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感染性心内膜炎的外科治疗

摘要: 目的 总结自身瓣膜感染性心内膜炎的外科治疗经验。 方法 2000年1月至2008年6月上海交通大学医学院附属仁济医院收治感染性心内膜炎患者49例，男27例，女22例；年龄14~74岁，平均年龄44.2岁。基础疾病：先天性心脏病12例，包括室间隔缺损、右心室流出道狭窄、主动脉窦瘤和动脉导管未闭等；后天性心瓣膜病34例，包括风湿性二尖瓣病变、主动脉瓣病变和老年性心瓣膜退行性变等。不合并基础心脏疾病3例。所有患者均在低温体外循环下施行先天性心脏病矫治术和心瓣膜置换术；术中尽可能清除赘生物，对受侵犯的组织采用碘伏溶液多次擦洗，再用生理盐水彻底冲洗。术后给予抗生素治疗4~6周。 结果 围术期死亡2例(4.08%)，1例因心力衰竭死亡，另1例因严重肺部感染死亡。术后2例患者持续发热，继续给予抗生素治疗2周后，体温渐趋平稳。随访35例(71.43%)，随访时间4个月至6年，失访12例。1例室间隔缺损、三尖瓣赘生物患者手术后1个月再次发热，再次入院接受抗生素治疗后治愈。3例发生抗凝治疗并发症，出现牙龈或结膜出血、皮肤瘀斑、血尿、消化道出血，暂停抗凝治疗后好转。随访期间未见感染性心内膜炎复发。 结论 早期诊断、正确把握手术时机，药物与手术相结合是成功治疗感染性心内膜炎的关键。

介入封堵术治疗先天性心脏病82例

目的 总结介入治疗先天性心脏病的临床经验，分析其疗效。 方法 2006年1月至2008年1月我院共施行介入封堵治疗82例常见先天性心脏病患者，男35例，女47例；年龄5~79岁，平均年龄20.3岁。其中继发孔型房间隔缺损（ASD）39例，缺损直径0.50～2.55 cm（1.60±0.55 cm）；室间隔缺损（VSD）23例，缺损直径0.30～1.72 cm（1.05±0.33 cm）；动脉导管未闭（PDA）20例，导管最窄处（腰部）直径0.40~1.10 cm（0.80±0.20 cm），均为管型。房间隔缺损封堵术及室间隔缺损封堵术均采用Amplatzer法，动脉导管未闭大部分采用Amplatzer法，仅1例采用Cook可控弹簧栓子法。出院后采用电话、信件、门诊方式进行随访。 结果 全部患者均无主要并发症发生，无死亡。封堵成功80例，其中房间隔缺损38例，室间隔缺损22例，动脉导管未闭20例。操作时间为55.0±18.5 min，住院天数为5.0±2.3 d，住院费用为39 880±5 830元。术后7 d、1个月、6个月、1年和2年时随访率分别为97.5%、91.2%、85.0%、73.8%和55.0%。 随访5~30个月无残余分流及严重心脏事件。彩色超声心动图提示：封堵器位置良好。 结论 充分评估病情，严格掌握适应证，经导管介入堵闭治疗先天性心脏病安全、可靠、成功率较高。

合并慢性肾功能不全患者的冠状动脉旁路移植术

目的 总结合并慢性肾功能不全的冠心病患者行冠状动脉旁路移植术（CABG）的临床经验。方法 1997年4月至2004年11月，对18例合并慢性肾功能不全[术前血清肌酐（Cr）129～497μmol／L（216.0±98.3μmol／L）]的冠心病患者行CABG，其中体外循环CABG和非体外循环CABG各9例。结果 术后住院死亡3例，其中大面积脑梗死、肾功能衰竭1例；肾脏和呼吸功能衰竭1例；肺部感染、呼吸功能衰竭1例。4例患者采用腹膜或血液透析。随访11例，失访4例，随访时间2～22个月（7.6±7.3个月），随访期间无明显的心绞痛发作5例，心绞痛较术前明显减轻5例，有较剧烈的胸痛发作1例。血清Cr较术前变化不明显4例（变化〈50μmol／L），较术前明显增高（Cr增高〉100μmol／L）5例。长期腹膜透析1例，脑出血1例，死亡2例（脑梗死、肺部感染）；抗凝治疗发生并发症1例。结论 对合并肾功能不全的冠心病患者积极改善肾功能，通过适当的围术期处理，行CABG后的近期结果是可以接受的。

