心脏直视手术中心肺再转流：附76例临床分析

心脏手术毕，心肺转流终止后已复苏的心脏可因心肌收缩功能恢复不全，心内畸形矫治不彻底，术中意外性大出血或损伤引起的完全性房室传导阻滞等原因需重建心肺转流。本文对７６例病人重建心肺转流的原因和结果进行的分析表明，适时重建心肺转流对提高手术成功率有利。     

胸部小切口心内直视手术810例临床应用

目的探讨胸部小切口在心内直视手术中的应用价值。方法1995年12月～2008年1月，经胸部小切口行心内直视手术810例，包括先天性心脏病660例，瓣膜病129例，心脏黏液瘤21例。经胸骨正中上段小切口手术36例，胸骨正中下段小切口59例，右胸骨旁小切口3例，右胸前外侧小切VI658例，右腋下小切口54例。其中382例在心脏跳动下手术。结果术后死亡12例，手术死亡率1．5％。术后呼吸机辅助（6．7±4．2）h，术后引流量（210±165）ml，术后住院时间（7．4±4．9）d，421例（52％）未输血。术后无胸骨裂开、纵隔感染。术后随访690例（85％），随访（48．2±25．3）月，无远期死亡。心功能Ⅰ级478例，Ⅱ-Ⅲ级212例，Ⅳ级0例，明显好于术前（310、438、62例，Z=-13．21，P=0．000）；心胸比率0．51±0．11（0．37～0．75），明显低于术前（0．53．4-0．08，t=4．065，P=0．000）；左心室射血分数0．63±0．11（0．36～0．75），明显高于术前（0．57±0．11，t=-10．529，P=0．000）。结论胸部小切口心内直视手术具有切口隐蔽美观、胸骨畸形及感染发生率低等优点，但必须选择适合的病例，应用必要措施改善显露，加上熟练的手术技巧，才能取得良好的手术及美学效果。     

A Meta‐Analysis of Pulmonary Function With Pulsatile Perfusion in Cardiac Surgery

The aim of this study was to determine whether pulsatile or nonpulsatile perfusion had a greater effect on pulmonary dysfunction in randomized controlled trials. MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials were used to identify available articles published before April 13, 2013. A meta‐analysis was conducted on the effects of pulsatile perfusion on postoperative pulmonary function, intubation time, and the lengths of intensive care unit (ICU) and hospital stays. Eight studies involving 474 patients who received pulsatile perfusion and 496 patients who received nonpulsatile perfusion during cardiopulmonary bypass (CPB) were considered in the meta‐analysis. Patients receiving pulsatile perfusion had a significantly greater PaO₂/FiO₂ ratio 24 h and 48 h post‐operation (P < 0.00001, both) and significantly lower chest radiograph scores at 24 h and 48 h post‐operation (P < 0.00001 and P = 0.001, respectively) compared with patients receiving nonpulsatile perfusion. The incidence of noninvasive ventilation for acute respiratory insufficiency was significantly lower (P < 0.00001), and intubation time and ICU and hospital stays were shorter (P = 0.004, P < 0.00001, and P < 0.00001, respectively) in patients receiving pulsatile perfusion during CPB compared with patients receiving nonpulsatile perfusion. In conclusion, our meta‐analysis suggests that the use of pulsatile flow during CPB results in better postoperative pulmonary function and shorter ICU and hospital stays.     

心脏手术围术期红细胞内三磷酸腺苷含量变化

目的对体外循环心脏手术患者术中及术后３天红细胞（ｒｅｄｂｌｏｏｄｃｅｌ，ＲＢＣ）内三磷酸腺苷（ａｄｅｎｏｓｉｎｅｔｒｉｐｈｏｓｐｈａｔｅ，ＡＴＰ）含量进行动态观察。方法１５例心脏手术患者分别于麻醉诱导前、锯胸骨、体外心肺转流建立、主动脉阻断５分钟、转流结束、手术结束、术后第１天、术后第２天和术后第３天９个时间点取动脉血，测定ＲＢＣ内ＡＴＰ含量。结果手术期间ＲＢＣ内ＡＴＰ含量呈升高趋势，于手术结束达最高点，术后３天明显下降。结论麻醉、体外循环及手术对ＲＢＣ能量代谢具有一定影响     

A Meta‐Analysis of Renal Function After Adult Cardiac Surgery With Pulsatile Perfusion

