严重主动脉瓣感染性心内膜炎患者主动脉根部置换的方法与疗效

目的总结严重主动脉瓣感染性心内膜炎患者行主动脉根部置换术治疗的临床经验,探讨其手术适应证和手术方法,以期提高外科治疗效果。方法1995年9月～2008年6月间手术治疗11例严重主动脉瓣或人工瓣膜感染性心内膜炎患者,其中活动期6例,静止期5例;术前动脉血细菌培养阳性6例。术前心脏超声心动图提示均有不同程度的主动脉瓣反流或瓣周漏,左心室收缩期末内径（LVESD）6．0±0．7cm,其中≥5．5cm 7例;左心室射血分数（LVEF）47．8％±11．2％,其中≤509／8例。手术均在彻底清创后应用人工带瓣管道（9例）或同种带瓣管道（2例）行主动脉根部置换术,同期行冠状动脉旁路移植术4例,二尖瓣环缩术3例,室间隔缺损修补术1例。结果术后心脏骤停死亡1例。发生Ⅲ°房室传导阻滞1例,后期植入永久性起搏器。术后随访10例,随访时间3个月～13．2年,术后32d因感染性心内膜炎复发死亡1例;其余患者均无感染复发和晚期死亡。结论当感染性心内膜炎合并主动脉根部或窦部瘤、感染累及主动脉窦壁或冠状动脉开口处、瓣环严重毁损或彻底清创后瓣环缺损广泛时,宜置换主动脉根部。手术的关键是彻底清创和防止根部出血。尽管手术较复杂,但局部清创彻底,有利于提高手术效果。     

心脏瓣膜置换术后并发感染性心内膜炎的外科治疗

目的总结心脏瓣膜置换术后并发感染性心内膜炎的外科治疗经验。方法对21例心瓣膜置换术后并发感染性心内膜炎的患者行再次二尖瓣置换术和主动脉瓣置换术,植入适当大小的机械瓣;术前、术后均进行内科治疗。结果本组近期死亡6例,其中3例患者死于金黄色葡萄球菌感染毒血症及中毒性休克,3例死于术后心力衰竭、多器官功能衰竭。随访15例,随访时间5个月至13年,远期再发感染性心内膜炎4例,其中2例死于感染性心内膜炎复发、败血症及中毒性休克;2例经内科治疗后痊愈。其余患者心功能明显改善(射血分数>0.45),9例复查心脏超声心动图未发现瓣周漏。结论心瓣膜置换术后发生感染性心内膜炎应早期诊断、适时手术和内外科联合治疗是治疗成功的关键。     

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.     

感染性心内膜炎的诊断及外科治疗

目的　探讨感染性心内膜炎的临床特点、手术时机选择及围术期处理。　方法　回顾分析 2 8例感染性心内膜炎患者手术治疗的临床资料。病因为原发性心内膜炎 2 4例 ,人工心脏瓣膜感染性心内膜炎 4例。施行主动脉瓣置换术 2 0例 ,同期施行右冠状窦破裂自体心包修补和经主肺动脉缝闭未闭动脉导管各 2例 ;二尖瓣置换术 7例 ,其中4例行再次二尖瓣置换术 ;肺动脉瓣置换术 1例。　结果　术后早期死亡 2例 ,随访 2 6例 ,随访时间 3个月至 12年 ,1例术前合并肺部感染 ,术后 6个月因心内膜炎复发死亡 ,1例再次二尖瓣置换术后 2年出现瓣周漏。其余患者疗效良好。　结论　感染性心内膜炎早期诊断、正确选择手术时机、术中彻底清除病灶、合理矫正病变及良好的围术期处理是提高疗效的关键。     

