal shunt in one case. CONCLUSION: The closure technique of "Swiss-cheese" trabecular multiple VSDs using a large single patch was not troubling. Transatrial approach prevented postoperative problems of ventricular incision. Using a large needle with a large pledgett is the key, which provides deep tissue penetration to avoid residual shunt.     

Use of Amplatzer septal occluder system for atrial septal defect closure

Short-term results of minimally invasive transcatheter closure of atrial septal defect using Amplatzer septal occluder system (AGA Medical Corporation, USA) at 72 patients are analyzed. Technique of surgical procedure is described in detail. Morphometric protocol used for determination of indications and contraindication for endoscopic closure is also described. The causes of impossibility of endovascular procedures are established. The rate of transoccluder blood bypasses in postoperative period is demonstrated.     

Histology of the nasal septal swell body (septal turbinate).

OBJECTIVE: To analyze the vascular and glandular elements of the nasal septal swell body (NSB) and quantitatively compare these to the inferior turbinate (IT) and non-swell body portion of septum. STUDY DESIGN: Fourteen healthy adults undergoing septoplasty and IT reduction were submitted to unilateral biopsies of the NSB, the adjacent inferior turbinate, and inferior septum. Photomicrography with morphometric analysis was used to determine the relative area proportions of each tissue type. RESULTS: NSB was rich in seromucinous glands (49.9% +/- 7.0%) compared to IT (19.9% +/- 5.5%), P < 0.01. Conversely, IT mucosa demonstrated increased area proportion of venous sinusoids (28.3 +/- 13.9) compared to NSB (10.0 +/- 6.0), P < 0.01. Inferior septal mucosa had glandular and vascular elements similar in proportion to that of NSB. CONCLUSIONS AND SIGNIFICANCE: NSB is a highly glandular structure of the anterior-superior septum, with moderate proportion of venous sinusoids. Located at the distal valve segment, the NSB appears structured for secretory function and vasoactive airflow regulation.