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.方法通过回顾性分析17例感染性心内膜炎的外科治疗,其中无原发心脏病2例,先天性心脏病11例,风湿性心脏瓣膜病2例,先天性心脏病修补术后1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6例,主动脉瓣置换术5例,二尖瓣置换术2例,瓣膜成形术3例,异物取出1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,16例治愈出院,随访6个月～14年,预后良好,无复发及死亡病例.结论外科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死亡率.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.     

急诊体外循环在心血管外科中的应用

目的:研究并讨论在心血管外科中应用急诊体外循环的经验和临床疗效,并对急诊体外循环在临床中应用指征的作用进行探讨。方法:选取进行急诊体外循环术救治的50例患者,其中包括5例心脏肿瘤,12例心瓣膜功能不全,14例冠状动脉的旁路移植手术,7例大血管手术,2例外伤性的心脏破裂,4例患者实施法洛四联症的急性缺氧的矫治手术和6例先天性的心脏病介入治疗失败急诊术。结果:进行急诊体外循环手术的50例患者中,在手术后有45例存活,其手术的成功率是90%。结论:急诊体外循环术是心外科中救治急危重患者的一种重要有效措施,也是临床上救治心外科患者的唯一有效方案,但在治疗过程中需要多科室进行协作,并及时掌握手术中的各项指征,及时建立体外循环,减少术后并发症的发生,从而提高手术的成功率。     

舒芬太尼在心脏手术麻醉中应用的研究进展

心脏手术应激反应强烈,易造成机体损伤。目前临床主要应用大剂量阿片类药物抑制手术所致的应激反应。舒芬太尼具有镇痛效能强、对心功能影响较小、血流动力学平稳、呼吸抑制轻微等特点,近年来在心脏手术麻醉中的应用日益广泛,包括先天性心脏病手术、冠状动脉旁路移植手术、瓣膜置换手术、快通道心脏麻醉等。现就舒芬太尼在心脏手术麻醉中应用的研究进展予以综述。     

先天性脊柱侧凸患者心血管异常的临床分析

目的回顾性分析先天性脊柱侧凸患者的异常心血管表现,以提高对先天性脊柱侧凸合并心血管异常的认识。方法回顾性分析我院2004年1月至2009年8月诊治的509例先天性脊柱侧凸患者的临床资料。结果先天性脊柱侧凸患者心脏结构异常的发生率高达21.6%,先天性心脏病的发生率为8.4%,分流性先天性心脏病的发生率为5.6%,瓣膜病的发生率为15.2%,以二尖瓣病变为主。心电图主要异常为PR间期缩短（发生率为39.8%）、电轴右偏（发生率为14.6%）、QRS波增宽（发生率为6.4%）、QTc延长（发生率为4.7%）。分流性先天性心脏病患者中52.2%的患者在脊柱手术前早期接受心脏手术。结论先天性脊柱侧弯的心脏结构异常常见,可能存在心电活动的异常。建议某些分流性先天性心脏病患者在骨科脊柱侧凸矫型术前接受心脏手术。     

负荷超声心动图的研究进展

负荷超声心动图是指运动、起搏或药物增加心脏负荷,用超声检测心血管系统对负荷的反应状况,从而反映和诊断心脏疾病。负荷超声心动图诊断心脏疾病具有优越性,随着影像学新技术的发展,诊断的敏感性和特异性不断提高。多巴酚丁胺负荷超声心动图对冠状动脉粥样硬化性心脏病的诊断已趋成熟,在先天性心脏病、心肌病、瓣膜病、心功能等方面也有相应的研究。     

胸骨正中小切口在心脏手术中的应用

目的总结56例胸骨下段正中小切口心脏手术的体会。方法2005年12月-2008年8月共进行胸骨下段小切口心脏手术56例,包括先天性心脏病手术37例,瓣膜手术17例,心脏粘液瘤切除2例。术中未使用任何特殊的手术器械。结果全组无早晚期死亡,体外循环时间18—58min,平均41min;主动脉阻断时间0—42min,平均36min。27例完成心脏不停跳手术,心脏停跳手术的29例中,开放循环后25例自动复跳,4例电击一次复跳。术后气管插管时间2—5h,平均3．2h。术后胸腔引流量120—350ml,平均280ml;术后42例需要输血,输血量（400±100）ml,平均200ml。全组术后ICU时间1d,术后恢复良好,切口甲级愈合。术后住院7—11d,平均8d。47例获随访,随访率83．6％,随访时间6—48个月,症状均明显改善。结论胸骨下段正中小切口心脏手术创伤小,安全可靠;皮肤切口小,美观;无须特殊器械,操作简单易行,在特定病例中可获得良好的手术效果。     