感染性心内膜炎手术危险因素分析

目的回顾性分析感染性心内膜炎导致死亡与瓣周漏的危险因素,评价感染性心内膜炎手术时机选择。方法回顾性分析2015年8月至2017年8月在我院行手术治疗的62例感染性心内膜炎患者的临床资料。其中男43例、女19例,年龄19～75(46.1±16.6)岁。将临床资料分为死亡组与生存组,瓣周漏组与无瓣周漏组,急诊手术组和非急诊手术组,探讨感染性心内膜炎手术危险因素及手术时机的选择。结果 62例术后患者,早期死亡3例,死亡率4.8%,其中1例死于肾功能衰竭,1例死于多器官脏器衰竭,1例死于急性左心衰。术后瓣周漏(反流束≥2 mm)患者8例,占总体的12.9%。单因素分析显示术前患者白蛋白含量、肌酐水平、体外循环总时间和升主动脉阻断时间与术后早期死亡相关(P0.05)。患者年龄、术前白蛋白含量、肌酐水平、体外循环总时间、升主动脉阻断时间与术后早期瓣周漏的发生相关(P0.05)。多因素logistic回归模型分析表明,升主动脉阻断时间长是感染性心内膜炎患者术后早期死亡的独立危险因素(P0.05),白蛋白低,年龄大是感染性心内膜炎患者术后早期瓣周漏的独立危险因素(P0.05)。急诊手术与非急诊手术在早期死亡和瓣周漏的发生率差异无统计学意义(P0.05)。结论感染性心内膜炎患者排除禁忌证后应早期手术治疗,手术方式的选择应根据患者实际情况分析选择,术前应注意患者白蛋白及肌酐水平,术中尽量缩短体外循环时间及升主动脉阻断时间有助于改善患者预后。     

感染性心内膜炎的外科治疗

目的评价外科手术治疗感染性心内膜炎的经验和效果。方法回顾性分析15例感染性心内膜炎的外科治疗方法。先天性心脏病5例,风湿性心脏瓣膜病9例,右心室异物1例。术前超声检查赘生物形成14例,血培养阳性4例。全组病例中行心脏缺损矫正修补5例,主动脉瓣置换术5例,二尖瓣置换术4例。结果全组病例均无术中死亡,1例术后因严重低心排综合征早期死亡,14例治愈出院,随访6个月～4a,预后良好,无复发及死亡病例。结论手术治疗感染性心内膜炎是一种有效的治疗措施,它降低了感染性心内膜炎的病死率。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关键。     

先天性心脏病并发感染性心内膜炎21例的外科治疗

目的总结21例先天性心脏病并发感染性心内膜炎患者的外科治疗体会。方法回顾性分析自2003年6月至2008年9月共21例先天性心脏病合并感染性心内膜炎患者行手术治疗的临床资料。结果全组无死亡病例,21例经手术及抗生素治疗后感染及心衰均控制,体温正常痊愈出院,术后随访2~24个月无死亡及心内膜炎复发病例。结论先天性心脏病并发感染性心内膜炎者,抗感染的同时积极手术,正确把握手术的时机、手术方式及选择有效抗生素是提高治愈率的关键。     

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。     

二尖瓣闭合性损伤的诊断与外科治疗

目的二尖瓣闭合损伤临床少见。为引起大家的注意和重视。方法总结４例闭合性二尖瓣损伤的诊断与治疗的经验与教训。结果２例为外伤性二尖瓣腱索断裂，分别行二尖瓣瓣环环缩术加二尖瓣腱索修补术和二尖瓣置换术治愈。１例为外伤性二尖瓣瓣叶撕裂伤、左股动脉假性动脉瘤，合并感染性心内膜炎，急诊行二尖瓣赘生物清除、二尖瓣叶修补术、假性动脉瘤切除术、股动脉修补术治愈。１例为二尖瓣置换术后８年，外伤性人工机械瓣瓣钩断裂，致急性心衰，未及时手术而死亡，尸检证实诊断。结论作者认为闭合性二尖瓣损伤临床上易误诊。一旦诊断宜早期手术。发生急性心衰或合并感染性心内膜炎时，应急诊手术。     