The aim of this meta‐analysis was to determine whether pulsatile perfusion during cardiac surgery has a lesser effect on renal dysfunction than nonpulsatile perfusion after cardiac surgery in randomized controlled trials. MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials were used to identify available articles published before April 25, 2014. Meta‐analysis was conducted to determine the effects of pulsatile perfusion on postoperative renal functions, as determined by creatinine clearance (CrCl), serum creatinine (Cr), urinary neutrophil gelatinase‐associated lipocalin (NGAL), and the incidences of acute renal insufficiency (ARI) and acute renal failure (ARF). Nine studies involving 674 patients that received pulsatile perfusion and 698 patients that received nonpulsatile perfusion during cardiopulmonary bypass (CPB) were considered in the meta‐analysis. Stratified analysis was performed according to effective pulsatility or unclear pulsatility of the pulsatile perfusion method in the presence of heterogeneity. NGAL levels were not significantly different between the pulsatile and nonpulsatile groups. However, patients in the pulsatile group had a significantly higher CrCl and lower Cr levels when the analysis was restricted to studies on effective pulsatile flow (P < 0.00001, respectively). The incidence of ARI was significantly lower in the pulsatile group (P < 0.00001), but incidences of ARF were similar. In conclusion, the meta‐analysis suggests that the use of pulsatile flow during CPB results in better postoperative renal function.     

心肌缺血的病理生理与心肌保护

心肌损伤是心脏手术引起的主要并发症之一。手术操作、全身炎性反应和心肌缺血-再灌注是造成心肌损伤的主要因素。轻柔而迅速的手术操作能减轻机械因素对心肌的损伤,缩短心肌缺血时间,从而减轻缺血-再灌注对心肌的损伤。良好的心肌保护效果是患者术后恢复的关键因素。近年来,通过调节心脏保护液的温度、成分、灌注方法而增加心肌氧供、降低氧耗、抑制炎性反应、清除氧自由基,并使用药物启动心肌细胞内源性保护机制,从而减轻心肌缺血-再灌注损伤,改善心肌保护效果。     

心脏不停跳心内直视手术成功地治疗高危病人（附4例报告）

我院应用心脏不停跳心内直视手术成功地治疗4例高危病人，1例重症二尖瓣置换（MVR），1例动脉导管未闭（PDA）并肺动脉高压（肺动脉压为10kPa) 1例70岁的左房粘液瘤并冠心病，1例主动脉窦瘤破裂入右房并三尖瓣关闭不全，多脏器功能衰竭，手术经过顺利，全部痊愈出院。     

单纯钾停跳氧合血持续灌注不降温心脏直视手术(附160例报告)

应用钾停跳、氧合血持续灌注心肌保护、不降温体外循环行心脏直视手术１６０例，手术均顺利，术后无低心排综合征、无严重心律失常发生。全组死亡２例（１．２５％）。部分病例进行了ＬＤＨ１／ＬＤＨ２、ＣＫ－ＭＢ及血清乳酸测定，与低温体外循环组比较无统计学明显差异（Ｐ＞０．０５）。作者认为，此方法临床效果满意，值得进一步研究、推广应用。     

Effect of Intra‐wound Vancomycin for Spinal Surgery: A Systematic Review and Meta‐analysis

Intra‐site prophylactic vancomycin in spine surgery is an effective method of decreasing the incidence of postsurgical wound infection. However, there are differences in the prophylactic programs used for various spinal surgeries. Thus, this systematic review and meta‐analysis aimed to evaluate the effectiveness of using intra‐wound vancomycin during spinal surgery and to explore the effects of dose‐dependence and the method of administration in a subgroup analysis. A total of 628 citations or studies were searched in PubMed, Ovid, Web of Science, and Google Scholar that were published before August 2016 with the terms “local vancomycin”, “intra‐wound vancomycin”, “intraoperative vancomycin”, “intra‐site vancomycin”, “topical vancomycin”, “spine surgery”, and “spinal surgery”. Finally, 19 retrospective cohort studies and one prospective case study were eligible for inclusion in the systematic review and meta‐analysis. The odds of developing postsurgical wound infection without prophylactic local vancomycin use were 2.83‐fold higher than the odds of experiencing wound infection with the use of intra‐wound vancomycin (95% confidence interval, 2.03–3.95; P = 0.083; I² = 32.2%). The subgroup analysis including the dosage and the method of administration, revealed different results compared to previous research. The value of I² in the 1‐g group was 27.2%, which was much lower than in the 2‐g group (I² = 57.6%). At the same time, the value of I² was 0.0% (P = 0.792, OR = 2.70) when vancomycin powder was directly sprinkled into all layers of the wound. However, there is high heterogenicity (I² = 60.0%, P = 0.007, OR = 2.83) when vancomycin powder is not exposed to the bone graft and instrumentation. There are differences found with the method of local application of vancomycin for reducing postoperative wounds and further studies are necessary, including investigations focusing on the dose‐dependent effects during spinal or the topical pharmacokinetic and other orthopaedic surgeries.     