再次冠状动脉旁路移植术一例

机器人辅助的微创冠状动脉旁路移植术

目的介绍机器人辅助的微创冠状动脉旁路移植手术. 方法应用da Vinci机器人系统取左乳内动脉,然后经左胸第2肋间小切口在体外循环下行冠状动脉旁路移植术. 结果本组34例患者无围术期死亡和心肌梗死;术后有4例发生低心排血量综合征,2例发生急性肾功能不全. 结论机器人辅助的微创冠状动脉旁路移植术是一种安全可靠的手术方法,可以减轻术后疼痛和促进术后恢复.

Surgical Treatment for Acute Aortic Dissection with Involvement of Aortic Root

Abstract:　Objective　To evaluate surgical strategies for the treatment of acute Stanford type A aortic dissection with involvement of the aortic root.　Methods　From January 2005 to December 2010, 62 consecutive patients underwent emergency surgical intervention for acute Stanford type A aortic dissection with involvement of the aortic root in Renji Hospital Affiliated to Medical School of Shanghai Jiaotong University. According to different methods for the management of proximal aortic dissection, these patients were divided into 3 groups: group A, aortic valve commissural suspension＋supracommissural replacement of the ascending aorta （SCR）,including 28 patients （20 males and 8 females，mean age 45.2±15.6 years）; group B, partial sinus remodeling+ascending aortic replacement, including 10 patients （7 males and 3 females，mean age 44.6±14.9 years）；group C, Bentall procedure,including 24 patients （17 males and 7 females，mean age 46.2±15.6 years）. Clinical outcomes were compared among the three groups.　Results　Six patients died peri-operatively and in-hospital mortality was 9.67% （6/62）. Fifty-four patients were followed up, and the mean follow-up time was 27.3±15.7 months. During follow up, 2 patients died, one for lung cancer and the other for unknown reason. One patient in group A underwent CT scan 6 months after surgery which showed aortic root pseudo-aneurysm. Cardiopulmonary bypass time and aortic cross-clamping time of group C were significantly longer than those of group A and group B （274±97 min vs. 194±65 min, 210±77 min, t=22.482, 30.419, P=0.002， 0.122；150±56 min vs. 97±33 min, 105±46 min, t=12.630, 17.089, P=0.000，0.034）. There was no statistical difference in mortality （t=1.352，P=0.516）, incidence of postoperative reexploration for bleeding, acute renal failure and neurological complication （t=0.855, 0.342, 2.281; P=0.652, 0.863, 0.320） among the three groups.　Conclusion　For patients with acute aortic dissection involving the aortic root, aortic valve commissural suspension+SCR，partial sinus remodeling＋ascending aortic replacement and Bentall procedure may be considered the surgical treatment of choice with respective advantages and disadvantages. Satisfactory clinical outcomes can be achieveed if surgical indications and procedures are properly employed.

Clinical Analysis of Off-pump Coronary Artery Bypass Grafting Following Acute Myocardial Infarction

Objective　To investigate clinical outcomes and perioperative management of off-pump coronary artery bypass grafting （OPCAB） for patients following acute myocardial infarction （AMI）.?Methods?From January 2006 to March 2010， 239 consecutive patients underwent OPCAB on the 14-27 （20.55±3.91） d following AMI（AMI group）in Renji Hospital，School of Medicine of Shanghai Jiaotong University. Preoperative MB isoenzyme of creatine kinase（CK-MB） level was （15.82±6.24） U/L and cardiac troponin I（cTnI） was （0.07±0.04） ng/ml. Clinical data of 406　patients without myocardial infarction history who underwent OPCAB during the same period were also collected as the control group for comparison.?Results?The 30-day mortality of AMI group was 2.51% （6/239）. The causes of death were circulatory failure in 4 patients， ischemic necrosis of lower extremity caused by intra-aortic balloon pump （IABP） in 1 patient and pneumonia with septic shock in 1 patient. Dopamine usage in AMI group was significantly higher than that of the control group （61.51% vs. 37.44%， P=0.001）. Intraoperative or postoperative IABP implantation was more common in AMI group， but there was no statistical difference between the two groups（P＞0.05） . Postoperative drainage and blood transfusion in AMI group were significantly larger than those of the control group （385.18±93.22 ml vs. 316.41±70.05 ml， P=0.022；373.68±69.54 ml vs. 289.78±43.33 ml， P=0.005， respectively）. But there was no statistical difference in re-exploration rate between the two groups （P＞0.05）. There was no statistical difference in the incidence of postoperative new onset atrial fibrillation between the two groups （P＞0.05）. Incidence of acute kidneyinjury of AMI group was significantly higher than that of the control group （13.81% vs. 8.62%， P=0.038）. Postoperative 30-day mortality of AMI group was higher than that of the control group， but there was no statistical difference between the two groups （2.51% vs. 1.48%，P＞0.05）. There was no statistical difference in ICU stay time and postoperative hospital stay between the two groups （2.01±0.95 d vs. 1.78±0.98 d；10.33±4.16 d vs. 9.89±4.52 d， respectively， P＞0.05）. A total of 211 patients （88.28%）in AMI group were followed up for 2.89±1.02 years， and 28 patients （11.72%） were lost during follow-up. Twenty-five patients died during follow-up including 14 cardiac deaths. One-year survival rate was 97.63%， and five-year survival rate was 88.15%.?Conclusion?It’s comparatively safe to perform OPCAB for patients at 2-4 weeks following AMI when their CK-MB and cTnI levels have returned to normal range.

