经冠状静脉窦逆行灌注心脏跳动中主动脉瓣置换术（附5例报告）

对3例主动脉瓣狭窄并关闭不全、2例主动脉瓣狭窄关闭不全并二尖瓣狭窄关闭不全患者,经冠状静脉窦逆行灌注,在心脏有节律的空跳中施行主动脉瓣置换或主动瓣二尖瓣双瓣置换手术。在整个手术过程中,心脏持续得到氧合血的供应,并测定术中及术后血清肌酸激酶（CPK）及乳酸脱氢酶（LDH）含量。结果术后患者恢复顺利,多巴胺用量少,未出现低心排出量综合征、严重心律失常及气体栓塞等严重并发症,术中及术后CPK及LDH含量无显著性差异。认为浅低温体外循环经冠状静脉窦逆行灌注心脏不停跳技术是一种简单、安全、接近生理状态的心肌保护措施。     

心脏瓣膜置换术经冠状静脉窦逆行灌注临床分析

目的应用经冠状静脉窦逆行灌注法对心脏不停跳心脏瓣膜替换手术进行临床分析。方法行心脏瓣膜置换术的患者在浅低温体外循环心脏不停跳的状态下完成。术中不使用心脏停跳液,经冠状静脉窦持续灌注机器血,灌注流量为0.2～0.5L/min,灌注压力为40～55mmHg,使心脏在术中持续得到氧合血供应。结果麻醉与灌注满意,阻断主动脉前后的血气酸碱分析、电解质的测定无明显变化,术后无多巴胺等正性肌力药物依赖和严重心律失常,病人恢复良好。结论经冠状静脉窦逆行灌注用于不停跳瓣膜置换术,是一种较接近生理状态的心肌保护措施,具有良好的心肌保护作用。     

Retrograde coronary sinus cardioplegia in myocardial revascularization: hemodynamic evaluation of the influence on the right-ventricular function.

The problem of the efficacy of right-ventricular protection with retrograde coronary sinus cardioplegia is studied. Sixty patients undergoing myocardial revascularization were prospectively assigned to receive cold St. Thomas' Hospital cardioplegia into the aortic root (30 patients) or retrogradely in the coronary sinus (30 patients). The two groups were similar concerning preoperative and operative data. The hemodynamic recovery postoperatively was good in both groups, the increase of the heart rate, the decrease of the mean aortic pressure and the right-ventricular stroke-work index were not significantly different in the two groups. However, right atrial pressure increased significantly (p less than 0.001) in patients who received cardioplegia anterogradely and decreased, but not significantly, in the retrograde group. The data suggest that the decrease of the right-ventricular stroke-work index in the anterograde group is related to a depressed contractility and in the group with retrograde delivery of cardioplegia to a decreased preload. There were no differences between the groups with respect to clinical outcome. We conclude that retrograde delivery of cardioplegia results in an excellent protection of the right-ventricular function in elective myocardial revascularization.     

Prophylactic aortic valve replacement in older patients for mild aortic stenosis during coronary bypass surgery

Coronary bypass surgery (CBS) is performed in many older patients who frequently also have mild calcific aortic stenosis. It is important that a correct assessment of the severity of aortic stenosis is done by calculating the aortic valve area. Mild aortic stenosis is aortic valve area >1.5 cm², >0.9 cm²/m²; severe aortic stenosis is aortic valve area = 1.0 cm², = 0.6 cm²/m². Patients who have severe aortic stenosis should have aortic valve replacement (AVR) at the time of CBS. Patients with mild aortic stenosis should not have AVR simultaneously with CBS because: 1) patients having AVR+CBS have a higher operative and 10-year mortality; 2) prosthetic heart valves are associated with a complication rate of 2%-6% per year; and 3) only about 12% of patients with mild aortic stenosis will have developed severe aortic stenosis in 10 years. Performing AVR for mild aortic stenosis at the time of CBS will probably result in 91 unnecessary AVRs and 29 excess deaths in 10 years.     

