非缺血性心脏瓣膜疾病合并冠心病同期手术治疗的临床分析

目的 总结非缺血性心脏瓣膜疾病合并冠心病同期手术患者的临床特征和手术效果,以提高手术疗效. 方法 2000年1月至2007年6月同期手术治疗105例非缺血性心脏瓣膜疾病合并冠心病患者,年龄36～79岁(61.96±7.61岁),其中风湿性心瓣膜疾病59例,退行性二尖瓣病变24例,老年性钙化性主动脉瓣病变13例;其它主动脉瓣病变9例.术前行冠状动脉造影明确诊断98例,术中探查发现冠心病7例.全组均行冠状动脉旁路移植术,共移植血管216支(2.06支/例),同期行二尖瓣置换术36例,二尖瓣成形术15例,主动脉瓣置换术43例,双瓣膜置换术11例. 结果 术后住院死亡6例(5.7%,6/105).死于严重低心排血量3例,肾功能衰竭2例,术后心脏骤停并发多器官功能衰竭1例.术后随访93例,随访时间1个月至7年,失访6例.无晚期死亡患者.心功能分级(NYHA)Ⅰ级25例,Ⅱ级53例,Ⅲ级10例,Ⅳ级5例.1例患者活动后仍有心绞痛存在. 结论 非缺血性心脏瓣膜疾病合并冠心病患者绝大多数无典型的心绞痛症状,50岁以上的患者必须行冠状动脉造影检查,对有冠心病易患因素者,应积极作冠状动脉造影检查;冠心病所致的心肌缺血可明显加重心脏瓣膜疾病所引起的心肌损害,术中心肌保护尤为重要;正确评价术前左心功能低下的患者是选择手术治疗的难点,更是影响手术效果的关键因素.     

同期心脏瓣膜手术与冠状动脉旁路移植术81例

目的总结同期施行心脏瓣膜手术和冠状动脉旁路移植术(CABG)的效果和临床经验。方法2000年1月至2005年12月我科同期施行心脏瓣膜手术/CABG 81例。风湿性心脏瓣膜疾病合并冠状动脉病变37例,冠心病合并心脏瓣膜功能不全44例。冠状动脉造影显示:单支血管病变18例,双支血管病变9例,多支血管病变54例。同期施行心瓣膜置换术和CABG 55例,瓣膜成形术和CABG 26例,其中同期行室壁瘤手术4例。人均冠状动脉远端吻合3.12±1.51个。术后发生低心排血量4例,需主动脉内球囊反搏支持。结果2例因手术后发生低心排血量和多器官功能衰竭死亡。再次开胸止血3例。79例患者取得了良好的临床效果,心脏功能明显改善。手术后随访64例,失访15例,随访时间1~74个月,平均随访14.2个月,随访期间死亡5例,均为非心源性死亡。其余患者生活质量明显改善。结论同期施行心脏瓣膜手术/CABG是有效可行的,近期效果满意。     

老年患者二尖瓣置换同期行冠状动脉旁路移植术的临床分析

目的总结老年二尖瓣疾病合并冠心病患者心瓣膜置换术同期行冠状动脉旁路移植术（CABG）的经验，以提高临床效果。方法2002年7月至2004年7月我科共30例老年二尖瓣疾病患者二尖瓣置换术同期行CABG。年龄66．0±9．1岁（60～73岁），4例为风湿性瓣膜病变，26例为二尖瓣瓣膜退行性病变。术前心功能分级（NYHA）：Ⅰ级3例，Ⅱ级5例，Ⅲ级17例，Ⅳ级5例。共移植旁路血管71支，使用左侧乳内动脉24例，其余均为大隐静脉。置换机械瓣27例，置换生物瓣3例；行三尖瓣De Vega成形术17例。结果术后早期死亡1例（3．3％）。随访29例，平均随访时间13个月，心功能均有明显改善，Ⅰ级18例，Ⅱ级10例，Ⅲ级1例，可从事简单的运动及正常家务劳动，生活质量满意。结论老年二尖瓣疾病患者二尖瓣置换术同期行CABG的危险性较大，充分的术前准备，正确的手术方案，术中良好的心肌保护及严密的术后处理是手术成功的重要因素。     

