2169例室间隔缺损的外科治疗

作者单位自１９６４年６月至１９９３年６月手术治疗室间隔缺损（室缺）２１６９例，其中围膜部室缺１５２０例，肺动脉下室缺３８０例，隔瓣后室缺２４９例，肌部室缺５例，左室右房通道７例，多发型室缺８例，手术死亡率为０．７４％，合并严重肺动脉高压２７１例中，５１例中进行肺组织活检，并按Ｈｅａｔｈ－Ｅｄｗａｒｄｓ分级，分为四级，术前应用硝普钠静点，可降肺血管阻力，作者重点介绍了各种类型室缺的手术适应证和修复方     

室间隔缺损合并严重肺动脉高压围手术期血管扩张药的应用

室间隔缺损合并严重肺动脉高压，肺高压导致心功能损害，术后并发症多，死亡率高，本文重点讨论室缺合并肺高压围手术期血管扩张药的应用等。     

8kg以下婴儿室间隔缺损伴肺动脉高压手术治疗

为提高小婴儿室缺伴肺动脉高压的手术疗效，总结１６例８ｋｇ以下室间隔缺损（室缺）伴肺动脉高压婴儿行急诊手术修补室缺的经验。其中１４例在深低温停循环下进行，手术效果满意；术后死亡１例（６％）。作者认为，婴儿巨型室缺应尽早手术治疗为宜，深低温停循环方法尤为适合；术后强调持续保持病婴镇静及呼吸道通畅，防止肺高压危象的发生。     

室间隔缺损合并肺动脉高压的外科治疗

目的探讨室间隔缺损合并肺动脉高压者的手术适应证,血管扩张剂的选择,肺动脉高压危象及肺部并发症的预防治疗。方法回顾性分析我院自2006年7月至2008年5月共收治53例室间隔缺损合并肺动脉高压病人的临床资料。结果55例室缺合并肺动脉高压,53例行手术治疗,2例已发展为艾森曼格,失去手术时机。肺动脉压力<60mmHg26例;60～90mmHg21例;>90mmHg8例,手术6例,总手术死亡率3.8%。结论室间隔缺损合并肺动脉高压手术治疗是最有效的治疗手段。     

复杂先天性心脏病的外科治疗

近15年来，本所手术治疗治疗法乐氏四联症、右室双出口、Ebstein心脏病畸形、单心室和三尖瓣闭锁、矫正型大动脉转位合并心内畸形、完全性肺静异位引流、主动脉狭窄、大动脉转位合并室缺和肺动脉狭窄以及室间隔完整的肺动脉闭锁等1880例，总的手术死亡率为4．05，本文重点介绍上述复杂先天性心脏病的外科治疗经验。     

旁气流通气监测法观察心内直视手术患者通气功能变化

目的：应用旁气流通气监测法（ＳＳＳ）观察心内直视手术患者通气功能的变化。方法：心内直视手术患者２４例，按病种不同分为四组：室间隔缺损组（ｎ＝６）；室缺合并肺动脉高压组（ｎ＝６）；法鲁氏四联症组（ｎ＝６）及瓣膜置换组（ｎ＝６），采用ＳＳＳ监测围术期的通气功能及气道力学的变化。结果：室缺组、室缺肺高压组潮气量、分钟通气量、顺应性逐渐下降，气道峰压、平台压逐渐升高，其中室缺肺高压组在停体外循环后１０分钟时与诱导后比较差异显著（Ｐ＜０．０５），顺应性环亦有相应变化。法四组、瓣膜组潮气量、分钟通气量、顺应性无明显变化，气道压轻度升高，但均无统计学意义。结论：ＳＳＳ可及时准确地反映呼吸功能和气道力学参数，发现异常情况，以便迅速纠正。     

婴儿先天性心脏病合并肺动脉高压围手术期处理

先天性心脏病 (先心病 )合并严重肺动脉高压的病婴外科治疗中 ,对肺动脉高压的围术期处理十分重要。现介绍我们2 8例的处理经验如下。临床资料　 2 0 0 0年 6月～ 2 0 0 2年 6月 ,我们手术治疗合并重度肺动脉高压 (肺动脉收缩压与血压收缩压比 ,即sPAP/sBP≥ 0 75 )先心病病婴 2 8例 (同期先心病直视手术 2 38例 )。全部病例术前均经心脏B超检查和体外循环前直接测压证实。男 13例 ,女 15例 ;年龄 2～ 12个月。室间隔缺损 (室缺 )17例 ,其中合并动脉导管未闭 3例 ;完全性肺静脉异位引流 7例 ,其中心内型 4例 ,心上型 3例 ;部分型房室隔缺…     

室间隔缺损合并重度肺动脉高压的外科治疗

室间隔缺损合并重度肺动脉高压的外科治疗耿希刚李兆志黄庆恒孙立侯立业作者单位：７１００６１西安医科大学第一临床医学院心脏外科１９８４年５月至１９９５年７月我们对１０４例室间隔缺损合并重度肺动脉高压病人的手术疗效进行分析并讨论如下：临床资料本组１０４例中...     