完全性房室隔缺损的外科治疗

目的回顾性总结手术纠治４５例完全性房室隔缺损（ｃｏｍｐｌｅｔｅａｔｒｉｏｖｅｎｔｒｉｃｕｌａｒｄｅｆｅｃｔ，ＣＡＶＤ），以期把握好手术时机，提高手术成功率和生存质量。方法根据Ｒａｓｔｅｌｉ分型：Ａ型２６例，Ｂ型２例，Ｃ型２例，过渡型１５例。手术采用单片心包补片修补方法。结果手术死亡３例，死亡率６．７％。死亡原因为伴发心内严重畸形法洛四联症２例，重度肺动脉高压１例；远期死亡２例，均为二尖瓣反流并发肺部感染和心力衰竭。结论ＣＡＶＤ早期出现肺动脉高压，手术应在６个月～１岁内为好，术后必须定期随访，早期了解房室瓣反流情况     

人工心脏瓣膜瓣周漏34例临床分析

目的探讨人工心脏瓣膜置换术后瓣周漏的治疗经验。方法分析1993年1月至2005年6月诊治的34例瓣周漏患者的临床资料,其中主动脉瓣位6例,二尖瓣位28例。9例行内科保守治疗,25例因明显贫血和（或）心功能衰竭（心衰）及内科治疗效果不好行外科手术治疗。手术直接修补瓣周漏漏口14例,另10例重新换瓣。结果保守治疗者中,2例在住院期死亡,死因分别为感染性休克、心衰;7例患者随访6～72个月,2例因心衰而死亡,余5例生活良好,超声心动图检查显示漏口无明显变化,心脏各房室无增大,心功能Ⅱ级。手术治疗者中,术中死亡1例,术后死亡3例（12％）;生存的21例患者术后随访4～132个月,1例二尖瓣和1例主动脉瓣瓣周漏修补术后瓣周漏复发,21例均生活质量良好,心功能Ⅱ级。结论对瓣周漏引起症状不严重,对血流动力学影响不明显,心功能良好的患者,可行内科保守治疗,定期随访。对有明显贫血和（或）心功能减退者,应尽早手术治疗。     

瓣膜病变合并冠状动脉病变外科治疗及围术期管理

目的 总结瓣膜病变合并冠状动脉病变的外科治疗及围术期管理经验。方法 对66例瓣膜病变合并冠状动脉病变病人的一般临床资料、术前心功能状态、冠状动脉病变相关因素、冠脉造影情况和手术结果进行分析。结果 围手术期死亡5例，死亡率为7.6%。结论 瓣膜病变合并冠状动脉病变的特点：⑴冠心病病史不常典型，必须重视术前冠状动脉造影检查。尤其年龄在45岁以上、来自冠心病高发区、即往有高血压、高血脂、糖尿病病史者。⑵术中心肌保护采用持续逆灌加间断顺灌。⑶手术重点放在再血管化分布范围广及对室壁运动有重要影响的分支。⑷瓣膜病变合并冠心病病人围术期心功能调整的重要原则是较好的处理心率（心律）、前负荷和后负荷以及心肌收缩力之间的综合关系。同时，治疗中严密注意电解质和酸碱平衡变化，及时酌情处理。     

Beyond Fontan conversion: Surgical therapy of arrhythmias including patients with associated complex congenital heart disease