冠状动脉旁路移植术同期行心脏瓣膜置换手术59例临床分析

目的 研究冠状动脉旁路移植同时行心脏瓣膜置换手术治疗非缺血性心脏瓣膜疾病合并冠心病的疗效.方法 59例冠状动脉旁路移植同时行瓣膜置换手术,包括二尖瓣瓣膜病变40例及主动脉瓣瓣膜病变11例,联合瓣膜病变8例,共搭桥132支.根据患者年龄及病变血管情况选用乳内动脉或大隐静脉作为血管桥.结果 本组1例术后1d死亡,死亡原因是严重的低心排综合征,搭桥4根.其他病例术后随访2个月至7年,均没有明显心绞痛复发并且心功能得到改善.结论 非缺血性心脏瓣膜疾病合并冠心病患者一般无典型心绞痛病史,有冠心病高危因素的患者术前应该常规行冠状动脉造影检查明确是否合并冠心病.采取术前改善心功能状态,缩短手术及心肌缺血时间等措施,同时行冠状动脉旁路移植手术及心脏瓣膜手术是有效可行的治疗手段.     

冠状动脉旁路术同期瓣膜手术的体会

目的 介绍冠状动脉旁路术(CABG)同时行心脏瓣膜手术的体会。方法 45例患者,平均年龄59岁(42～75岁);心功能(NYHA)Ⅱ级7例、Ⅲ级30例、Ⅳ级8例;二尖瓣病变30例、主动脉病变7例、联合瓣膜病变8例,均伴有单支或多支冠状动脉病变。手术在中度低温体外循环下完成。心脏停跳后,先作静脉桥的远端吻合,然后置换瓣膜。心脏复苏后完成大隐静脉与升主动脉的吻合,或在升主动脉1次阻断下完成。乳内动脉的吻合在换瓣后心脏复苏前完成。本组6例行二尖瓣成形,31例行机械瓣置换,8例行进口生物瓣置换。结果 本组患者无手术死亡。术后呼吸机使用时间平均18．7h,ICU监护1．8d。住院时间平均9．2d。随访6个月～4年患者无死亡,心功能Ⅰ级35例、Ⅱ级10例。结论 冠状动脉旁路移植术同时行瓣膜手术是安全、有效的。     

牛心包生物瓣膜的临床应用

目的 报告牛心包生物瓣膜置换治疗瓣膜疾病的临床经验和手术效果.方法 自2003年1月至2005年12月,52例患者接受心瓣膜置换术,其中心功能分级(NYHA)Ⅱ级11例,Ⅲ级34例,Ⅳ级7例,36例患者合并心房颤动;行二尖瓣置换术25例,三尖瓣置换术6例,主动脉瓣置换术13例,肺动脉瓣置换术1例,主动脉瓣加二尖瓣置换术6例,二尖瓣加三尖瓣置换术1例;术后通过电话随访患者恢复情况.结果 住院期间死亡1例,手术死亡率为1.9%(1/52);术后并发呼吸道感染2例,51例患者均顺利康复出院;术后住院时间10.8±3.3 d(6～22 d).术后随访37例,随访时间15d～24个月,随访率72.5%(37/51),心功能均恢复到Ⅰ～Ⅱ级,无1例患者出现出血和栓塞,无再次瓣膜手术.结论 生物瓣膜具有较高的手术安全性,患者的心功能恢复较好,术后出血、栓塞、瓣膜毁损和感染性心内膜炎、再次瓣膜手术的发生率可能较低,具有较好的疗效,患者的生活质量较高.     

