双孔成形术治疗二尖瓣关闭不全

目的总结双孔二尖瓣成形术治疗二尖瓣关闭不全的经验。方法诊断为二尖瓣关闭不全接受此手术治疗30例，男12例，女18例，年龄14～52（33±17）岁。心功能Ⅱ级5例，Ⅲ级23例，Ⅳ级2例，用超声心动图对瓣膜进行评价。结果全组术前二尖瓣反流面积（9．8±3．5）cm^2，术后为（0．72±0．31）cm^2。全组无术后死亡，痊愈出院。随访1～48个月，效果满意，心功能为Ⅰ～Ⅱ级。结论双孔二尖瓣成形术是一种简单有效的手术方法。     

非风湿性二尖瓣关闭不全成形术后二尖瓣狭窄

非风湿性二尖瓣关闭不全成形术后二尖瓣再次关闭不全是成形手术失败的常见原因,但术后二尖瓣狭窄非常罕见。该文报道了4例因粘液变性或缺血性二尖瓣返流患者二尖瓣成形术后的二尖瓣狭窄。 方法 研究对象为1990年1月～1999年12月行二尖瓣成形术后的478例二尖瓣粘液变性及40例缺血性二尖瓣返流患者。术中、出院前及术后每年均行心脏彩超检查。随访时间12     

经皮二尖瓣球囊成形术治疗二尖瓣狭窄伴主动脉瓣关闭不全的疗效评价

目的　探讨风湿性心脏病 (RHD)二尖瓣狭窄 (MS)合并轻、中度主动脉瓣关闭不全 (AR)患者行经皮二尖瓣球囊成形术 (PBMV)的效果。方法　将 2 6例MS合并轻、中度AR患者 (A组 )和 34例单纯MS患者 (B组 )的PBMV术后即刻及随访结果作对比研究。结果　A组左心房平均压力(MLAP)从术前 2 3 5± 4 6mmHg降至 11 2± 2 9mmHg(P <0 0 1) ,二尖瓣跨瓣压差 (MVG)从 17 2±7 7mmHg降至 2 3± 2 6mmHg(P <0 0 1) ,二尖瓣口面积 (MVA)从 1 1± 0 2cm2 增至 2 1± 0 2cm2(P <0 0 1) ,左心房内径 (LAD)从 43 3± 5 0mm降至 36 4± 3 7mm(P <0 0 1)。二尖瓣区舒张期杂音消失率为 73%。心功能分级 (NYHA)从术前 2 7± 0 5级改善至 1 1± 0 7级 (P <0 0 1)。随访与术后比较 ,除MVA外各项指标均无显著性差异 (P >0 0 5 )。以上各项参数与B组比较 ,差异均无显著性(P >0 0 5 )。且A组随访左心室内径 (LVD)仍在正常范围 ,亦无主动脉瓣返流增加。结论　对于MS合并轻、中度AR ,PBMV是一种有效和安全的治疗措施 ,应列入PBMV的手术适应症。     

二尖瓣成形术在婴幼儿先天性心脏病中的应用

目的：总结二尖瓣成形术在婴幼儿先天性心脏病（先心病）中的应用.方法：自2007年10月至2012年10月,108例二尖瓣关闭不全（不包括完全性或部分性房室通道）婴幼儿行二尖瓣成形手术,所有婴幼儿中有3例（2.7％）行再次二尖瓣成形术.术中根据瓣膜病变情况选择合适的成形方法,包括二尖瓣瓣环环缩、Wooler瓣环成形术、瓣裂修补、乳头肌缩短技术及复合技术.对所有患者均行临床和超声心动图检查评估二尖瓣功能.结果：全组婴幼儿无死亡病例,所有婴幼儿复查超声心动图提示：二尖瓣残留少量反流23例（21.3％）,中度反流12例（11.1％）,重度反流3例（2.7％）,3例重度反流患几分别于术后2年、2年9个月及4年行再次手术,再次手术后1例无反流,2例少量反流.结论：二尖瓣成形术是婴幼儿先心病中二尖瓣关闭不全手术的首选术式,均能取得良好的治疗效果     

