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纵隔巨大淋巴结增生症一例

感染性心内膜炎104例的临床分析

目的　探索感染性心内膜炎的临床特点及治疗结果，以提高其临床疗效。 方法 回顾性分析2008年1月至2009年12月北京阜外心血管病医院104例感染性心内膜炎患者的临床资料，其中男64例、女40例，平均年龄40.8岁，血培养阳性47例（45.2％）。超声心动图检查提示：90例（86.5%）心脏瓣膜或流出道有赘生物，赘生物位于主动脉瓣36例，二尖瓣32例，三尖瓣11例，右心室流出道3例，多个瓣膜6例。据血培养结果行药物或外科手术治疗，术前及术后应用敏感抗生素治疗。 结果 全组33例行内科药物治疗，病死率为33.3% （11/33）；72例行外科手术清除赘生物及进行心脏基础病变治疗，病死率为4.1% （3/72）。死亡原因1例为低心排血量，1例感染，1例脑梗塞。赘生物培养均为阴性。体外循环时间（117.5±63.3） min，主动脉阻断时间（82.7±44.8） min。总的中位住院时间30.9 d，术后住院时间13 （6～41） d。术后有3例感染再发，2例因为瓣周漏引起感染再发，1例行瓣膜成形术后感染再发。 结论 基础心脏病仍是感染性心内膜炎常见病因。早期、有效、规律的抗生素治疗仍是治疗基础，及时的外科治疗可降低病死率。

右心辅助循环在下腔静脉疾病外科治疗中的应用

Surgical Treatment of ⅢA-N2 Stage Non-small Cell Lung Cancer：Controversies and Consensus

The optimal treatment of stage ⅢA-N2 non-small cell lung cancer （NSCLC） remains controversial. Resultsof primary surgery alone are not satisfied. Surgery after induction chemotherapy yields better outcomes compared to resectiononly which has been widely accepted. Randomized studies show induction chemotherapy followed by either radiotherapy or surgery have approximately equivalent survival outcomes，significant improved survival can be achieved by combined surgery in selected patients. Low-grade N2，effective response and mediastinal downstaging after induction therapy，and successful complete resection by lobectomy，are good indications of surgery. Ideal treatments are approached base on theheterogeneity of N2 . Patients with bulky or fixed N2 disease should be considered for radical chemo-radiotherapy，and surgeryshould be a part of multi-modality management for patients with non-fixed，non-bulky，single-zone N2 disease. Further randomized trials of surgery added to multi-modality management in patients with multi-zone N2 disease should be taken in order to establish possible subgroups of patients might be benefitted more from the addition of surgery.

复杂先天性心脏病右心室流出道重建困难的处理

目的　探讨复杂先天性心脏病在纠治过程中右心室流出道（RVOT）重建困难的处理方法和其适应证、手术方法、应用中的注意要点。 方法　回顾性分析2008年1月至2010年12月广州市妇女儿童医疗中心26例复杂先天性心脏病患者行手术治疗的临床资料。其中男14例，女12例；年龄（2.9±2.0）岁；体重（12.2±6.0） kg。所有患者在纠治过程中RVOT重建困难，分别采用以下方法进行处理： （1）肺动脉从根部切断与主动脉交叉后吻合于右心室切口； （2）肺动脉从根部切断直接下拉吻合于右心室切口； （3） 肺动脉切断后远心端与右心室切口间的后壁用左心耳或右心耳做后壁，人工补片做前壁，重建RVOT； （4）肺动脉与右心室切口间用自体心包做成的心包卷管道连接。　结果　无手术死亡，无Ⅲ°房室传导阻滞。10例患者因尿少行腹膜透析治疗，心脏压塞和/或胸腔出血开胸止血4例。所有患者随访0.5～3.0年复查：应用肺动脉从根部切断与主动脉交叉后吻合于右心室切口和肺动脉从根部切断直接下拉吻合于右心室切口两种方法的7例患者中肺动脉血流速度加快3例，2.5～3.0 m/s；残留中度以上肺动脉高压5例；中至重度肺动脉反流6例，其中肺动脉血流速度增快2例，残留中度肺动脉高压4例。　结论　以上4种RVOT重建方法在复杂先天性心脏病RVOT重建中应用得当有良好的手术效果；前2种方法有肺动脉血流速度增快的可能性；肺动脉瓣反流与术后肺动脉高压或肺动脉梗阻有关。

全胸腔镜下纵隔良性肿瘤切除术22例

Surgical Treatment for Atrioventricular Valve Regurgitation in Patients with Single Ventricle