同期施行瓣膜和冠状动脉手术的危险因素

目的探讨行冠状动脉旁路手术同时行心脏瓣膜手术的危险因素。方法回顾性分析2000年12月至2005年1月间126例行体外循环下冠状动脉旁路移植术（CABG）同期行瓣膜手术患者的临床资料。按照性别分为男性组和女性组,男84例,女42例。采用胸骨正中切口,2组都在中度低温体外循环心脏停跳下完成搭桥和瓣膜手术。结果2组患者术前体重、糖尿病及风湿性二尖瓣狭窄、冠状动脉三支血管病变等差异都有统计学意义（P〈0．05）,患者术后病死率和并发症的发生率差异有统计学意义,二尖瓣置换手术女性明显多于男性（P〈0．05）,男性组术后死亡5例,其中心脏衰竭1例,应激性高血糖昏迷1例,严重心律失常2例,心。肾肺多脏器衰竭1例;女性组术后死亡7例,其中心脏衰竭1例,应激性溃疡消化道大出血1例,严重心律失常3例,心肾肺多脏器衰竭2例。结论CABG同期行瓣膜手术是安全有效的,女性的并发症发生率和病死率高于男性,这与女性的低体重及风湿性二尖瓣狭窄病变等构成独立的危险因素有关。     

同期施行冠状动脉旁路移植术和心脏瓣膜手术

对冠心病和心脏瓣膜病并存的病人 ,需同期施行冠状动脉旁路移植术和心脏瓣膜手术 ,手术操作复杂、时间长、技术要求高。我们近 2年共施行此类手术 2 3例 ,效果满意。临床资料　 2 3例中男 2 0例 ,女 3例。年龄 5 0～ 80岁 ,平均 6 4 5岁。 16例风湿性心脏病、心功能不全者 ,手术前冠状动脉造影发现冠状动脉病变 ;7例心肌缺血同时合并瓣膜病变。 2 3例中冠状动脉单支病变 13例 ,双支病变 6例 ,三支病变 4例。左室造影发现室壁瘤 3例。合并高血压病 9例 ,糖尿病 6例 ,有心衰史者 8例 ,心房纤颤 11例。手术前左室舒张末期内径 45～ 87ｍｍ ,平…     

再次直视心脏瓣膜置换术疗效分析

目的 总结再次直视心脏瓣膜置换术的治疗体会.方法 2002年1月至2009年12月完成再次直视心脏瓣膜置换术104例,占同期瓣膜置换手术的2.92%(104/3557).男性53例,女性51例,年龄13～72岁,平均(46±14)岁.心功能(NYHA分级)Ⅱ级7例,Ⅲ级67例,Ⅳ级30例.其中二尖瓣或主动脉瓣置换术后其他瓣膜病变28例,二尖瓣瓣膜成形术后再发二尖瓣关闭不全10例,瓣周漏19例,生物瓣衰败7例,先天性心脏病矫治术再发瓣膜病变18例,人工瓣膜心内膜炎10例,人工瓣膜机械功能障碍9例,其他3例.再次手术方式包括二尖瓣和主动脉瓣双瓣置换2例,二尖瓣置换59例,主动脉瓣置换24例,三尖瓣置换16例,Bentall术3例.两次手术间隔1个月～19年.结果 全组早期死亡8例,早期死亡主要原因为术后低心排血量综合征、肾功能不全或多脏器功能衰竭,病死率7.7%.术中大出血2例,术后再次开胸止血2例,胸骨正中切口感染1例.随访3个月～7年2个月,平均3年4个月.晚期死亡2例,1例抗凝过量颅内出血,另1例原因不明.其余存活患者术后半年随访心功能(NYHA分级)Ⅰ级67例,Ⅱ级27例.结论 再次换瓣手术如恰当掌握手术时机、术中加强心肌保护、保证准确的手术操作、注重围手术期处理,临床近、远期效果满意.     