鱼精蛋白致严重冠状动脉痉挛的处理

鱼精蛋白是心内直视手术中和肝素的必用药物。其所导致的过敏反应、低血压、非心源性肺水肿和严重的肺血管痉挛已引起人们的重视[1] ,但鱼精蛋白引起严重冠状动脉痉挛还罕有文献报道。我院 1990～ 2 0 0 0年共进行体外循环心脏直视手术麻醉 2 4 0 0余例 ,转流后用鱼精蛋白中和肝素时发生严重冠状动脉痉挛 7例 ,现将有关临床表现和处理情况报道如下。临床资料一般资料　 7例中男 4例 ,女 3例 ,年龄 1～ 15岁 ,体重6～ 4 8ｋｇ。所施手术分别是单纯室缺和房缺修补术各 1例 ,室缺合并严重肺动脉高压行室缺修补术 1例 ,室缺合并动脉导管未闭行室…     

右室双出口的外科治疗

目的：总结手术纠治右室双出口６７ 例的经验。资料与结果：手术年龄４ 个月～１２ 岁,平均（４ ．９８ ±２ ．９６） 岁;体重４ ．１ ～３６ ．０ｋｇ,平均（１５ ．１３ ±５ ．５４）ｋｇ 。其中伴右室流出道梗阻４８ 例,肺动脉高压１８例,肺动脉瓣闭锁１ 例。１３ 例行姑息手术者无死亡。５４ 例行根治术,其中４ 例又行ＩＩ期根治,６ 例行Ｆｏｎｔａｎ 纠治术;根治手术死亡５ 例,病死率８ ．６２ ％ 。本组总病死率７ ．４６ ％ 。结论：右室双出口伴肺动脉高压者,必须早期手术,防止肺血管病变发生。对肺动脉瓣下型室缺的手术纠治较困难,死亡率高。心内隧道补片方法,术后需定期随访,及时发现左室流出道梗阻,必要时需再次手术解除。     

Surgery for ventricular septal defect

Of 255 patients undergoing closure of ventricular septal defect (VSD), 48% were younger than 2 years, 59% had associated cardiac and 26% non-cardiac abnormality, 13% had multiple, and only 29% isolated VSD. VSD was closed via the left ventricular apex in seven cases, without increased morbidity or mortality. The three early and six late deaths occurred in patients with complicated defects. Pulmonary vascular occlusive disease caused four deaths (1 early, 3 late). At follow-up (mean c. 3, range 1-11 years), 79% of the patients were well, 10% had cardiac symptoms and 7.5% had symptoms from associated noncardiac anomalies. Reoperation for significant residual VSD was required in 12 cases (4 single and 8 multiple VSD). Complete, pacemaker-requiring A-V block was found in four patients (none with simple VSD closure). It is concluded that 1) concomitant cardiac and non-cardiac lesions are common in VSD, 2) mortality is closely related to such lesions and to pulmonary vascular occlusive disease, 3) the latter is a rare, but real cause of death, 4) left ventricular approach need not increase mortality or morbidity, 5) significant residual VSD is rare after single, but common in multiple VSD, and 6) risk of complete A-V block after simple VSD closure is very low.     

The optimal procedure for the great arteries and left ventricular outflow tract obstruction. An anatomical study.