Techniques and follow-up results of coronary artery by-pass grafting with special reference to Indian subset of patients

Coronary artery by-pass surgery is fast becoming the most commonly performed major operation even in our country. Coronary heart disease in Indian patients has a lot of peculiarity which distinguishes it from the western population. Indian patients are younger in age, more often diabetic and hyperlipidaemic. Smoking and obesity are not as common as in the west. The coronary arteries are smaller in diameter and are affected diffusely with the atherosclerotic process. These factors make the operation technically more difficult. The techniques have been perfected to a very high level and are being performed in India with results comparable to the western world. The average operative mortality for coronary artery by-pass grafting (CABG) is around 2%.     

Pattern of cardiac diseases in children in Pokhara, Nepal

Objective: The objective of the study was to point out the relative public health problems of cardiac diseases in childhood. Material and methods: A study of the cardiac diseases in children attending the Paediatric OPD of Manipal Teaching Hospital, Pokhara, Nepal was done over a period of 2 years. The idea was to see the pattern of diseases, as being a developing country, these diseases would be a large public health problem. 107 cases had been studied and it was found that 52% were congenital heart diseases and 25% were rheumatic heart diseases. Other cases included dilated cardiomyopathy, Pericardial diseases and a few cases of hypertension. All the cases were investigated by ECG, X-ray and echocardiographic studies. These cases are under follow up and some have undergone surgical treatment. Results: In this study in a short period of 2 years we had 107 cases of heart diseases of which 51% were CHD, 25% RHD and others were pericardial disease, DCM, hypertension and some had no demonstrable lesions. All the cases of RHD are being followed by regular Penicillin prophylaxis. Among them one has had mitral valve replacement done and 2 had mitral valvotomy. Of the CHD cases 5 cases have had VSD operated upon, one PDA also had surgery and one case of Fallot's is shortly going to undergo corrective surgery. Conclusion: Heart disease in neonates could be benign or very significant and a high level of suspicion and knowledge of physiology will differentiate between the two. Early recognition of CHD will help to treat the child and if possible get corrective surgery done. Similarly a history of rheumatic fever is important and all children need to be followed up till at least 18 years of age. Key words: CHD-congenital heart diseases, RHD- rheumatic heart diseases, DCM- dilated cardiomyopathy, VSD-Ventricular septal defect, ASD-atrial septal defect, PDA-patent ductus arteriosus.     

Anaesthetic management of port-access minimally invasive cardiac surgery

Minimally invasive cardiac surgery is the talk of the day among anaesthetists and cardiothoracic surgeons. Port-access minimally invasive cardiac surgery was performed among 116 patients at Loyola University Medical Center since July, 1997. This technology uses a system of 5-channel internal jugular vein and femoral artery/vein catheters and cannulae to provide a closed chest cardiopulmonary by-pass permitting the heart to be arrested and protected with cardioplegic solution in a manner equivalent to used that in open cardiac surgery. Out of 116 patients, 2 experienced coronary sinus rupture for which they were converted to standard conventional approach. All patients had done well postoperatively. The advantages of this method include less postoperative discomfort, decreased hospitalisation and reduced health care costs. Concern exists regarding technical results which according to some are not equivalent to conventional method.     

人工心脏瓣膜再次置换29例分析

目的总结29例人工心脏瓣膜再次置换手术的方法及疗效。方法自1995年1月至2004年12月,29例人工心脏瓣膜换瓣病人再次接受了瓣膜置换手术。初次换瓣到再次换瓣时间为0.5-12年,平均(8.82±1.20)年。手术均在体外循环下进行,其中心脏停跳19例,心脏不停跳10例。置换的瓣膜有主动脉瓣6例,二尖瓣23例。结果住院期间死亡2例,死于低心排1例,急性呼吸衰竭1例,其余治愈。结论再次换瓣手术应恰当掌握手术时机,可应用传统的心脏停跳法及不停跳法, 手术疗效确切。     

