主动脉根部憩室合并感染性心内膜炎1例

我院收治1例感染性心内膜炎病人，红细胞沉降率（ESR）长期居高不下，术中探查发现罕见主动脉根部憩室。行双瓣置换术并主动脉根部憩室封闭术。术后加强抗炎治疗，恢复良好，ESR降至正常，现报道如下。     

保留主动脉瓣主动脉根部置换术治疗主动脉根部瘤的疗效分析

目的评价使用保留主动脉瓣主动脉根部置换术治疗主动脉根部瘤的临床应用疗效。方法 2001年2月至2010年9月阜外心血管病医院对60例主动脉根部瘤患者行保留主动脉瓣主动脉根部置换术,其中男44例,女16例;年龄9～64(37.2±13.0)岁。主动脉夹层15例,升主动脉瘤10例,马方综合征25例,主动脉瓣二瓣化畸形2例。行主动脉根部重建术53例,主动脉瓣瓣叶再植术7例。比较术前、术后心功能及主动脉瓣反流程度等指标。结果全组中无手术死亡和严重并发症发生,呼吸机使用时间中位数为13(2～1 110)h,住ICU时间1～18(2.7±2.5)d。术后复查超声心动图提示:主动脉瓣反流程度均明显减轻,仅3例为中大量反流,其余无反流或微少量反流。术后随访2～122(61.5±35.9)个月,随访56例,失访4例,随访期间死亡9例,生存率83.9%(47/56)。2例因主动脉瓣反流分别于术后13个月和14个月再次入院行主动脉瓣置换术。47例患者心功能较术前明显改善,心功能Ⅰ级35例(74.4%),Ⅱ级8例(17.0%)。免于主动脉瓣中重度反流40例(85.1%)。结论保留瓣叶的主动脉根部置换术治疗主动脉根部瘤的远期疗效满意,瓣膜相关并发症发生率低。     

保留主动脉瓣主动脉根部置换术的研究进展

多年以来,主动脉瓣和主动脉根部置换术被认为是主动脉根部瘤的标准治疗方法。随着人们对主动脉瓣置换术后并发症危害性认识的增加,和对主动脉瓣根部解剖及生理特点认识的深入,保留主动脉瓣主动脉根部置换技术有了较大发展。我们主要介绍主动脉瓣关闭不全的病因和分类、主动脉瓣保留技术及临床结果。     

感染性心内膜炎的外科治疗

目的探讨感染性心内膜炎（IE）的外科手术治疗效果及围术期处理原则。方法回顾性分析2001年3月～2010年10月接受感染性心内膜炎手术治疗患者15例的临床资料。术前经超声心电图检查证实心内赘生物形成者15例。所有患者均经外科手术清除感染病灶及赘生物,并纠治瓣膜病变和心脏畸形,术前术后应用大剂量敏感抗生素。结果术后早期死亡1例（6.7%）,术后随访时间3～48月,随访14例（93.3%）,均无心内膜炎复发,心功能恢复I级12例,Ⅱ级2例。结论外科手术治疗感染性心内膜炎是一种有效的治疗方法。正确掌握手术时机,彻底清除感染病灶,恢复瓣膜功能以及围手术期应用有效抗生素是提高感染性心内膜炎治愈率的生要措施。     

感染性心内膜炎的外科治疗

1999年1月至2003年12月我院共收治15例感染性心内膜炎（IE）患者，经外科手术治疗，效果较好。     

感染性心内膜炎外科治疗30例

我院2000年1月至2004年12月间共治疗感染性心内膜炎（IE）患者30例，现将其治疗经验进行总结。     

感染性心内膜炎62例外科治疗分析

目的 总结感染性心内膜炎(infective endocarditis,IE)的外科治疗经验.方法 对我院62例IE患者行全麻体外循环下心内直视手术,术中清除感染病灶,行心内畸形纠正和瓣膜置换.结果 本组术中植入生物瓣12例,机械瓣49例,另单独行动脉导管未闭缝合术1例.术后死亡1例,为人工瓣感染心内膜炎后再次换瓣,死于感染性休克和心功能不全.其余患者经过抗炎治疗4～6周后体温平稳出院.术后随访1年,未有复发病例.结论 早期给予足量、有效的抗生素治疗,感染无法控制时及时手术治疗,完善的手术纠治是治疗成功的关键.     