OBJECTIVE: To describe the optimal surgical strategy in heart specimens with transposition of the great arteries (TGA) and left ventricular outflow tract obstruction (LVOTO). METHODS: Thirty-three specimens with LVOTO were selected: TGA with intact ventricular septum (TGA/IVS) (10), TGA/VSD (21), and Taussig-Bing (2). RESULTS: LVOTO in TGA/IVS consisted of combinations of bicuspid pulmonary valve (four), subpulmonary fibrous ridge (four), obstructive muscular conus (two) and bulging muscular septum (four). Arterial switch operation (ASO) with LVOTO resection/valvotomy was feasible in nine hearts. Obstructive anterior papillary muscle prohibited LVOTO relief in one specimen. In TGA/VSD and Taussig-Bing LVOTO consisted of combinations of bicuspid (nine) or unicommissural (one) pulmonary valve, fibrous ridge (three), obstructive muscular conus (five), malaligned outlet septum (six), accessory mitral valve tissue (two), straddling mitral valve (two) and anterior mitral valve rotation (four). VSDs were subpulmonary in 13 (9 perimembranous, 4 muscular), subaortic in 3 (2 perimembranous, 1 anterior muscular), doubly committed in 2, inlet in 3 (2 perimembranous, 1 muscular), non-committed and anterior in 1, and finally 1 VSD extended both into inlet and subpulmonary outlet septum. LVOTO resection and ASO with VSD closure was possible in 10. In six specimens, both a Rastelli and a Nikaidoh operation were feasible. For two hearts, a Nikaidoh procedure was the only option, while Rastelli was considered optimal in another specimen. Mitral valve anomalies prevented LVOTO relief in four, only permitting for Senning/VSD closure (one) or univentricular palliation (three). CONCLUSIONS: LVOTO resection and pulmonary valvotomy frequently permits an ASO. Inlet VSD, impossibility of VSD enlargement, straddling mitral valve, distant aorta and small right ventricle make the Nikaidoh procedure the best option. Mitral anomalies preventing LVOTO relief can make biventricular repair impossible.     

Abnormalities of regional lung function associated with ventricular septal defect and pulmonary artery band.

Xenon-133 ventilation-perfusion scans and technetium-99m angiocardiograms were performed 47 times in 34 patients. All patients had ventricular septal defect (VSD), 17 with pulmonary artery band (PAB), 6 with isolated VSD, 4 with pulmonary valvar stenosis (PS), and 7 with transposition of the great arteries (d-TGA), VSD, and PAB. Patients with VSD had slightly depressed ventilation fraction of the left lung and slightly elevated perfusion fraction of the left lung, both before and after closure of the VSD. Patients with VSD and PAB had slightly depressed ventilation fraction of the left lung but perfusion fraction of the left lung that was either markedly elevated or markedly depressed. After closure of VSD and removal of PAB the perfusion abnormality returned toward normal in some patients but remained abnormal in most. The findings were similar in most patients with d-TGA. Ventilation-perfusion ratio was nearly normal in patients with VSD alone, both before and after closure of VSD. In patients with VSD with PAB the severe abnormality of ventilation-perfusion ratio returned toward normal after corrective operation but did not reach normal. There was no abnormality of distribution of perfusion along the cephalocaudal axis of the lung with the patient supine.     

One stage repair of aortic arch anomalies and intracardiac defects

Between August 1985 and May 1990, 27 neonates and infants underwent combined correction of intracardiac and aortic arch anomalies through a median sternotomy. Coarctation (CoA) was combined with VSD (6), AVSD (2), Taussig-Bing (TB) heart (5), transposition of the great arteries (TGA) (1), TGA + VSD (2), congenitally corrected TGA + VSD (1) and VSD + myxoid stenotic outlet valves (1). Interrupted aortic arch (IAA) was combined with VSD (10) and TB heart (1). Two patients had IAA type B as well as CoA. Age at operation varied from 2 to 243 days with a mean age of 51 days. Twenty patients (70%) were younger than 30 days. One TGA + VSD and all TB hearts had maligned outlet septum and right ventricular outflow tract obstruction (RVOTO). Posterior outlet septum deviation and left ventricular outflow tract obstruction (LVOTO) occurred in 8 patients with malalignment VSD and IAA (7) or CoA (1). Aortic arch reconstruction was performed using extended end-to-end anastomoses. In 3 patients, arch hypoplasia necessitated patch implantation. VSDs were closed through the right atrium unless the anatomy dictated otherwise. One TB heart was reconstructed with a Kawashima procedure. All other TB hearts and all TGAs were corrected with arterial switch operation. Obstructing outlet septum was resected whenever necessary. Follow-up was complete and included echo-Doppler control. Eleven patients had postoperative heart catheterisation. Early mortality was 18.5% (5 patients). Persisting LVOTO or RVOTO was responsible. There was no late mortality. Five patients were reoperated upon: 3 for stenotic anastomoses and 2 for a subaortic membranous stenosis. Successful balloon dilatation of recoarctation was performed four times.(ABSTRACT TRUNCATED AT 250 WORDS)     