先天性二尖瓣关闭不全的再次手术

目的:回顾性分析先天性二尖瓣关闭不全再次手术的问题。方法:自2002年至2009年间共438例先天性二尖瓣关闭不全(不包括完全性或部分性房室通道)患儿行二尖瓣成形手术,所有患儿中有15例(3.4%)行再次二尖瓣手术,其中再次行二尖瓣成形术12例(组1),二尖瓣置换术3例(组2)。再次手术的原因包括:严重溶血和残余或复发二尖瓣关闭不全。术中根据瓣膜病变情况选择合适的成形方法,包括二尖瓣瓣环环缩、腱索转移、双孔成形和瓣膜置换手术。对所有患者均行临床评估和超声心动图检查评估二尖瓣功能。结果:全组患儿无死亡病例,所有15例随访患儿亦无死亡。组2患儿年龄、体质量和心胸比均大于组1。组1患儿中术中见原缝线撕裂2例,瓣环扩大4例,瓣叶局部裂3例,组1患儿术后超声心动图见二尖瓣关闭不全较术前明显减轻(P0.01)。组2中3例患儿均行二尖瓣双叶机械瓣置换。结论:二尖瓣成形术仍是先天性二尖瓣关闭不全再次手术的首选术式,对术前心功能差且瓣膜条件不理想的患儿行瓣膜置换手术是理智的选择。     

二尖瓣成形术在缺血性二尖瓣关闭不全治疗中的应用

目的总结二尖瓣成形术（MVP）治疗缺血性二尖瓣关闭不全（IMR）的经验。方法21例冠心病合并IMR患者在行冠状动脉搭桥术（CABG）同时行MVP,其中交界环缩4例、人工瓣环成形术7例、双孔成形术5例、腱索修复术3例、双孔成形术＋交界环缩术2例。结果术后早期死亡2例,其余痊愈出院。出院时心功能NYHA分级Ⅰ级13例、Ⅱ级5例、Ⅲ级1例。术中及术后早期超声心动图左室舒张末径和左房内径均较前缩小（P均〈0.05）。结论中度反流以上的IMR应进行积极MVP手术治疗,MVP术式的选择取决于瓣膜病理改变和心功能状态。     

二尖瓣关闭不全成形术效果的术中评价

在二尖瓣关闭不全的治疗中,保留自体二尖瓣的成形术优于二尖瓣瓣膜置换术。它能够提高患者的生存率,减少并发症,而且保留了二尖瓣器,故能维持较好的左心功能。由于二尖瓣成形术的手术指征常常难以掌握,操作技术比较复杂,术后仍有可能出现二尖瓣返流。如何在闭胸前准确评价手术效果是心外科医生面临的难题。二尖瓣关闭不全成形术的主要目的在于恢复瓣膜的正常启闭功能,而非恢复正常解剖结构。临床评价成形术成功与否,常以术后二尖瓣返流减轻或消失作为重要指标。此     

二尖瓣成形术与二尖瓣置换术治疗退行性二尖瓣关闭不全的远期疗效比较研究

背景退行性变是西方国家二尖瓣关闭不全常见的病因,与二尖瓣置换术(MVR)相比,二尖瓣成形术(MVP)不仅无需长期抗凝,避免了抗凝相关并发症,而且能够有助于左心功能的维护。目前MVR与MVP治疗退行性变的远期疗效尚不明确。目的比较MVP与MVR治疗退行性二尖瓣关闭不全的远期疗效。方法选取2003—2008年在俄罗斯巴库列夫心血管外科研究中心接受瓣膜手术的退行性二尖瓣关闭不全患者274例为研究对象。根据手术方式的不同,将患者分为MVP组(129例)和MVR组(145例)。收集患者一般资料,统计患者5年、10年累积生存率、无脑卒中发生率及再次瓣膜手术情况。分别根据患者随访终点时死亡情况、脑卒中发生情况,将患者分为死亡组(42例)和非死亡组(232例)、脑卒中组(30例)和非脑卒中组(244例)。采用单因素分析和多因素Cox回归分析探讨退行性二尖瓣关闭不全患者死亡、发生脑卒中的影响因素。结果MVP组患者体外循环时间、主动脉阻断时间、术后住院时间长于MVR组(P<0.05)。死亡组患者体外循环时间、呼吸机使用时间长于非死亡组,MVP率低于非死亡组(P<0.05)。脑卒中组患者入院时血肌酐、入院时左心室射血分数(LVEF)高于非脑卒中组,MVP率低于非脑卒中组(P<0.05)。多因素Cox回归分析结果显示,MVP是退行性二尖瓣关闭不全患者死亡[HR=0.053,95%CI(0.005,0.585)]、发生脑卒中[HR=0.095,95%CI(0.013,0.698)]的保护因素(P<0.05)。MVP组患者5年累积生存率低于MVR组,10年累积生存率高于MVR组(P<0.05)。MVP组患者5年、10年累积无脑卒中发生率低于MVR组(P<0.05)。MVP组和MVR组患者再次瓣膜手术率比较,差异无统计学意义(P>0.05)。结论MVP是退行性二尖瓣关闭不全患者死亡、发生脑卒中的保护因素,对于退行性二尖瓣关闭不全患者,行MVP者的远期预后优于行MVR者,临床应积极推广MVP。     