Retrograde left ventricular catheterization in patients with an aortic valve prosthesis

Twenty-seven consecutive patients with an aortic valve prosthesis were evaluated with retrograde left ventricular catheterization. The prosthesis was successfully crossed, permitting hemodynamic and angiographic evaluation of function of the prosthetic valve, left ventricle and mitral valve in all 27 cases. No complications were encountered. In patients with active endocarditis or recent embolization, the retrograde technique was avoided when possible, and attempts were made to utilize other techniques for study. However, three such patients were evaluated with the retrograde technique without complication. Examination of pressure tracings and cineangiographic films suggested only minor interference with valve poppet movement induced by the catheter transversing the valve. In three cases, hemodynamic data were recorded with the catheter crossing the prosthesis at one time and a paraprosthetic valve defect at another time. Identical gradients were recorded. This series documents the safety and efficacy of the retrograde approach, which is proposed as an alternative to the transseptal technique and left ventricular puncture.     

Retrograde coronary sinus perfusion of cold cardioplegic solutions in the presence of coronary arterial occlusions. Experimental study

Coronary arterial stenoses impose a constraint on the delivery of cold cardioplegic solutions conventionally perfused via the aortic root, resulting in uneven myocardial cooling and protection. Therefore the hearts undergoing coronary bypass operations show impaired cooling of the post-occlusive myocardial regions, and temperature gradients among different myocardial fields are registered after cold cardioplegic perfusion. We applied retrograde coronary sinus perfusion of cold cardioplegic solution in canine hearts with occluded multiple left coronary arterial branches to overcome the above-mentioned drawbacks, and a uniform left ventricular cooling was demonstrated by this technique.     

二叶式与三叶式主动脉瓣狭窄患者的临床对照研究

目的 通过对二叶式与三叶式主动脉瓣狭窄患者进行临床特征及围术期指标的回顾性对比分析,以期指导二叶式主动脉瓣狭窄患者的术前管理、手术方案制定及术后治疗。方法 选取我院心外科自 2011 年 01 月至 2017 年 12 月期间收治的所有因主动脉瓣狭窄而单纯行主动脉瓣置换术的患者90例（术中处理主动脉、马凡综合征、主动脉夹层及临床资料不全等患者未纳入本研究）,根据瓣叶特点分为二叶式主动脉瓣组（BAV组,n=45）和三叶式主动脉瓣组（TAV组,n=45）。分别收集两组患者围术期临床资料,从术前、术中、术后三个方面对比两组差异,所有资料均应用SPSS20.0进行相关统计分析。结果 BAV组患者中男性29名、女性16名,约2:1。在术前指标对比方面,相比较TAV组,BAV组发病年龄明显较小（47.76±10.80 vs.54.58±9.29 岁,P=0.002）,合并升主动脉扩张的比例高（66.7％ vs.37.8％,P=0.006）,且升主动脉直径更大（39.55±6.77 vs.35.55±4.78 mm,P=0.002）;BAV组合并三尖瓣反流的比例明显高于TAV组（62.2％ vs.40.0％,P=0.035）;对比两组左室内径、主动脉瓣口流速及跨瓣压差,差异无统计学意义（P ＞0.05）。在术中指标对比方面,BAV组主动脉阻断时间明显长于TAV组(72.07±22.05 vs.55.80±16.77 min,P=0.000)。在术后指标对比方面,两组患者在ICU时间、ICU呼吸机时间、住院时间及复查超声上差异无统计学意义（P ＞0.05）。结论 二叶式主动瓣狭窄患者容易较早发病,并且具有男性优势,所以应提高心脏疾病筛查能力,以便于早诊断、早治疗。同时,二叶式主动脉瓣狭窄患者易合并升主动脉扩张和三尖瓣反流,且升主动脉直径和主动脉阻断时间明显大于三叶式主动脉瓣狭窄患者,因此依据指南并结合手术经验术中积极处理扩张主动脉、修复三尖瓣是非常必要的,此外还应加强围手术期心肌保护、缩短阻断时间来减少术中损害。     

Aortic valve replacement in patients with mild or moderate aortic stenosis and coronary bypass surgery