目的　总结单心室瓣膜反流的外科治疗经验，观察治疗效果。 方法　回顾性分析2006年7月至2012年1月上海交通大学医学院附属新华医院61例单心室患者的临床资料，其中男36例，女25例；手术年龄2个月至 20岁；体重2～58 kg。右心室型41例，左心室型13例，未定型型7例。根据瓣膜反流程度不同分为3组，无/微量反流组：28例，瓣膜未行处理；轻/中度反流组：21例，瓣膜未行处理；重度反流组：12例，手术同期行瓣膜成形。收集所有患者住院及随访资料，分析轻/中度反流组、重度反流组瓣膜反流变化趋势，以及影响瓣膜反流的因素。结果　住院死亡5例，住院死亡率8.2% （5/61）。重度反流组患者行瓣膜成形术后反流程度较术前明显减轻（由术前4.00级下降至术后2.08级）。随访56例，随访时间6～38个月，重度反流组随访10例，随访期间死亡2例，其余8例中重度反流2例，中度反流3例，轻度反流2例，微量反流1例；瓣膜反流程度增加趋势明显（由术后平均2.08级增加至平均2.75级）。轻/中度反流组随访19例，随访中无死亡，其中反流程度增加至重度3例（原1例轻度反流，2例中度反流），反流程度由轻度增加至中度3例，瓣膜反流程度由术后平均2.33级增加为平均2.58级。轻/中度反流组瓣膜反流增加率与无/轻微反流组比较差异无统计学意义（瓣膜反流增加率为31.5% vs. 19.2%，χ2=0.36，P=0.55）。单因素分析结果显示，瓣膜反流增加者在随访过程中心功能较瓣膜反流无变化或减轻者明显降低（术后左心室射血分数53.11%±5.61% vs. 59.65%±3.32%，t =-5.49，P=0.00），而左心室舒张期末容积较瓣膜反流无变化或减轻者明显增加（t =2.58，P=0.01）。 结论　单心室合并重度瓣膜反流行瓣膜成形术近期效果较好，但随着心功能下降、心室扩张，瓣膜反流程度加重趋势明显；轻/中度瓣膜反流可暂不进行处理，但部分患者瓣膜反流有增加趋势，提示应注重术后随访。

儿童支气管黏液表皮样癌一例

胸外科进展 ——第21届欧洲胸外科医师年会介绍

Mid-term Results of Cardiovascular Surgery Employing Extracorporeal Circulation in Patients Dependent on　Dialysis

Objective　To summarize our experience of cardiovascular surgery for patients dependent on dialysis, and evaluate its safety and efficacy.?Methods?Clinical data of 10 consecutive patients dependent on maintenance dialysis underwent cardiovascular operations between Dec. 2004 and April 2011 in Peking Union Medical College Hospital were analyzed retrospectively. There were 6 male and 4 female patients, aged between 23 to 71 （57.6±13.2） years. They were put on dialysis 3-98 （25.2±30.6） months prior to operation due to diabetic nephropathy in 6 patients, chronic glomerulitis in 3 patients and systemic lupus erythemus in 1 patient, and 8 were dependent on hemodialysis and 2 on peritoneal dialysis. Five patients underwent coronary artery bypass grafting, one underwent Bentall procedure，two underwent aortic valve replacement, one underwent mitral valve replacement, and one underwent superior vena cava thrombectomy and patch repair. Patients underwent dialysis on the day before elective operation, followed by continuous ultra-filtration during cardiopulmonary bypass, and then bedside heparin-free continuous veno-venous hyperfiltration-dialysis started 5-32 hours after the operation. Conventional peritoneal dialysis or hemodialysis was resumed 4-7 days after operation.?Results?All operations were successfully completed. Cardiopulmonary bypass time was （125.8±33.5）minutes, aortic clamp time was（77.2±25.5） minutes. One in-hospital death occurred due to septic shock after deep chest wound infection. One patient underwent re-exploration due to pericardial temponade to achieve hemostasis. Three patients experienced atrial fibrillation and were all converted to sinus rhythm by amiodarone. Nine patients recovered to discharge and were followed-up for 8-76 months. Two late deaths occurred due to intracranial hemorrhage and liver carcinoma respectively. Seven survived patients were all in New York Heart Association grade II functional class, and none of them experience major advertent cardiac events related to grafts or prosthetic valve. One patient switched to hemodialysis 14 months after discharge due to peritonitis.Conclusion?Cardiovascular surgery can be practiced in patients dependent on maintenance hemodialysis or peritoneal　dialysis with appropriate peri-operative management, so that symptoms can be relieved and quality of life improved.