BACKGROUND: Arrhythmia operations may be extended to patients with failed ablation procedures or associated structural defects requiring surgical intervention. The purpose of this study is to review our experience with arrhythmia operations in 29 patients who did not have Fontan conversions after the introduction of catheter ablation. METHODS: Between July 1992 and January 2002, 29 patients had operations for refractory atrial (n = 24) or ventricular (n = 5) arrhythmias. Mechanisms of arrhythmia included atrial reentry (n = 11), atrial fibrillation (n = 5), automatic atrial (n = 3), accessory connections (n = 6), atrioventricular nodal reentry (n = 2), and ventricular tachycardia (n = 5). Median age at operation was 12.3 years (range, 6 days to 45 years). Two patients had structurally normal hearts; the remaining 27 patients underwent concomitant repair of structural heart disease, including atrioventricular valve replacement or repair (n = 8), anatomy-specific repair of Ebstein's anomaly (n = 4), tetralogy of Fallot repair or revision (n = 4), atrial septal defect closure (n = 3), ventricular septal defect repair (n = 2), Mustard takedown with arterial switch (n = 2), initial Fontan (n = 2), right ventricle-to-pulmonary artery conduit revision (n = 2), Norwood procedure (n = 1), 1 ventricular repair for Uhl's anomaly (n = 1), Mustard baffle revision (n = 1), pulmonary valve replacement with aneurysm resection (n = 1), and aortic valve replacement with complex repair (n = 1). RESULTS: No patient developed heart block, and the surgical mortality rate was 7%. One patient died after Mustard takedown and arterial switch operation, and 1 neonate died after repair of severe Ebstein's anomaly. There was one late death after arterial switch conversion at another institution. Recurrent clinical supraventricular tachycardia was present in 2 patients (2 of 27, 7.4%) and 2 patients had new-onset tachycardias with different underlying mechanisms of arrhythmia at late follow-up (median follow-up 47 months). CONCLUSIONS: Successful surgical therapy of arrhythmias can be performed safely at the time of repair of complex congenital heart disease or in patients with failed catheter ablation procedures. Early consideration for single-stage therapy of arrhythmia and structural heart disease is indicated.     

Obstruction of mechanical valve prostheses: Clinical diagnosis and surgical or nonsurgical treatment

Twenty patients underwent nonsurgical and/or surgical treatment for obstruction of mechanical prosthetic valves. The obstructed prosthetic valve was in the aortic position in 11 patients, in the mitral position in 5, and in the tricuspid position in 4. Twelve patients had a bileaflet valve (3 aortic, 5 mitral, 4 tricuspid), and 8 had a tilting disk valve (all aortic). The diagnosis of prosthetic valve obstruction was made by cineradiography and echocardiography. Thrombolytic therapy was instituted in a series of our 10 most recent patients (11 cases), except for one patient with acute renal failure, regardless of the position of the obstructed prosthetic valve. Successful thrombolysis was achieved in 6 cases (54.5%). Six patients required surgical treatment subsequent to either failed or incomplete thrombolysis, and one patient died of congestive heart failure 1 month after surgery. Nonfatal neurologic events occurred in 2 cases (18.2%). A total of 16 patients underwent surgical treatment. Two (12.6%) of the 16 patients died of causes unrelated to the operative procedures before discharge from the hospital. These results suggest that thrombolytic therapy appears to be an attractive nonsurgical alternative for valve thrombosis when the patient's clinical condition is not critical, and thus surgical treatment should only be performed in an emergency on seriously ill patients.     

原发性心脏肿瘤232例临床分析

目的 总结原发性心脏肿瘤的临床特征及治疗结果。方法回顾性分析232例原发性心脏肿瘤患者的临床资料。良性肿瘤218例（94．0％）,其中左房黏液瘤200例（86．2％）;恶性肿瘤14例（6．0％）。临床表现为心悸、气短202例（87．1％）。230例手术,其中完整切除223例,局部切除2例（左心室恶性间皮瘤）,5例（均为恶性肿瘤）仅行活检。瘤体为实性的5例同期行二尖瓣置换术,1例肺动脉瓣黏液瘤行肺动脉瓣置换术,5例行经股动脉取瘤栓术。结果术前死亡2例。术中死亡3例。术后随访6个月～24年185例（81．5％）,其中良性肿瘤174例、恶性肿瘤11例;死亡21例,其中良性肿瘤10例（因良性肿瘤死亡6例,其他原因死亡4例）,恶性肿瘤11例,3例复发（良性1例、恶性2例）,其余恢复良好。结论原发性心脏肿瘤中左房黏液瘤最常见,最常见的临床表现是心悸、气短。一经确诊应尽早手术,良性肿瘤手术效果好,恶性肿瘤预后差。     