PURPOSE: To assess whether there is survival benefit for patients with mild or moderate aortic stenosis if they undergo aortic valve replacement at the time of coronary artery bypass surgery. METHODS: From 1985 to 1995 we evaluated all patients at our institution who underwent coronary artery bypass surgery and who had the echocardiographic diagnosis of mild (mean gradient <0 mm Hg and/or valve area >1.5 cm(2)) or moderate (mean gradient > or =30 and < or =40 mm Hg and/or valve area >1.0 < or =1.5 cm(2)) aortic stenosis. Using propensity analysis, survival was compared between 129 patients who underwent coronary artery bypass surgery alone and 78 patients who underwent concomitant coronary artery bypass surgery and aortic valve replacement. RESULTS: Perioperative mortality was similar among patients who underwent coronary artery bypass surgery alone compared with patients who underwent concomitant coronary artery bypass surgery and aortic valve replacement. By Kaplan-Meier analysis, 1-year and 8-year survival were better at 90% and 55% for patients who underwent concomitant coronary artery bypass surgery and aortic valve replacement compared with 85% and 39% for patients who underwent coronary artery bypass surgery alone (P <0.001). This benefit was limited to patients with moderate aortic stenosis (propensity-adjusted relative risk = 0.43; 95% confidence interval: 0.20 to 0.96; P = 0.04). CONCLUSION: Concomitant aortic valve replacement at the time of coronary artery bypass surgery for mild or moderate aortic stenosis appears to convey a survival advantage for patients with moderate aortic stenosis but not for those with mild aortic stenosis.     

Valve preserving surgery in patients with bicuspid aortic valve

Bicuspid aortic valve can be associated with clinically important aortic regurgitation and dilatation of ascending aorta. Aortic valve repair seems to be optimal therapeutic option how to avoid valve-related and anticoagulation-related complications. We have analyzed midterm outcomes of patients after bicuspid aortic valve repair.MethodsBetween January 2008 and December 2015, 91 patients (mean age 40.9 ± 12.2) with bicuspid aortic valve (type 0 or 1) underwent valve-sparing surgery for aortic valve insufficiency or aortic aneurysm. Urgent procedures and patients of age more than 65 were not included. The cohort of patients was retrospectively divided into two groups. Forty-nine patients underwent aortic valve-sparing procedure with root replacement (group 1). Forty-two patients underwent aortic valve repair without root replacement (group 2). The mean length of follow-up was 57.5 months.ResultsThere was no death in connection with aortic valve repair during follow up. Three patients from group 2 required in-hospital reoperation for early repair failure. Another seven patients (4 from group 1 and 3 from group 2) were reoperated for recurrent aortic insufficiency during follow-up period. Freedom from aortic valve reoperation at 5 years was 90% in group 1 and 87% in group 2. Freedom from recurrent aortic insufficiency (>2°) at 5 years was 85% in group 1 and 78% in group 2.ConclusionBicuspid aortic valve repair is a safe procedure, which can be performed with acceptable midterm results. Risk of repair failure depends on preoperative valve morphology and choice of repair technique. Repair technique needs to be tailored to the specific anatomy of the valve.     

Prevalence of coronary artery disease in patients with isolated aortic valve stenosis.

The prevalence of significant coronary artery disease (reduction in luminal diameter by more than 50%) among 88 consecutive patients with aortic stenosis requiring aortic valve replacement at Hammersmith Hospital was examined. Twenty two (34%) patients had significant coronary disease. Nineteen of 42 (45%) patients with typical angina had coronary disease; three of 20 (15%) patients with atypical chest pain had coronary disease, while none of 26 patients free of chest pain had significant coronary disease. Risk factors for coronary disease were equally distributed among patients with and without significant luminal obstruction. Because of the small, but definite, hazard of coronary arteriography and in the interest of cost containment it is suggested that patients with aortic stenosis who are free of chest pain do not require routine coronary arteriography. This applies particularly to patients requiring urgent aortic valve replacement.     

24例微创主动脉瓣置换术临床分析

目的:探讨采用PORT ACCESS技术,进行微创主动脉瓣置换手术的安全性。方法:回顾性分析我院2010年6月至2012年5月期间,24例微创主动脉瓣替换术患者的临床资料,并与48例传统正中开胸主动脉瓣置换患者资料作对比性研究。结果:微创组虽然在平均体外循环时间、主动脉阻断时间[(124±39)vs.(102±34)min;(97±33)vs.(83±24)min]较传统正中开胸组长,两组患者在手术时间差异无统计学意义。微创组在减少手术输血量、平均住ICU时间、平均住院时间[(8 vs.38)mL;(1.2±0.6)vs.(2.5±1.7)d;(11.1±4.3)vs.(19.7±7.8)d]上优于传统正中开胸组。结论:微创主动脉瓣置术换创伤小、术中输血少、术后恢复快,是治疗主动脉瓣疾病安全选择。     