Anti‐Inflammatory Strategies to Reduce Acute Kidney Injury in Cardiac Surgery Patients: A Meta‐Analysis of Randomized Controlled Trials

Acute kidney injury (AKI) after cardiac operations is a serious complication associated with postoperative mortality. Multiple factors contribute to AKI development, principally ischemia‐reperfusion injury and inflammatory response. It is well proven that glucocorticoid administration, leukocyte filter application, and miniaturized extracorporeal circuits (MECC) modulate inflammatory response. We conducted a systematic review of randomized controlled trials (RCTs) in which one of these inflammatory system modulation strategies was used, with the aim to evaluate the effects on postoperative AKI. MEDLINE and Cochrane Library were screened through November 2011 for RCTs in which an inflammatory system modulation strategy was adopted. Included were trials that reported data about postoperative renal outcomes. Because AKI was defined by different criteria, including biochemical determinations, urine output, or dialysis requirement, we unified renal outcome as worsening renal function (WRF). We identified 14 trials for steroids administration (931 patients, WRF incidence [treatment vs. placebo]: 2.7% vs. 2.4%; OR: 1.13; 95% CI: 0.53–2.43; P = 0.79), 9 trials for MECC (947 patients, WRF incidence: 2.4% vs. 0.9%; OR: 0.47; 95% CI: 0.18–1.25; P = 0.13), 6 trials for leukocyte filters (374 patients, WRF incidence: 1.1% vs. 7.5%; OR: 0.18; 95% CI: 0.05–0.64; P = 0.008). Only leukocyte filters effectively reduced WRF incidence. Not all cardiopulmonary bypass‐related anti‐inflammatory strategies analyzed reduced renal damage after cardiac operations. In adult patients, probably other factors are predominant on inflammation in determining AKI, and only leukocyte filters were effective. Large multicenter RCTs are needed in order to better evaluate the role of inflammation in AKI development after cardiac operations.     

Similar Cerebral Protective Effectiveness of Antegrade and Retrograde Cerebral Perfusion During Deep Hypothermic Circulatory Arrest in Aortic Surgery: A Meta‐Analysis of 7023 Patients

In aortic arch surgery, deep hypothermic circulatory arrest (DHCA) combined with cerebral perfusion is employed worldwide as a routine practice. Even though antegrade cerebral perfusion (ACP) is more widely used than retrograde cerebral perfusion (RCP), the difference in benefit and risk between ACP and RCP during DHCA is uncertain. The purpose of this meta‐analysis is to compare neurologic outcomes and early mortality between ACP and RCP in patients who underwent aortic surgery during DHCA. PubMed, EMBASE, and the Cochrane Library were searched using the key words “antegrade,” “retrograde,” “cerebral perfusion,” “cardiopulmonary bypass,” “extracorporeal circulation,” and “cardiac surgery” for studies reporting on clinical endpoints including early mortality, stroke, temporary neurologic dysfunction (TND), and permanent neurologic dysfunction (PND) in aortic surgery requiring DHCA with ACP or RCP. Heterogeneity was analyzed with the Cochrane Q statistic and I² statistic. Publication bias was tested with Begg's funnel plot and Egger's test. Thirty‐four studies were included in this meta‐analysis, with 4262 patients undergoing DHCA + ACP and 2761 undergoing DHCA + RCP. The overall pooled relative risk for TND was 0.722 (95% CI = [0.579, 0.900]), and the z‐score for overall effect was 2.9 (P = 0.004). There was low heterogeneity (I² = 18.7%). The analysis showed that patients undergoing DHCA + ACP had better outcomes than those undergoing DHCA + RCP in terms of TND, while there were no significant differences between groups in terms of PND, stroke, and early mortality. This meta‐analysis indicates that DHCA + ACP has an advantage over DHCA + RCP in terms of TND, while the two methods show similar results in terms of PND, early mortality, and stroke.     