二尖瓣成形术治疗二尖瓣后叶脱垂

目的分析总结33例非风湿性二尖瓣后叶脱垂成形手术的效果。方法回顾性分析我院2005年5月至2011年5月行二尖瓣成形术治疗二尖瓣后叶脱垂（除外其他合并畸形、风湿性病变及前叶脱垂）患者33例,男性18例,女性15例,平均年龄46．5岁。术前二尖瓣中重度关闭不全9例、二尖瓣重度关闭不全24例。通过部分瓣叶矩形切除、瓣环环缩及成形环的综合运用修复二尖瓣,同期置入二尖瓣爱德华弹性环28枚。结果全组病例均痊愈出院,无围术期死亡。患者术前心脏彩超检查：左房内径（49．26±17．13）mm,左室内径（60．29±8．32）mm,射血分数（66．1±9．6）％,左室短轴缩短率29．78±6．81。术后1周心脏彩超检查：左房内径（40．23±7．93）mm,左室内径（50．63±4．67）mm,射血分数（53．0±8-3）％,左室短轴缩短率23．50±5．01。术后6个月复查心脏彩超检查：左房内径（36．16±7．46）mm,左室内径（45．61±5．67）mm,射血分数（65．0±7．6）％,左室短轴缩短率29．67±5．91。随诊6-70个月,平均随访18．2个月,二尖瓣功能正常或有微量反流22例,有微少量和少量反流9例,有少中量反流2例。无因二尖瓣关闭不全而再次手术者。结论对于二尖瓣后叶脱垂的病变,术中在经食管超声的帮助下,通过部分瓣叶矩形切除、瓣环环缩及成形环的综合运用,能够修复几乎所有非风湿性所导致的二尖瓣后叶脱垂,避免瓣膜置换。对于非风湿性二尖瓣后叶病变,瓣膜成形技术成熟、可靠,修复效果满意。     

经导管二尖瓣夹合术的临床结果介绍

目的 评估经导管二尖瓣夹合术（MitraClip）治疗中重度或重度二尖瓣反流患者的安全性和有效性.方法 2013年10月至2014年3月,使用MitraClip系统对10例有症状的中重度（1例）或重度（9例）二尖瓣反流患者行经导管二尖瓣修复术,分析10例患者手术即刻效果和30d随访结果.结果 10例患者的平均年龄（74±10.6）岁,功能性反流8例,器质性反流2例.所有手术均成功开展,顺利置入1个（5例）或2个（5例）MitraClip.手术即刻效果提示,5例患者二尖瓣反流下降3级,5例患者下降2级,未发生相关并发症.30d超声心动图随访提示,所有患者二尖瓣反流较术前降低≥2级,左心室射血分数（LVEF）由（40.2±11.9）％提高到（44.8±11.6）％,左心房内径和舒张期左心室内径分别由（6.4±0.5） cm和（6.1±0.8） cm缩小至（6.0±0.5） cm和（6.0±0.8） cm.所有患者的主观症状较术前有不同程度的改善,纽约心功能分级均较术前提高1级,生活质量评分和6 min步行试验分别由（0.7±0.2）和（279.0±123.0）m提高到（0.9±0.1）和（347.0±91.0）m.结论 本中心初步经验提示,经导管二尖瓣夹合术（MitraClip）可以带来超声心动图指标的改善和早期的临床获益,是安全有效的,但中远期效果有待于进一步随访.     

Duodenal GIST: a single center experience

Purpose

The duodenum as primary site for gastrointestinal stromal tumors (GISTs) is rare and mitotic rate, tumor size, type of mutation and number of chromosomal aberrations have prognostic implications.

Methods

We analyzed the outcome of 13 patients with duodenal GISTs who underwent surgical tumor resection. Either segmental duodenectomy or pylorus-preserving duodenopancreatectomy was performed. The tumors were histopathologically examined and the risk of progression was assessed based on tumor size and mitotic count. Additionally, mutation analysis of the KIT and PDGFRA receptor tyrosine kinase genes and comparative genomic hybridization (CGH) were performed in all cases.

Results

Eight patients underwent segmental duodenectomy and five patients were treated with pylorus-preserving duodenopancreatectomy. None of the five GISTs with low or no risk for malignancy according to the Miettinen classification developed tumor progress. In contrast, five of eight cases (62.5%) with high-risk tumors revealed tumor progress, and four of these patients died (50%). The median overall survival for all patients was 66 months, and the median disease-free survival 41 months. The operative procedure and type of mutation did not correlate with long-term survival. CGH analysis displayed ?15q in 12/13 tumors, and ?1p in 11/13 cases as characteristic chromosomal aberrations for intestinal origin. Notably, ?22q was present in three of four cases with tumor progress.