脂肪脱细胞基质联合封闭式负压引流对猪创面炎症反应的影响研究

目的初步探讨脂肪脱细胞基质(decellularized adipose tissue,DAT)联合封闭式负压引流(vacuum sealing drainage,VSD)对猪创面炎症反应的影响。方法取自愿捐赠人脂肪组织,经反复冻融、胰蛋白酶消化及异丙醇萃取制备DAT。大体观察冻干前后DAT外观,HE染色观察其结构和脱细胞效果。取雄性巴马小型猪18只,于每只猪背部制备4个直径4 cm皮肤软组织创面,并随机分为4组;其中,DAT/VSD组创面DAT覆盖联合VSD治疗,DAT组创面单纯DAT覆盖,VSD组创面采用VSD治疗,对照组创面无菌纱布覆盖。治疗后第3、7、10、14天取创面组织,HE染色观察中性粒细胞浸润情况,实时荧光定量PCR检测炎性因子IL-1β、IL-6、TNF-α以及M1型、M2型巨噬细胞表型标记物诱导性一氧化氮合酶(inducible nitric oxide synthase,iNOS)、精氨酸酶1(arginase 1,ARG-1)mRNA的表达情况,ELISA检测iNOS、ARG-1含量。结果大体及HE染色观察示DAT呈疏松多孔结构,未见细胞残留。动物实验组织学观察显示,治疗后第3天DAT/VSD组中性粒细胞计数低于对照组和DAT组(P<0.05),与VSD组比较差异无统计学意义(P>0.05);第7、10、14天,DAT/VSD组中性粒细胞计数明显低于其他组(P<0.05)。实时荧光定量PCR检测显示,治疗后第3、7、10、14天,DAT/VSD组创面组织IL-1β、IL-6、TNF-α和iNOS mRNA表达均低于其他组,而ARG-1 mRNA表达升高(P<0.05)。ELISA检测显示,DAT/VSD组治疗后第3、7、10、14天创面组织iNOS含量均低于其他组(P<0.05),ARG-1含量高于其他组(P<0.05)。结论DAT联合VSD治疗猪皮肤软组织创面,可以减少继发于炎症反应的组织损害,效果优于二者单独使用以及常规换药。     

Successful surgical treatment of a case of corrected transposition in situs inversus with associated anomalies

A 33-year-old female with corrected transposition (situs inversus) with ventricular septal defect (VSD), atrial septal defect (ASD), and pulmonary stenosis (valvular and subvalvular) was operated successfully. Closure of ASD and infracristal VSD was performed through right atrial approach. In order to get complete exposure of VSD, a part of anterior leaflet of mitral valve was detached temporally. An external conduit was interposed between the morphologic left ventricle and the main pulmonary artery to relieve pulmonary stenosis. Postoperative course was uneventful except a transient complete heart block for a day. Several technical aspects of the radical operation were discussed including VSD closure method to avoid damaging the atrioventricular conducting tissues and reconstructive procedure of morphological left ventricular outflow.     

Repair of ventricular septal defect in adults

To evaluate the outcome of ventricular septal defect (VSD) with long duration of haemodynamic derangement, a retrospective study was made of 42 consecutive patients who underwent closure of VSD as adults (age range 15-48, mean 27 years). The mean systolic pulmonary arterial pressure was 53 mmHg, mean pulmonary vascular resistance 2.5 Wood units and mean pulmonary/systemic flow ratio 2.4. VSD was complicated by aortic regurgitation in 12 cases, mitral regurgitation in 4, and sinus of Valsalva fistula in 6 cases. There were 15 supracristal, 24 infracristal and 3 muscular VSDs. In addition to VSD closure, surgery included aortic valve replacement (7 cases), mitral valve replacement (2), valve repair by suture (7) and repair of Valsalva sinus fistula (6 cases). Two patients died in the early postoperative period and two during follow-up (1-10, mean 4.5 years). The early and the late mortality were related to large infracristal VSD, pulmonary hypertension and irreversible pulmonary vascular changes which could not be anticipated on the basis of high calculated shunt flow at preoperative catheterization. No patient with supracristal VSD died. Recurrent VSD was diagnosed in five patients, three of whom needed reoperation and recovered uneventfully. Reduction of heart size and improved exercise tolerance were the most pertinent follow-up findings. The results suggest that large supracristal VSD with aortic valve involvement can be successfully closed in adults, but that the prospect for large infracristal VSD is less favourable if correction is postponed until adulthood.     