主动脉根部瘤外科治疗危险因素和疗效评估

目的 评估主动脉根部瘤外科治疗危险因素和疗效.方法 1996年8月至2009年11月,连续92例主动脉根部瘤手术中男56例,女36例;年龄14～77岁,平均(44.8±1.4)岁.合并主动脉夹层动脉瘤45例,中度以上主动脉瓣关闭不全72例,马方综合征47例.行经典Bentall术59例,纽扣法Bentall术13例,主动脉瓣悬吊术14例,用带主动脉窦人工血管作David Ⅰ术6例.结果 住院死亡8.7%,并发症率31.7%.随访期死亡18例,远期并发症12例.单变量分析术后并发症危险因素为男性、非马方综合征、同期手术、深低温停循环、主动脉阻断≥120 min和术后第1天输血＞1500 ml;住院死亡危险因素为紧急手术、同期手术、主动脉阻断≥120 min、主动脉夹层和术后第1天输血＞1500 ml.Logistic多因素回归分析认为同期手术和术后第1天输血＞1500 ml是并发症和住院死亡危险因素.所有病人1年、5年和10年生存率分别为(97.1±2.0)%、(88.1±4.7)%和(54.0±9.2)%,平均生存(9.9±0.6)年,95%可信区间8.7～11.0.结论 各种主动脉根部瘤手术安全、有效,早、中、长期结果较满意,提倡用纽扣法Bentall术,谨慎选择合适病人作主动脉根部重建术.

Abstract：

Objective Evaluate the outcome of aortic root reconstruction on the analysis of the risk factors influencing surgical results. Methods Between August 1996 and November 2009, 92 patients(56 men, 36 women) aged from 14 to 77years [mean (44.8 ±1.4) years] with aortic root aneurysm underwent aortic root reconstruction. 72 patients had over moderate aortic valve insufficiency. 47 patients suffered from Marfan syndrome. The aortic pathology was aortic dissection in 45. Bentall technique was used in 59 patients, the button technique in 13, the David I with the Valsalva graft in 6 patients and the aortic valve resuspension in 14 patients. Results The hospital mortality rate was 8.7%. The major complications 31. 7%. 18patients died during the period of follow-up. Late complications among 55 survivors were 12. Univariate predictors of the morbidity were the presence of male, non-Marfan, concomitant procedure, deep hypothermia cardiac arrest, aortic cross clamp time and blood infusion. Risk facts for mortality were emergent or urgent operation, aortic dissection, concomitant procedure, aortic cross clamp time and blood infusion. Multivariate analysis revealed risk factors of concomitant procedure and blood infusion were responsible for both morbidity and mortality. The overall long-term survival rate is (97.1 ±2.0)% at 1-year, (88.1 ±4.7)% at 5-year, (54.0 ±9.2)% at 10-year. The mean for survival time is (9.9 ±0.59) years, 95% confidence interval 8.70 -11.01. Conclusion The aortic root restitution procedures are safe and effective in general. The short and long-term outcome is satisfactory. The button technique is the first choice for reimplantation coronary patch. Valve-sparring aortic root reconstructions show promise in safety and applicability.     

结核性感染性心内膜炎1例

病人　男,2 3岁。3个月前出现畏寒、发热(38～39℃)、大汗,经反复抗炎治疗,体温下降,但随后出现心悸、气促、不能平卧、腹胀并下肢水肿。查体:贫血貌,消瘦。心脏向左下扩大,主动脉瓣区闻及3～4 VI级舒张期杂音。腹膨隆,肝肋下5横指,腹水( ) ,下肢水肿。心脏B超示感染性心内膜炎并重度主动脉瓣漏。于2 0 0 2年8月在体外循环下行2 3#人工心脏瓣膜主动脉瓣置换术。术中见右冠瓣穿孔约1cm ,瓣上有一约2 0cm×1 5cm×1 2cm赘生物,瓣膜组织糜烂。镜下见瓣膜表面肉芽肿形成并干酪样坏死,抗酸染色( )。术后病理:亚急性结核性感染性心内膜炎,(主…     

人工机械瓣膜替换术后晚期感染性心内膜炎

瓣膜替换术做心脏瓣膜病变确切可行的治疗方法，已被广泛应用，术后并发症也随之而来，我院1990年1月到1994年8月共为123例病人行人工机械瓣膜替换，术后晚期（指术后二个月以后）发生感染心内膜炎5例，发生率为4．07％，现报告如下。     

A Safer Technique of Aortic Root Replacement After Aortic Valve Replacement

Aortic root replacement after aortic valve replacement (AVR) is often complicated by bleeding around the aortic root, which increases the risk of morbidity and mortality, making it a technically challenging procedure. We describe a new technique of aortic root replacement designed to minimize bleeding around the aortic root. This surgical technique focuses on safe dissection and exposure of the aortic root to avoid inadvertent entry into the right atrium or right ventricle; on modifying the proximal anastomosis of the graft to the aortic annulus; and on performing a coronary artery reimplantation that achieves complete hemostasis at the suture lines. We performed aortic root replacement after AVR in four patients over a 4-year period, without encountering any bleeding around the aortic root.     