不同体、脑灌注方式对StanfordA型主动脉夹层患者的脑保护研究

摘要：目的探讨不同的体、脑灌注方式对StanfordA型主动脉夹层患者脑保护的影响。方法回顾性分析哈尔滨医科大学附属第一医院2007年4月至2012年3月117例StanfordA型主动脉夹层手术患者的临床资料,依据不同的体、脑灌注方式将患者分为3组,组1：45例,股动脉插管行体循环灌注＋停循环后单侧或双侧顺行性脑灌注组;组2：38例,锁骨下动脉或无名动脉插管行体循环灌注和单侧顺行性脑灌注或双侧顺行性脑灌注组;组3：34例,锁骨下动脉或无名动脉插管＋股动脉插管行顺逆结合体循环灌注和单侧顺行性脑灌注或双侧顺行性脑灌注组。对比分析术后短暂性神经系统功能障碍（transientneurologicaldysfunction,TND）、永久性神经系统功能障碍（permanentneurologicaldysfunction,PND）的发生情况以及影响因素。结果组1脑部并发症发生率高于组2、组3（37．77％vs．13．16％vs．14．71％）,差异有统计学意义（P〈0．05）;组3体外循环的降温速度比组1、组2快（35．56±4．35VS．40．00±5．63、39．58_＋6．03）,差异有统计学意义（P〈0．05）;其他指标各组间差异无统计学意义（P〉0．05o结论顺行性、逆行结合的体外循环灌注方法联合顺行性脑灌注降温速度均匀快速,可能具有良好的脊髓、肾脏、腹腔器官的保护作用,特别是降低脑部并发症方面证明其是目前最佳的器官保护方法。     

Prophylactic Use of Intra‐Aortic Balloon Pumps in Open Heart Surgery

During a 1‐year period, intra‐aortic balloon pumps (IABPs) were used in open heart surgery on 57 patients. Indications were prophylactic usage for coronary artery bypass grafting (CABG) in 52 patients, prophylactic usage for valve replacement in three patients, and cardiopulmonary bypass (CPB) weaning during valve replacement in two patients. The 52 CABG patients comprised 94.5% of all CABG procedures during the period. Sheathless 8 Fr IABPs were used in all cases. The 57 patients using IABPs were analyzed. The mean duration of IABP use was 41.7 h. Morbidity was not associated with using IABPs. There was one case of balloon rupture. Hemostasis was performed easily after removing IABP catheters by compressing the groin for approximately 15 min. The lowest blood pressure during anastomosis or cardiac arrest was also assessed. The lowest peak pressure was 55.9 ± 17.3 mm Hg for patients with IABP still turned on, and the lowest mean pressure was 34.7 ± 6.5 mm Hg for patients with IABP temporarily turned off. Peak blood pressure after CPB was 73.8 ± 17.8 mm Hg. During open heart surgery under anesthesia with the low blood pressure presented by this series, use of IABPs enabled patients to tolerate the procedure. In conclusion, aggressive use of IABPs is easy, safe, and effective with no related morbidity.     

A New Device for Intraoperative Renal Blood Flow Measurement During Open‐Heart Surgery: An Experimental Study and the Clinical Pilot Study

Renal blood flow (RBF) may vary during cardiopulmonary bypass and low flow may cause insufficient blood supply of the kidney triggering renal failure postoperatively. Still, a valid intraoperative method of continuous RBF measurement is not available. A new catheter combining thermodilution and intravascular Doppler was developed, first calibrated in an in vitro model, and the catheter specific constant was determined. Then, application of the device was evaluated in a pilot study in an adult cardiovascular population. The data of the clinical pilot study revealed high correlation between the flow velocities detected by intravascular Doppler and the RBF measured by thermodilution (Pearson's correlation range: 0.78 to 0.97). In conclusion, the RBF can be measured excellently in real time using the new catheter, even under cardiopulmonary bypass.     

先天性心脏病术后完全性房室传导阻滞的防治

目的探讨１７５４例先天性心脏病直视术后１０例完全性房室传导阻滞（ＣＡＶＢ）的发生原因和转归，提出正确的防治方案。方法手术中立即发生ＣＡＶＢ８例；其中６例立即再次阻断主动脉重新修补，２例使用心外膜起搏和异丙肾上腺素处理，其中１例术后第７天再次手术重新修补缺损；手术后３～４天由于ＣＡＶＢ发生心源性昏厥２例，均安置临时心内膜起搏器。结果全组患者无住院死亡，全部康复出院未留置永久性心内膜起搏器。结论ＣＡＶＢ的发生与房间隔缺损（ＡＳＤ）、室间隔缺损（ＶＳＤ）的位置和手术操作有关；正确认识房室传导组织的解剖是防止损伤的关键，术中一旦发生ＣＡＶＢ应果断拆除原修补缝线，重新修补缺损；术后安置心外膜或心内膜临时起搏器对防止心源性昏厥非常有效。     