Conclusions

Both segmental duodenectomy and pylorus-preserving duodenopancreatectomy are appropriate options to treat duodenal GIST and should be implemented depending on resectability and the patient's performing state. The Miettinen classification and CGH findings correlate with the clinical course.     

Incidence and patterns of valvular heart disease in a tertiary care high-volume cardiac center: A single center experience

Background

Diseases of the heart valves constitute a major cause of cardiovascular morbidity and mortality worldwide with rheumatic heart disease (RHD) being the dominant form of valvular heart disease (VHD) in developing nations. The current study was undertaken at a tertiary care cardiac center with the objective of establishing the incidence and patterns of VHD by Echocardiography (Echo).

Methods

Among the 136,098 first-time Echocardiograms performed between January 2010 and December 2012, an exclusion criterion of trivial and functional regurgitant lesions yielded a total of 13,289 cases of organic valvular heart disease as the study cohort.

Results

In RHD, the order of involvement of valves was mitral (60.2%), followed by aortic, tricuspid and pulmonary valves. Mitral stenosis, predominantly seen in females, was almost exclusively of rheumatic etiology (97.4%). The predominant form of isolated MR was rheumatic (41.1%) followed closely by myxomatous or mitral valve prolapse (40.8%). Isolated AS, more common in males, was the third most common valve lesion seen in 7.3% of cases. Degenerative calcification was the commonest cause of isolated AS (65.0%) followed by bicuspid aortic valve (BAV) (33.9%) and RHD (1.1%). Multiple valves were involved in more than a third of all cases (36.8%). The order of involvement was MS + MR > MS + AR > MR + AR > AS + AR > MR + AS > MS + AS. Overall, 9.7% of cases had organic tricuspid valve disease.

Conclusion

RHD contributed most to the burden of VHD in the present study with calcific degeneration, myxomatous disease and BAV being the other major forms of VHD. Multiple valves were affected in more than a third of all cases.     

Double versus single autotransplantation in multiple myeloma; a single center experience of 100 patients

One hundred patients with newly diagnosed multiple myeloma (MM) were treated with high-dose chemotherapy followed by single or double autologous stem cell transplantation (ASCT). Up-front treatment with a double ASCT tended to prolong progression-free and overall survival.     

Pneumatosis cystoides intestinalis: a single center experience

AIM: To share our experience of the management and outcomes of patients with pneumatosis cystoides intestinalis (PCI).METHODS: The charts of seven patients who underwent surgery for PCI between 2001 and 2009 were reviewed retrospectively. Clinical features, diagnoses and surgical interventions of patients with PCI are discussed.RESULTS: Seven patients with PCI (3 males, 4 females; mean age, 50 ± 16.1 years; range, 29-74 years) were analyzed. In three of the patients, abdominal pain was the only complaint, whereas additional vomiting and/or constipation occurred in four. Leukocytosis was detected in four patients, whereas it was within normal limits in three. Subdiaphragmatic free air was observed radiologically in four patients but not in three. Six of the patients underwent an applied laparotomy, whereas one underwent an applied explorative laparoscopy. PCI localized to the small intestine only was detected in four patients, whereas it was localized to the small intestine and the colon in three. Three patients underwent a partial small intestine resection and four did not after PCI was diagnosed. Five patients were diagnosed with secondary PCI and two with primary PCI when the surgical findings and medical history were assessed together. Gastric atony developed in one case only, as a complication during a postoperative follow-up of 5-14 d.CONCLUSION: Although rare, PCI should be considered in the differential diagnosis of acute abdomen. Diagnostic laparoscopy and preoperative radiological tests, including computed tomography, play an important role in confirming the diagnosis.     

应用激光鞘拔除电极导线(附五例报道)

目的探讨应用激光鞘拔除电极导线的安全性、可行性。方法回顾分析北京大学人民医院应用激光鞘拔除电极导线的5例患者资料,总结电极导线拔除原因、电极导线特点、手术相关并发症、手术时间、曝光时间、曝光量等。结果 5例患者(2例女性),年龄(62.8±16)岁,其中1例为Ⅱa类适应证,4例为I类适应证,共拔除电极导线8根(2根除颤电极导线),均成功拔除,无并发症发生,手术时间、曝光时间、曝光量的中位数分别为4 min、1min 35 s、1.305 mgy。结论对于大的、有经验的中心,应用激光鞘拔除电极导线是安全、可行的。     

A clinical study of acute lymphoblastic leukemia in adolescents:a single center experience

<正>Objective To explore the clinical and laboratory characteristics,treatment,prognostic factors of acute lymphoblastic leukemia(ALL)in adolescents.Methods Adolescents de novo ALL patients in Blood Disease Hospital,Peking Union Medical College,Chinese Academy of Medical Sciences from September 1999 to September2013 were enrolled in this study.Clinical data,thera-