Assessment of coronary artery disease using coronary computed tomography angiography in patients with aortic valve stenosis referred for surgical aortic valve replacement

Background

In patients referred for aortic valve replacement (AVR) a pre-surgical assessment of coronary artery disease is mandatory to determine the possible need for additional coronary artery bypass grafting. The diagnostic accuracy of coronary computed tomography angiography (coronary CTA) was evaluated in patients with aortic valve stenosis referred for surgical AVR.

Methods

Between March 2008 and March 2010 a total of 181 consecutive patients were included. All patients underwent pre-surgical coronary CTA (64- or 320-detector CT scanner) and invasive coronary angiography (ICA). The analyses were performed blinded to each other.

Results

The mean ± SD age of the included patients was 71 ± 9 years and 59% were male. The prevalence of significant coronary artery stenosis > 70% by ICA was 36%. Average heart rate during coronary CTA was 65 ± 16 bpm. In a patient based analysis 94% of the patients (171/181) were considered fully evaluable. Coronary CTA had a sensitivity of 68%, a specificity of 91%, a positive predictive value of 81%, and a negative predictive value of 83%. Advanced age, obstructive lung disease, NYHA function class III/IV, and high Agatston score were found to be significantly associated with disagreement between ICA and coronary CTA in univariate analysis.

Conclusion

In patients with aortic valve stenosis referred for surgical AVR the diagnostic accuracy of coronary CTA to identify significant coronary artery disease is moderate. Coronary CTA may be used successfully in a subset of patients with low age, no chronic obstructive lung disease, NYHA function class < III and low coronary Agatston score.     

Relationship between position of the coronary sinus catheter and distribution of cardioplegia

BACKGROUND AND AIMS OF THE STUDY: The use of retrograde cardioplegia is controversial, mainly due to differences in theoretic and methodologic aspects. The aim of this study was to identify an optimal position for the cardioplegia catheter within the coronary sinus. METHODS: Thirteen cadaver hearts was used, and three different catheter positions in the coronary sinus were compared, using a radio-opaque dye which had a viscosity similar to that of blood. The distribution of dye at different segments of the heart was examined. RESULTS: Dye distribution, indicative of cardiac perfusion, was found to be related to the position of the catheter in the coronary sinus and the quantity of dye injected. CONCLUSIONS: This study demonstrated the efficiency of retrograde cardioplegia, and also that optimal positioning of the catheter and the use of high-volume cardioplegia are required concomitantly for successful perfusion.     

胸腔镜辅助小切口手术在二尖瓣置换患者中的对照研究

目的:探讨胸腔镜辅助小切口手术在二尖瓣置换患者中的疗效及安全性。方法:回顾性分析我院2016年1月至2018年12月,行二尖瓣置换术(MVR)患者81例临床数据资料,按照其手术方式不同分为胸腔镜辅助小切口组(40例),行右胸微MVR,常规开胸组(41例),行常规正中开胸MVR;对比分析两组术中与术后指标、疼痛程度、并发症及术后6个月超声心动参数。结果:小切口组切口长度(5. 27±1. 23) cm、术中输血量(1. 74±0. 27) U、术后引流量(205. 84±10. 36) m L、ICU时间(16. 38±5. 45)d、住院时间(8. 16±2. 25) d明显小于开胸组(18. 12±3. 54) cm,(3. 22±1. 35) U,(412. 28±20. 57) m L,(23. 26±6. 24) d,(12. 27±3. 52) d(P<0. 05)。小切口组疼痛程度明显低于开胸组(χ~2=43. 976,P=0. 000)。小切口组(10. 0%)并发症发生率明显低于开胸组(46. 3%,P <0. 05)。术后6个月,两组超声心动参数均明显好转(P<0. 05),且组间差异无统计学意义(P>0. 05)。结论:胸腔镜辅助小切口手术在MVR中对患者损伤小,患者术后恢复快,疼痛程度低且并发症少,疗效良好,值得在临床中推广应用。