Carbon Dioxide and Acetate‐Free Biofiltration: A Relationship to be Investigated

As the name reveals, acetate‐free biofiltration (AFB) is featured by lack of acetate and this would seem to allow better hemodynamic stability. However, AFB also has a unique characteristic of carbon dioxide (CO₂)‐free dialysate, whereas all other modern dialysis techniques imply an overload of CO₂ from dialysate to the patient. This notwithstanding the role of CO₂ in tolerance to dialysis treatment, both AFB and all other dialysis techniques seem not investigated in due depth. Specifically, the amount of CO₂ coming back to the patient's bloodstream during AFB and bicarbonate dialysis (BD) is unknown. We measured partial pressure of CO₂ (pCO₂) in blood samples withdrawn from the venous line of the extracorporeal circuit during BD and subsequently during AFB in 22 stable chronic hemodialysis outpatients. The amount of CO₂ coming back to the patient's bloodstream is higher in BD (59.1 ± 4.0 mmol/L) than in AFB (42.8 ± 4.5 mmol/L, P < 0.0001). Such difference exceeds 30%. Moreover, shifting from BD to AFB shows, notably for each patient, the reduction of pCO₂ toward physiological values. BD implies CO₂ overload from dialysate, whereas AFB does not. Further studies are required to evaluate if AFB would be the most appropriate dialysis technique in patients affected by chronic, but especially acute, lung diseases.     

Cup‐Cage Solution for Massive Acetabular Defects: A Systematic Review and Meta‐Analysis

Our systematic review compiled multiple studies and evaluated survivorship and clinical outcomes of cup‐cage construct usage in the management of massive acetabular bone defects. This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) guidelines. Various combinations of “acetabular”, “pelvis”, “cup cage” and their corresponding synonyms were used to search relevant articles in the Cochrane, EMBASE, and PubMed databases. Basic information of the functional scores, implant revision rate, and complication rate were selected as outcomes for analysis. Finally, a total of 11 articles published between 1999 and 2019 were selected, which include 232 patients with an average age of 68.5 years (range, 30–90). The mean follow‐up period was 48.85 months (range, 1–140). Our study shows that the cup‐cage construct has a good clinical outcome with a low revision rate and a low complication rate. Improved clinical outcomes of cup‐cage constructs were seen with a revision rate of 8% and an all‐cause complication rate of 20%. The most commonly reported complication was dislocation, followed by aseptic loosening, infection, and nerve injuries. In summary, it is a promising method for managing large acetabular bone defects in total hip revision.     

Autografts vs Synthetics for Cruciate Ligament Reconstruction: A Systematic Review and Meta‐Analysis

To describe the outcomes of autografts and synthetics in anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) reconstruction with respect to instrumented laxity measurements, patient‐reported outcome scores, complications, and graft failure risk. We searched PubMed, Cochrane Library, and EMBASE for published randomized controlled trials (RCT) and case controlled trials (CCTs) to compare the outcomes of the autografts versus synthetics after cruciate ligament reconstruction. Data analyses were performed using Cochrane Collaboration RevMan 5.0. Nine studies were identified from the literature review. Of these studies, three studies compared the results of bone–patellar tendon–bone (BPTB) and ligament augmentation and reconstruction system (LARS), while six studies compared the results of four‐strand hamstring tendon graft (4SHG) and LARS. The comparative study showed no difference in Lysholm score and failure risk between autografts and synthetics. The combined results of the meta‐analysis indicated that there was a significantly lower rate of side‐to‐side difference > 3 mm (Odds Ratio [OR] 2.46, 95% confidence intervals [CI] 1.44–4.22, P = 0.001), overall IKDC (OR 0.40, 95% CI 0.19–0.83, P = 0.01), complications (OR 2.54, 95% CI 1.26–5.14, P = 0.009), and Tegner score (OR ?0.31, 95% CI ?0.52–0.10, P = 0.004) in the synthetics group than in the autografts group. This systematic review comparing long‐term outcomes after cruciate ligament reconstruction with either autograft or synthetics suggests no significant differences in failure risk. Autografts were inferior to synthetics with respect to restoring knee joint stability and patient‐reported outcome scores, and were also associated with more postoperative complications.