风湿性二尖瓣、主动脉瓣与三尖瓣联合病变的外科治疗

目的总结心脏联合瓣膜病变外科治疗的经验。方法227例风湿性二尖瓣、主动脉瓣与三尖瓣联合瓣膜病变患者,术前心功能Ⅱ级31例,Ⅲ级132例,Ⅳ级64例,行主动脉瓣、二尖瓣双瓣膜置换术(DVR)106例,DVR+三尖瓣置换术2例,DVR+三尖瓣成形术119例;同期行左心房血栓摘除术62例,左心房折叠术8例,改良迷宫手术2例。结果术后早期死亡10例,其中死于心力衰竭6例,心搏骤停2例,细菌性心内膜炎1例,药物过敏1例,其余217例患者治愈出院。随访181例,随访时间3个月~13年,心功能Ⅰ~Ⅱ级149例,Ⅲ级23例,Ⅳ级9例;其中1例因心力衰竭死亡。结论幼年期即出现明显心功能不全的联合心脏瓣膜病变患者,于中年就诊时要慎重手术;作三尖瓣成形术前,应常规测试瓣膜关闭不全部位,再酌情选择成形术式;术前给予强心利尿等治疗,使心功能明显改善后再行手术治疗,有利于心功能的恢复;出院后定期随访,继续给予药物治疗,保护心功能。     

Coronary flow reserve and coronary occlusive disease

The functional effects of coronary occlusive disease (COD) in cardiac transplant patients on small-resistance coronary vessels are unclear. We investigated the changes in coronary flow reserve (CFR) in response to the non-specific smooth muscle vasodilator papaverine. A 3F Doppler probe was inserted into the left anterior descending (LAD) coronary artery in 61 patients following orthotopic heart transplantation. Studies were performed in 57 males and 4 females with a mean age of 46 years (range 20–61 years). The median time from operation was 4 years (range 3 months to 10 years). Coronary blood velocity was measured at rest (RFV) and maximum hyperaemia (PFV) produced by intracoronary papaverine. Coronary flow reserve (CFR) was defined as the ratio of PFV to RFV. Minor lesions in epicardial vessels were found in 23 transplant patients. The mean percentage diameter of the most severe lesion in the coronary tree was 23% SD 3% including 12 lesions in the LAD coronary artery itself (mean 24% SD 4%). Patients with COD had an impaired CFR (2.6 SEM 0.2) compared with normals (3.9 SEM 0.2, P = 0.0003), adjusting for year after operation. Mean resting flow velocity was similar in both groups (minor COD, 6.8 cm/s SEM 1.2; normals, 7.1 cm/s SEM 0.6), but mean peak flow velocity response to papverine was reduced (16.5 cm/s SEM 2.5 versus 27.3 cm/s SEM 2.6; P = 0.007). In the presence of minor epicardial disease, coronary flow reserve in resistance vessels was reduced due to impairment of peak flow. This demonstrates that non-endothelial-dependent coronary resistance vessel vasodilatation is abnormal and may be caused by a defect in vascular smooth muscle function.     

70岁以上心脏病患者手术治疗体会

目的 总结70岁以上心脏病患者的手术治疗体会。方法 自1995年5月至2000年7月进行70岁以上高龄患者心脏手术23例,单纯冠状动脉搭桥术13例,单纯瓣膜手术5例,瓣膜手术同时冠状动脉搭桥术3例,心包剥脱同期冠状动脉桥术1例,左房粘液瘤摘除术1例。结果 术后出现并发症5例（21．7％）,死亡1例（4．3％）,无围手术期心肌梗塞、高血压危象和酮症酸中毒等。存活22例随访1个月－5年,心功能和生活质量明显改善。结论 高龄心脏病应及时就诊,一旦有手术适应证应及早外科治疗,临床效果满意,积极的围术期管理是手术成功的关键。     

Dor法治疗左心室室壁瘤

目的总结Dot法治疗左心室室壁瘤的临床疗效。方法 1999年1月至2006年2月应用Dor法治疗69例冠心病心肌梗死室壁瘤病人，比较其术前、术后心功能、射血分数等指标的变化。结果 手术死亡5例（7．2％）。随访1-68个月，平均（52．6±23．2）个月，死亡6例（8．6％），失访3例（4．3％）。心功能（NYHA）从术前平均（3．19±0．69）级改善到术后平均（1．71±1．07）级（P〈0．01），射血分数从术前的0．37±0．08提高到术后的0．47±0．10（P〈0．01）。左心室容积较术前明显减少。舒张末容积指数从术前（123．54±52．49）ml／m^2降至术后（74．28±28．49）ml／m^2（P〈0．01），收缩末容积指数从术前（83．47±43．78）ml／m^2降至术后（41．25±17．99）ml／m^2（P〈0．01）。结论 Dot法能有效改善左心室室壁瘤病人的心功能。     