Changing pattern of heart diseases in Shanghai from the 1950s to 1980s

Objective　To determine the pattern of dynamic change in types of heart diseases in the past 4 decades for providing a reference to treatment and prevention of heart diseases in China.Methods　All adult cardiac patients admitted to the Zhong Shan Hospital and Hua Shan Hospital from 1948 to 1989 were analyzed. The constituent ratio of different heart diseases in the 1950s, 1960s, 1970s and 1980s was compared.Results　The percentage of heart diseases among medical inpatients increased in each of the recent 4 decades, from 9.89%, 15.69%, 20.90% to 23.54% respectively. The constituent ratio of different heart diseases changed, coronary heart disease constituted the highest proportion, next came rheumatic heart disease, and congenital heart disease was in third place. Congenital heart disease, myocarditis, cardiac dysrhythmia without organic heart disease, cardiomyopathy and endocarditis increased, rheumatic heart disease, pulmonary heart disease and hypertensive heart disease apparently decreased; syphilitic heart disease could rarely be encountered.Conclusion　China is now facing a low overall death rate, a long life expectancy and an aging population. The incidence of heart diseases increased gradually and patterns of heart diseases kept changing. The overall trend is that heart diseases which were not related to infection are increasing while heart diseases related to bacterial infection are decreasing.     

131例心脏直视手术的体会

目的总结131例先天性和后天性心脏病在体外循环下行心内直视手术的外科治疗经验。方法机械瓣膜置换术33例,其他多为先天性心脏病纠治术。结果院内死亡1例(0.76%),主要并发症:出血,低心排出量综合征,心包填塞,心律失常,肺炎肺不张。结论术中处置得当,术后严密监护,是手术成功的关键。     

冠状动脉心肌桥16例外科治疗

目的 探讨冠状动脉心肌桥的诊断、手术方式和手术效果.方法 16例冠状动脉心肌桥行外科治疗,男9例,女7例,年龄12～71岁.所有病例术前均行冠状动脉造影检查,收缩期狭窄60%～98%,合并瓣膜病13例,合并先天性心脏病1例,单纯心肌桥2例.非体外循环不停跳下完成心肌桥松解术8例,心脏停跳下完成6例;行冠状动脉旁路移植术...     

Angioplasty versus coronary artery by-pass surgery: a reappraisal

Revascularisation is the main principle of treatment of obstructive coronary artery disease. This technique is available either by catheter intervention like angioplasty or by-pass surgery. The superiority of one over the other is still undetermined. In symptomatic single vessel disease angioplasty may be a better option than by-pass surgery. In two-vessel coronary artery disease angioplasty may also be preferred especially with good left ventricular function. In patients with double-vessel disease particularly involving proximal left anterior descending artery in association with diabetes mellitus surgery has better long term results. In multivessel disease by-pass surgery is a preferred option although initial results of angioplasty in this group may be very satisfactory. The incidence of further intervention either by surgery or repeat angioplasty is high in patients undergoing angioplasty in multivessel disease. Left main stem disease should be dealt with by-pass surgery. With continued advancement in the revascularisation technology of coronary artery disease both in catheter intervention and surgical fronts there is no room for unequivocal or universal strategy plan in the management of coronary artery disease. Both the techniques are complimentary to each other. Cost consideration is a major consideration in India. Choice should be made after proper evaluation of coronary anatomy, underlying clinical condition, local experience, social and especially economic circumstances.     

妊娠期心脏手术及心脏手术后妊娠81例分析

目的：为了探讨心脏手术对妊娠的影响，方法：妊娠期心脏手术及心脏手术后妊娠８１例回顾性分析，先天性心脏病手术后妊娠４６例；风湿性心脏病手术３５例，其中二尖瓣扩张后妊娠２３例，瓣膜置换术后妊娠６例术后妊娠共２９例，孕期二尖瓣扩张术后继续妊娠６例，结果：７９例新生儿存活，无１例产妇死亡，结论：心脏手术改善心脏，使妊娠获得成功，瓣膜置换术合理抗凝，机械瓣优于生物瓣。     