主动脉瓣环扩大联合环上瓣置换术治疗成人小瓣环主动脉瓣狭窄近中期疗效分析

目的评价主动脉瓣环扩大联合环上瓣置换术治疗成人小瓣环主动脉瓣狭窄的近中期结果。方法对2007年1月至2011年7月北京安贞医院心外科38例成人小瓣环主动脉瓣狭窄患者行主动脉瓣环扩大后植入环上型人工瓣膜,男12例、女26例,年龄16~58（38.6±21.0）岁,体重48~78（58.5±12.0）kg,身高153~176（162.8±12.0）cm,体表面积（1.67±0.32）m2。风湿性主动脉瓣狭窄19例,先天性主动脉瓣二叶瓣畸形合并狭窄11例,主动脉瓣退行性钙化伴狭窄5例,主动脉瓣狭窄合并感染性心内膜炎3例。入院时心功能分级（NYHA）Ⅱ级8例,Ⅲ级29例,Ⅳ级1例。主动脉瓣环内径15~20（17.6±2.8）mm,平均跨瓣压差53~75（62.8±10.5）mm Hg。结果体外循环时间83~145（112±29）min,升主动脉阻断时间58~116（87±28）min,手术中测瓣器测得主动脉瓣环径15~20（17.3±2.6）mm,扩大瓣环后测瓣器测得瓣环径20~25（22.6±2.3）mm,主动脉瓣环周径增加12~17（14.0±2.6）mm,植入瓣膜增加2~3个标号。无围手术期死亡,无出血等严重并发症。住ICU时间12~41（26±14）h,总住院时间9~15（12.5±3.2）d。37例（97.4%）门诊随访2年以上,所有患者心功能分级（NYHA）Ⅰ级,3例主动脉瓣听诊区存在2/6级收缩期杂音。35例心电图显示左心室肥厚心电图表现显著改善或消失,2例表现为左心室轻度肥厚劳损,无明显心肌缺血表现,无室性心律失常及严重房室传导阻滞。结论主动脉瓣环扩大联合环上瓣置换术治疗成人小瓣环主动脉瓣狭窄近中期效果满意,远期结果有待进一步随访。     

非原位主动脉瓣置换术治疗主动脉瓣环严重毁损性病变的方法与疗效

目的总结非原位主动脉瓣置换术(AVR)的方法和疗效。方法 2008年3月至2010年12月第二军医大学长海医院收治5例主动脉瓣环严重毁损患者,男4例,女1例;平均年龄46.3(38～53)岁。AVR术后并发严重瓣周漏再次手术4例(白塞氏病2例、大动脉炎2例),严重主动脉瓣感染性心内膜炎1例。术中发现主动脉瓣环严重毁损,无法施行常规AVR,改行非原位AVR,即将人工主动脉瓣环固定的位置提高到毁损的主动脉瓣环以上,固定人工瓣环的缝线从主动脉腔外进针、腔内出针。必要时行冠状动脉旁路移植术(CABG)。结果 5例手术患者均顺利康复出院,无出血再次手术或其它并发症。术后5例患者均获得随访,生存良好,心功能分级(NYHA)Ⅰ～Ⅱ级;分别于术后6个月(4例)、1年(2例)和3年(1例)行主动脉心脏三维CT成像(CTA)检查,均未见有主动脉根部瘤或假性动脉瘤形成,显示左心室流出道延长,左、右冠状动脉形态良好。心脏超声心动图检查均未发现有瓣周漏。结论对主动脉瓣环毁损严重的患者采用非原位AVR,人工瓣膜固定可靠,可以防止术后并发瓣周漏或根部假性动脉瘤。     

感染性心内膜炎的治疗

回顾分析１９９１～１９９５年间２３例感染性心内膜炎（ＩＥ）治疗经验。本组均使用过多种抗生素，ＩＥ未能控制。其中８例于感染活动期行手术治疗；１３例于感染未完全获得控制时行手术治疗；２例心脏直视手术后发生霉菌性心内膜炎，经抗霉菌药物治疗无效，改用大蒜素治疗，效果满意。本组２１例施行手术治疗者无手术死亡，术后随访无复发病例。结论：感染性心内膜炎即使血培养阳性，亦应在大剂量有效抗生素保护下尽早手术。早期诊断、及时手术是控制感染、降低死亡率的主要措施     