Cardiac events after combined surgery for coronary and carotid artery disease

Objective: To evaluate serious cardiac events after combined (either single or two stage) coronary artery surgery (CAS) and carotid endarterectomy (CEA) for concomitant coronary and carotid artery disease. Methods: We have analyzed our 15 year experience (January 1981–September 1996) with 201 consecutive patients operated on using both approaches. Group A consisted of 48 patients with the single-stage procedure, while in group B (153 patients), two stage procedure was carried out, either as carotid endarterectomy (CEA), followed by coronary artery bypass surgery (CAS) (group B₁⁻ 103 patients), or as CAS followed by CEA (group B₂⁻ 50 patients). Five patients from B₁ group died after the CEA procedure, but were included, despite the fact they never reached the second stage. Left main coronary artery disease was found in 41 patients (20.4%), poor left ventricular function in 49 (24.4%) previous MI in 133 (66.2%), while 136 (67.7%) were in NYHA functional class III or IV. Bilateral carotid involvement was present in 61 patients (30.3%). Unstable angina was more prevalent in groups A and B₂ (P<0.0001), NYHA class III/IV in group A (versus B₁, P=0.001 and versus B₂, P=0.02), low ejection fraction in groups A and B₂ (P<0.0001), bilateral carotid stenosis in group B₁ (versus A, P=0.003 and versus B₂, P<0.0001), and ulcerated plaque in group B₁ (P<0.0001). These differences dictated the surgical strategy, which resulted in different protocols for clinical and operative management. Results: Early mortality for the entire group was 5.5% (11/201) 6.2% in group A, 7.8% in group B₁ and 0% in group B₂, respectively; (P>0.05). Serious morbidity occurred in 7.5% of patients (8.3% in group A, 7.8% in group B₁ and 6% in group B₂, respectively; P>0.05). Univariate analysis revealed only bilateral carotid stenosis to influence early outcome (P=0.04). Conclusion: Patients with concomitant coronary and carotid artery disease have relatively good immediate operative results, providing all existing lesions are corrected. Despite it did not reach the statistical significance, cardiac events were less frequent in groups A and B₂ indicating possible protective effect of prior CAS in patients with concomitant disease.     

Myocardial revascularization in patients with end-stage renal disease: Comparison of percutaneous transluminal coronary angioplasty and coronary artery bypass grafting

Background: Ischemic heart disease is the major cause of death inpatients with end-stage renal disease. The high prevalence of coronary artery disease results in a rising number of dialysis patients requiring myocardial revascularisation. Objective: The objective of this study was to compare the outcomes of recurrent angina, myocardial infarction, rate of reinterventions and cardiovascular death following percutaneous coronary angioplasty (PTCA) or coronary artery bypass grafting (CABG) inpatients with end-stage renal disease. Patients and methods: In a retrospective investigation 40 patients with chronic renal failure undergoing primarily PTCA and 65 patients undergoing CABG were included. Both groups were comparable for gender, duration on dialysis and the number of cardiovascular risk factors per patient. Patients undergoing PTCA were younger (53 ± 12 years vs. 57 ± 8 years; p < 0.05) and more often diabetics (30% vs. 14%; p < 0.05). Results: Most patients in both groups had a multi-vessel disease (95% in the CABG group vs. 74% in the PTCA group), in the CABG group there were significantly more patients with a triple-vessel disease (62% with vs. 40%in the PTCA group; p < 0.01), PTCA was primarily successful in 95% of the patients while complete revascularization was achieved in 88% of patients undergoing CABG. The perioperative mortality after CABG was 4.8% as compared to none after interventional revascularisation. The cumulative freedom of angina after 6, 12 and 24 months after intervention was significantly lower after PTCA (54%, 40%, 29%) than after bypass grafting (97%, 94%, 90%, p < 0.001). The frequency of reinterventions following PTCA was significantly higher compared to patients following CABG (p < 0.001). After PTCA 15 patients needed further revascularisations, 8 of them underwent CABG, whereas after CABG only two patients required additional myocardial revascularisation. There was no significant difference in the overall mortality between both groups; the survival rate after 12 and 24 months was 95% and 82% after PTCA and 93% and 86% after CABG, respectively. Condition: Although patients receiving CABG had a more severe coronary artery disease the overall mortality was comparable and clinical and functional outcome was improved compared to patients after coronary angioplasty. This revised version was published online in June 2006 with corrections to the Cover Date.     