心脏外科主要手术出血患者输血模式

目的 了解心脏外科主要手术出血患者的围手术期输血模式,为促进临床合理、规范用血提供数据参考。方法 从2015至2016年开展的全国多中心(4家医院)调查中,纳入大血管手术、冠状动脉旁路移植手术、心脏瓣膜手术和先天性心脏病手术患者(≥18岁),描述患者特征及术后结局,探讨其出血情况,围手术期自体、异体血(红细胞、血浆、血小板)的输注模式(比例、输注量及组合方式)。结果 术中心脏瓣膜手术自体血输注比例最高(58.84%),而大血管手术自体血输注量最大(722 ml),且异体血术中输注比例(53.28%)尤其是血小板输注比例(39.34%)显著高于其他手术患者。相对异体红细胞,其他成分在各类手术中的输注时机较为集中,其中单独输注血浆比例在术后1 d最高。随着出血量增加,成分联合输注比例逐渐上升为主要的输血方式。结论 不同心脏手术类型、围手术期阶段或出血量下,患者的输注模式存在差异,需要在了解现况的基础上进一步研究有针对性的输血实践方案,节约血液并提高患者输血安全。     

心脏手术患者围术期肝素诱导的血小板减少症

目的：了解心脏手术患者围术期肝素诱导的血小板减少症(heparin-induced thrombocytopenia,HIT)发生率 及其抗体阳性率,探索HIT发病及其抗体产生的影响因素。方法：检测连续的315例心脏手术病例手术前后血小板计 数、HIT抗体、血小板因子4(platelet factor 4,PF4)。按4Ts评分诊断HIT。按性别、年龄、病种等分别统计发生率及其 抗体阳性率并分析影响因素。结果：HIT发生率3.5%(11/315),HIT抗体阳性率36.5%(115/315)。其中冠心病患者HIT 发生率(17.1%)高于心脏瓣膜病患者(1.9%,P<0.05)和先天性心脏病患者(0.8%,P<0.05)。先天性心脏病患者HIT抗体阳 性率(51.7%)高于心脏瓣膜病患者(30.5%,P<0.05),心脏瓣膜病患者HIT抗体阳性率高于冠心病患者(14.6%,P<0.05)。 HIT患者术后严重并发症发生率(36.4%)高于非HIT患者(10.5%,P<0.05)。Logistic回归示HIT发病的影响因素为年龄, HIT抗体产生的影响因素有年龄和体外循环。结论：心脏手术患者围术期HIT发生率较低,但易产生严重并发症,致 残致死率高,应警惕HIT发病的危险因素。     

心脏术后心源性休克的体外膜肺氧合辅助治疗

目的总结体外膜肺氧合(ECMO)对心脏术后心源性休克患者进行循环辅助的临床经验。方法2004年6月至2009年10月,共计50例心脏术后心源性休克患者需行ECMO辅助,其中冠心病23例,瓣膜病9例,先天性心脏病7例,扩张性心肌病5例,大血管疾病2例,冠心病合并瓣膜病1例,其他病种3例。患者年龄7个月～76(46.4±19.3)岁,体重6.5～170.0(65.8±23.4)kg。结果辅助时间8～336(85.3±78.4)h,33例(66.0%)患者脱机,其中16例脱机后死亡,17例存活出院(34.0%)。结论ECMO可以有效地为心脏术后心源性休克患者提供循环辅助。     

先天性心脏病感染性心内膜炎的外科治疗

目的 总结１９９０年３月至１９９８年７月在我院手术治疗的４４例先天性心脏病并发心内膜炎患者的诊断和治疗经验。方法 男３０例,女１４例,平均年龄３１．２岁,血培养２８例,阳性１２例,３７例在感染控制后手术,７例于感染活动期手术。所有病例均彻底清除了感染灶,纠治瓣膜病变及先心病。     

实时三维超声心动图在先天性心脏瓣膜病诊断中的临床价值

目的：探讨实时三维超声心动图（RT-3DE）诊断先天性心脏瓣膜病的可靠性、优越性及其临床应用价值。方法：对20例先天性心脏瓣膜病患者行经胸超声心动图（TTE）及RT-3DE检查,观察心脏瓣膜病变的范围、程度,病变与瓣上或瓣下结构的关系,并与外科手术结果对比TTE与RT-3DE对病变诊断符合率的一致性和差异。结果：①RT-3DE可形象、立体、多角度地显示心脏瓣膜及其瓣上瓣下结构的真实形态,从而发现一些TTE难以发现的病变。②RT-3DE对先天性心脏瓣膜病诊断符合率稍高于TTE。③TTE和RT-3DE检查结果一致（Kappa=0.615,P〈0.05）。结论：RT-3DE在先天性心脏瓣膜病的诊断中可获得比TTE更丰富的空间信息,是TTE的有益补充。