Prosthetic Aortic Valve Endocarditis Due to Stenotrophomonas Maltophilia Complicated by Subannular Abscess

Annular abscesses are serious complications of infectious native and prosthetic valve endocarditis. In this patient, we isolated Stenotrophomonas maltophilia, a rare cause of subaortic abscess with high mortality/morbidity rates although virulent gram-positive cocci, S. Aureus in particular, have been the most commonly isolated agents. We treated this case of endocarditis and the subannular abscess observed 1 year after the initial operation by aortic root replacement with resternotomy in addition to appropriate antibiotics.     

Allograft Aortic Root Replacement in Prosthetic Aortic Valve Endocarditis: A Review of 32 Patients

Background. This study was conducted to evaluate allograft aortic root replacement in the setting of complicated prosthetic valve endocarditis with extensive annular destruction.

Methods. From January 1990 through March 1996, 32 patients diagnosed with complicated prosthetic valve endocarditis underwent allograft root replacement. Mean age was 58.3 ± 13.2 years; 23 patients were men. Mean preoperative New York Heart Association functional class was 3.4. Staphylococcus epidermidis (50%) and Enterococcus faecalis (19%) were the predominant causative microorganisms. Annular abscesses were found in 26 patients (81%), aortic-mitral discontinuity in 14 patients (43%), and left ventricular-aortic discontinuity in 11 patients (34%). A cryopreserved allograft was used in 31 patients (97%) and a fresh antibiotic-treated allograft was used in 1 patient (3%). Mean aortic cross-clamp time was 150 ± 29 minutes. Mean duration of the postoperative antibiotic treatment was 38.5 ± 11.8 days.

Results. There were three operative deaths (9.4%); causes of death were multiorgan failure in 2 patients (6.2%) and low cardiac output in 1 patient (3.2%). Six patients (18%) had complete heart block (4 patients already before the operation), 3 patients (9.4%) had temporary respiratory insufficiency, and 1 patient (3.2%) needed temporary hemodialysis. Mean follow-up was 37.4 ± 22.4 months. Two late deaths occurred: 1 patient had recurrent endocarditis, leading to a false aneurysm, and died at reoperation; another patient died of lung cancer. Actuarial 5-year survival was 87.3% (70% confidence interval, 76.8% to 97.8%); actuarial 5-year freedom from recurrent endocarditis was 96.5% (70% confidence interval, 90.0% to 100%)

Conclusions. Allograft aortic root replacement is a valuable technique in the complex setting of prosthetic valve endocarditis with involvement of the periannular region. Mortality and morbidity are low.     

感染性心内膜炎瓣膜损害的手术治疗

报告２３例感染性心内膜炎瓣膜损害的手术治疗。在体外循环下行机械瓣置换术１６例１９个瓣膜，行瓣膜成形术７例８个瓣膜，同时矫治先天性心脏病１０例。结果：死亡３例，随访中死亡１例。结论：在心内膜炎致瓣膜损害后手术治疗是积极有效的，术中应尽量修补保存自身瓣膜，术后必须积极预防和治疗并发症。     

主动脉瓣重度狭窄伴左心室收缩功能受损患者的外科疗效分析

目的分析主动脉瓣置换术在治疗主动脉瓣重度狭窄伴左心室收缩功能受损患者中的疗效。方法回顾性分析2000年1月至2011年12月在第二军医大学长海医院接受手术治疗的主动脉瓣重度狭窄伴左心室收缩功能受损[左心室射血分数（LVEF）〈50％]患者的临床资料,排除二尖瓣狭窄患者。共纳入29例患者,男22例、女7例,年龄14～76（56.3±12．9）岁。将患者手术前后临床及心脏超声心动图相关指标进行比较,评价手术效果,并根据患者LVEF恢复情况,分析可能影响患者术后心脏功能恢复的危险因素。结果术后早期死亡1例。其余28例患者术后主动脉瓣跨瓣压差由（97．6±25．1）mmHg降至（25．0±9．7）mmHg,LVEF由41％±6％增加至56％±11％,左心室舒张／收缩期末直径／容积均较术前明显改善（P均〈0．001）。结论主动脉瓣膜置换术是主动脉瓣重度狭窄伴左心室收缩功能受损患者的有效治疗方法,术后左心室超声指标显著改善。术前左心室扩大程度较低可能更利于术后LVEF的恢复。