Does direct visualization of peripatch areas in beating heart eliminate the risk of residual ventricular septal defect in adult patients?

AIM: Although the incidence of residual ventricular septal defect (VSD) following surgical therapy in the modern series is very low, especially the risk of hemodynamically insignificant shunt still exists. Intraoperative assessment of residual shunt is useful in identifying patients at risk of having subsequently required reoperation and reintervention for residual VSD before chest closure. METHODS: In 87 patients who were operated because of isolated VSD (Group I), VSD was closed under cardioplegic arrest and right atriotomy or right ventriculotomy were closed in the beating heart after aortic cross-clamp removal. The VSD patch was watched out for residual shunt and additional sutures were placed if it existed. Results of this technique have been compared with the other 216 (Group II) in which all procedures of the VSD closure were performed under cardioplegic arrest. Transosephageal echocardiography (TEE) was performed for evidence of residual shunting intraoperatively and postoperatively in all patients. RESULTS: In group I, additional sutures were placed for residual shunt in 14 patients (16.1%), and insignificant residual shunt was detected in only one (1.1%) patient at early postoperative period (p<0.05, according to group II). In group II, there was hemodynamically insignificant residual shunt in 31 patients (14.5%), and 9 patients (4.2%) were reoperated for significant shunt (p<0.05). CONCLUSION: Transatrial or transventricular inspection to peripatch areas in the beating heart is a safe technique to detect a residual shunt, an observation that may eliminate reoperation.     

Pulmonary Vascular Protective Mechanisms in Adult Patients with an Isolated Large Ventricular Septal Defect: A 21-Year Experience

Abstract  Background: Ventricular septal defects (VSDs) are one of the most common congenital heart defects in adults. In adult patients with an anatomically large VSD and relatively preserved pulmonary vascular system, several pulmonary flow-limiting cardiac morphologic alterations (PFMA) are encountered. Patients: Ninety-eight male patients (mean age 22.5 ± 2 years) operated for an anatomically large VSD in our institution were retrospectively reviewed. PFMA in patients with an anatomically large but functionally mild-to-moderate VSD (when ratio of pulmonary to systemic flow (Q_p/Q_s) < 2.2 and ratio of pulmonary to systemic vascular resistance (R_p/R_s) < 0.3) were recorded. Results: Thirty patients (31.2%) revealed a mild-to-moderate VSD in functional severity. Five PFMA were encountered in these patients: (1) ostium (os) infundibulum (n = 10, 33.3%), (2) aneurysm of the membranous septum (AMS) (n = 10, 33.3%), (3) systolic bulging of the conal septum toward the right ventricular outflow tract (n = 6, 20%), (4) prolapse of the aortic cusps (n = 2, 6.7%), and (5) attachment of the tricuspid septal leaflet to the septal crest (n = 2, 6.7%). Double-chambered right ventricle was encountered in four patients with os infundibulum and classic tetralogy-type septal malalignment in one patient with aortic cusp prolapse. Concurrent to VSD repair, resection of the os infundibulum and the AMS and aortic valve repair were performed. Conclusion: Presence of a large VSD and relatively preserved pulmonary vascular system in adults is associated with several PFMA. Preoperative awareness and concurrent surgical treatment of these alterations seem to be crucial to improve the expected benefit of surgical repair of VSD in this subgroup of the patients.     

经胸超声心动图对室间隔缺损介入治疗适应证选择的应用价值

目的评价经胸超声心动图（TTE）在选择室间隔缺损（VSD）介入治疗适应证方面的应用价值。方法VSD患者62例，男性27例，女性35例，年龄2．5～43岁，平均（14．89士8．5）岁。术前由超声心动图检查严格筛选，确定VSD类型、形态，精确测量缺损大小、残缘距主动脉瓣、三尖瓣根距离，术中指导释放封堵器，术后即刻观察封堵效果。结果62例VSD患者进入导管室，其中4例经X线左室造影后放弃手术，5例封堵失败，53例在TTE和DSA监测下成功封闭VSD（其中2例行二次封堵成功）。成功病例术前TTE测VSD3～17（5．88±2．25）mm，X线左室造影测VSD2～17（5．17±2．63）mm，两者无明显差异，相关性好（r＝0．909），都与封堵器大小存在显著相关。结论TTE在VSD封堵术前适应证方面具有重要应用价值，术中及术后均起着举足轻重的作用。