三维超声评价Dor法切除左心室室壁瘤对左心室形态和功能的影响

目的使用三维超声建立一种新的左心室形态定量指标,评价Dor法室壁瘤切除术对左心室形态和功能的影响。方法2003年5月至2004年4月,18例冠心病病人,根据术前二维心脏超声诊断,分为室壁瘤组、左心室扩大组和正常对照组,每组6例。比较3组病人术前、术后心功能和心室三维形态指数(心室锥度,C值)的变化。结果3组均无手术死亡。正常对照组术前、术后的EF、左心室容积、形态没有明显变化。室壁瘤组术后左心室容积明显减少,EF从术前0.43±0.06提高到术后0.54±0.08(P=0.02);左心室三维形态更接近类圆锥体(C值接近于1),舒张心室锥度从术前0.36±0.04提高到术后0.56±0.04(P=0.02),收缩末心室锥度从术前0.42±0.03提高到术后0.60±0.05(P=0.03)。室壁瘤组心室形态改善显著。结论Dor法能有效改善左心室室壁瘤病人的心功能和心室形态。三维超声是进行心室形态定量研究的精确、有效、经济的新手段。     

Coronary laser angioplasty

Percutaneous coronary angioplasty has become an accepted method of non-surgical myocardial revascularization. The constant problem of restenosis has stimulated the research of new techniques able to completely eliminate the atherosclerotic plaque. Excimer laser energy has demonstrated in vitro and in vivo capability of plaque dissolution with minimal damage to surrounding tissue.In seven patients with critical coronary stenoses, before surgical anastomoses, a mono- or multifibre catheter (0.6–1.6 mm) was introduced via the coronary arteriotomy coupled with a specifically designed Xe-Cl pulsed laser (308 nm) at the time of cardio-pulmonary by-pass. Eleven stenoses were treated: three successfully and five with perforation. Technical progress is needed to eliminate this serious complication.     

血栓前状态预测老年冠心病非心脏手术患者围术期心脏事件的价值

目的 评价血栓前状态(PTS)预测老年冠心病非心脏手术患者围术期心脏事件的价值.方法 择期全麻下行腹部手术的冠心病老年患者128例,年龄65 ～ 75岁,性别不限,ASA分级Ⅰ或Ⅱ级,NYHA分级Ⅰ或Ⅱ级.采用全凭静脉麻醉.术前采集静脉血样,测定血浆D-二聚体、血栓前体蛋白及P-选择素的浓度,根据此3项指标判断是否存在PTS.根据术中和术后3d内是否发生心脏事件分为非心脏事件组和心脏事件组.记录患者一般资料及术中情况各指标,将组间差异有统计学意义的因素进行logistic回归分析,筛选心脏事件的危险因素.结果 29例患者发生心脏事件,与非心脏事件组比较,心脏事件组年龄、肥胖、糖尿病比率、手术时间和PTS比率差异有统计学意义(P＜ 0.05或0.01);logistic回归结果显示:高龄、糖尿病、手术时间长和PTS是心脏事件的独立危险因素(P＜O.O1).结论 PTS对老年冠心病非心脏手术围术期心脏事件的发生有一定的预测价值.