Application of Acute Kidney Injury Criteria and Classification to Predict Mortality Following Cardiovascular Surgery

Abstract：　Objective　To evaluate the incidence and prognosis of postoperative acute kidney injury （AKI） in　patients after cardiovascular surgery， and analyse the value of AKI criteria and classification using the Acute Kidney Injury Network （AKIN） definition to predict their in-hospital mortality.　Methods　A total of 1 056 adult patients undergoing cardiovascular surgery in Renji Hospital of School of Medicine， Shanghai Jiaotong University from Jan. 2004 to Jun. 2007 were included in this study. AKI criteria and classification under AKIN definition were used to evaluate the incidence and in-hospital mortality of AKI patients. Univariate and multivariate analyses were used to evaluate preoperative， intraoperative，　and postoperative risk factors related to AKI.　Results　Among the 1 056 patients， 328 patients（31.06%） had AKI.　In-hospital mortality of AKI patients was significantly higher than that of non-AKI patients （11.59% vs. 0.69%， P＜0.05）. Multivariate logistic regression analysis suggested that advanced age （OR=1.40 per decade）， preoperative hyperuricemia（OR=1.97）， preoperative left ventricular failure （OR=2.53）， combined CABG and valvular surgery （OR=2.79）， prolonged operation time （OR=1.43 per hour）， postoperative hypovolemia （OR=11.08） were independent risk factors of AKI after cardiovascular surgery. The area under the ROC curve of AKIN classification to predict in-hospital mortality was 0.865 （95% CI 0.801-0.929）.　Conclusion　Higher AKIN classification is related to higher in-hospital mortality after cardiovascular surgery. Advanced age， preoperative hyperuricemia， preoperative left ventricular failure， combined CABG and valvular surgery， prolonged operation time， postoperative hypovolemia are independent risk factors of AKI after cardiovascular surgery. AKIN classification can effectively predict in-hospital mortality in patients after cardiovascular surgery， which provides evidence to take effective preventive and interventive measures for high-risk patients as early as possible.

The design and assessment of a novel simulated training system for cardiac surgery

Simulations can mimic the environment that refers to the surgery operation to improve the technical skills of the trainees. In this paper, we designed a new cardiac surgery simulative training system. The isolated pig heart was selected as the heart model. A mechanical device was designed to achieve the beating of heart model. At the same time, adjusting frequencies of mechanical movement could change the rating of heartbeat. In order to validate the rationality of the system, 12 non-medical specialty students and 12 medical specialty students were divided into two groups, which consecutively accepted seven-days of training for off-pump coronary artery bypass grafting using the cardiac surgery simulative training system. The time for completing bypass grafting before and after training were recorded. And the bridging outcomes of each trainee were assessed by 3 surgery cardiac surgeons using the object structured assessments of technical skill (OSATS) criteria. After training, each trainee could finish the bypass suturing in a shorter time than before training, and the scores of each trainee assessed by OSATS criteria were also improved. The results showed that the cardiac surgery simulative training system had better training effect in improving the surgical techniques, operation skills and proficiency of surgical instruments of trainees.