肾移植术后早期死亡原因分析

目的:分析肾移植术后早期(6个月内)死亡原因,总结经验,提高和改善移植效果。方法:回顾性分析2000年1月~2005年2月施行433例尸体肾移植患者的临床资料,对其中19例术后早期死亡原因及相关因素进行探讨。结果:术后早期死亡病因包括感染7例,占36.8%;急性心力衰竭4例,占21.1%;肾破裂致失血性休克3例,占15.8%;弥漫性血管内凝血2例,占10.5%;暴发性肝功能衰竭1例、急性心肌梗死1例、肺动脉栓塞1例,各占5.3%。除暴发性肝功能衰竭患者于术后118天死亡外,其余均在术后1个月内死亡。结论:感染是肾移植术后早期死亡最常见的原因,与术后免疫抑制过度、营养不良及术后并发症等有关,其中以肺部和泌尿系感染最重要;心血管疾病是引起移植术后早期死亡的另一重要因素,尤其是高龄和糖尿病患者;肾移植早期死亡与肾功能延迟恢复(包括急性排斥反应和急性肾小管坏死)有密切关系,积极合理的治疗对预防肾移植术后早期死亡具有重要意义。     

Primary lung carcinoma after heart or lung transplantation: management and outcome

OBJECTIVE: We sought to examine our management and outcome of lung carcinoma occurring after thoracic organ transplantation. METHODS: We performed a retrospective review of cases of primary lung carcinoma diagnosed between 1990 and 2000 in patients who have previously undergone thoracic transplantation at our institution. RESULTS: Seventeen patients were identified (1 lung and 16 heart transplants). Median time from transplantation to diagnosis of lung carcinoma was 89 months (range, 46-138 months). Predominant presentation was as an incidental finding at chest radiography (13/17). All patients had smoked cigarettes before transplantation, with 5 continuing to smoke after transplantation. Histologic types were squamous (n = 11), adenocarcinoma (n = 3), small cell (n = 2), and undifferentiated (n = 1). Revised International Union Against Cancer (UICC) clinical stage at the time of diagnosis was stage I or II in 11 of 17 patients. Of these, 9 underwent surgical resection; 2 patients unfit for surgical intervention had radiotherapy. Surgical procedures were lobectomy (n = 5), wedge excision (n = 3), and no resection (n = 1). Median survival after diagnosis was 12 months for all patients and 24 months if the tumor was resected. Six patients who had surgical resection subsequently died (survival of 2, 9, 21, 21, 36, and 67 months); 2 remain alive after 12 and 54 months, respectively. CONCLUSIONS: When possible, surgical intervention should be undertaken for early stage lung cancer occurring after thoracic transplantation because medium-term survival is achievable. Sublobar excisions and definitive radiotherapy should be considered if comorbidity prevents optimal surgical treatment.     

Surgical correction of congenital heart defects in infants and young children]

The results of surgical treatment of congenital heart diseases in 595 children under 3 years of age are generalized. There were no fatal outcomes after correction of coarctation of the aorta (9 cases), patent ductus arteriosus (312), pulmonary and aortic stenoses (7). Among 62 patients who underwent removal of an atrial septal defect 3 (4.8%) died. Operations were performed on 140 patients for a ventricular septal defect with high pulmonary hypertension, 31 (22.1%) of them died from various causes. Operations for complicated heart diseases were acts of despair in children whose condition was critical.     

Surgical correction of the rheumatic concomitant mitral-aortal failure complicated by thrombosis of the left auricle

The results of surgical treatment of 51 patients with the thrombosis of the left auricle (LA), occurred after performance of intervention for the rheumatic concomitant mitral-aortal failure (RCMAF) of the heart were analyzed. The substitution of two valves was performed in 37 patients, valve-preserving operations in combination with the prosthesis--in 14. The massive thrombosis of LA (more than 1/3 volume) occurred in 16 (31%) patients. On the hospital stage 17 patients, mainly with complicated current and organic failure of the tricuspid valve in combination with the adhesive pericarditis, calcinosis of the valves, and also previously operated for the heart, died. The late results (from 1 to 12 yrs) of intervention were studied in 33 patients. Good result was noted in 20 (60.6%) patients, satisfactory--in 5 (15.2%), nonsatisfactory--in 1 (9.1%). 5 (15.2%) patients died mainly because of the thromboembolic complications. The thromboembolic complications were not noted in patients to whom the valve-preserving procedures were conducted. All the patients in this group are alive.