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冠状动脉旁路移植术的发展与前景

小口径人工血管的研究进展

摘要 为提高小口径人工血管的远期通畅率，一方面需要寻找顺应性更好的材料；另一方面则是在现有人工血管内壁种植内皮细胞。这包括单期种植法，二期种植法以及自体静脉碎片快速种植法。用于种植的内皮细胞可来源于自体静脉、人脐静脉和皮下脂肪微血管。通过在人工血管内壁上衬附可吸收的细胞外黏附蛋白、细胞生长刺激因子，利用生物素与抗生物素蛋白的特异结合能力，或改变植入的内皮细胞的带电性，以及在体外对植入的内皮细胞进行流体切应力锻炼等方法，可以提高内皮细胞的黏附力。植入基因工程改造过的内皮细胞，也是提高小口径人工血管通畅率的一种新尝试。

Ross 手术治疗先天性主动脉瓣膜疾病

目的 总结Ross 手术治疗先天性主动脉瓣膜疾病的临床经验和手术结果. 方法 自1998年3月至2002年7月,16例主动脉瓣膜疾病患者(平均年龄14.0±9.9岁)接受Ross手术,即自体肺动脉瓣移植术.诊断为主动脉瓣二瓣化畸形,主动脉瓣狭窄9例,主动脉瓣发育不良呈穹隆状狭窄2例;主动脉瓣脱垂5例,其中合并室间隔缺损和动脉导管未闭各1例. 结果 无手术死亡,全部患者治愈出院.随访1～48个月,平均30±13个月 ,无远期死亡,无瓣膜相关并发症.所有患者心功能Ⅰ级.超声心动图提示主动脉瓣及同种肺动脉瓣功能良好,仅1例患者主动脉瓣有极少量反流;所有患者主动脉瓣跨瓣压差2.1±0.8 mmHg(1 kPa=7.5 mmHg),左心室流出道及主动脉瓣环随着年龄的生长而增长,平均瓣环直径较术后增加4.0±2.1 mm. 结论 Ross 手术治疗主动脉瓣膜疾病安全,效果好, 随机体发育而生长,可适于某些主动脉瓣瓣膜疾病,尤其适于小儿及年轻患者.

心外管道全腔静脉肺动脉吻合术治疗复杂性先天性心脏病

目的 评价心外管道全腔静脉肺动脉吻合术(TCPA)治疗复杂先天性心脏病的临床应用价值. 方法 1998年6月～2002年7月,26例先天性心脏病复杂畸形的患者接受了心外管道TCPA,包括单心室伴完全型大动脉转位16例,三尖瓣下移畸形2例,右心室双出口伴大动脉转位3例,三尖瓣闭锁伴右心室发育不良5例. 19例在全身麻醉低温体外循环下手术,7例在非体外循环下手术. 结果 无手术死亡,全部患者治愈出院.术后随访1～47个月,无晚期死亡.所有患者症状消失,无静脉压明显升高现象,超声心动图检查示心外管道血流通畅,无血栓形成,心电图检查示无严重的心律失常,血氧饱和度0.93～0.96,心功能均达Ⅰ～Ⅱ级. 结论 心外管道TCPA是一种较为简单的手术方式,易于掌握;术后疗效满意,优于其他术式.

心瓣膜置换术后电机械分离五例

冠状动脉旁路移植术后围术期心肌缺血

目的 探讨冠状动脉旁路移植术(CABG)术后出现围术期心肌缺血(PMI)的相关危险因素及其处理措施. 方法 回顾性总结2 680例CABG患者的临床资料,并根据术后是否发生PMI将其分为PMI组(30例)和非PMI组(2 650例),分析CABG后出现PMI的危险因素. 结果 PMI组中11例进行急诊再血管化,其余行主动脉内球囊反搏(IABP)或药物治疗;院内死亡7例,死亡率为23.3%.心绞痛症状缓解22例,心电图完全或部分复原9例,残留心肌梗死改变14例.非PMI组院内死亡58例,死亡率为2.2%.两组死亡率之间比较差别具有显著性意义(χ2＝56.04,P＝0.001).多因素分析表明,术前无心肌梗死史、冠状动脉弥漫性病变和术中内膜剥脱为相关危险因素.结论 PMI是CABG术后一种比较危险的并发症,严重者可危及生命,及早诊断和适当的治疗尤为重要,对于因旁路血管堵塞造成的PMI,急诊再次血管移植是挽救患者生命的必要措施.

冷脑保护液对大脑皮层组织丙二醛、血栓素A2及前列环素的影响

目的 研究深低温停循环间断灌注充氧脑保护液对大脑皮层组织丙二醛(MDA)、血栓素A2(TXA2)及前列环素(PGI2)的影响.方法 杂种犬10条,随机均分为两组.A组:单纯深低温停循环120分钟;B组:深低温停循环后间断灌注充氧脑保护液.两组动物分别于不同时相测定大脑皮层组织MDA,TXA2的代谢产物血栓素B2(TXB2)及PGI2代谢产物6-Keto-PGF1a的含量. 结果 恢复循环45分钟后,A组MDA和TXB2含量明显高于心肺转流术前(P＜0.01),6-Keto-PGF1a含量明显低于B组(P＜0.01). 结论 深低温停循环间断灌注充氧脑保护液能明显减少恢复循环后大脑皮层组织MDA和TXA2的生成,增加PGI2的生成,发挥其对大脑皮层组织的保护作用.

先天性心脏病继发感染性心内膜炎的外科治疗

目的 总结先天性心脏病继发感染性心内膜炎41例外科治疗的经验。方法 手术均在体外循环下进行畸形矫正和赘生物清除。室间隔缺损(VSD)直接缝合16例，补片修补10例；动脉导管未闭(PDA)均采用直视缝合法。同期行肺动脉瓣成形术5例，三尖瓣置换术2例，主动脉瓣置换术12例，主动脉瓣和二尖瓣置换术2例。结果 1例急诊VSD修补同时行主动脉瓣置换术，术后并发脑栓塞死亡；其余患者均痊愈出院。随访35例，随访时间3～102个月，无1例死亡和心内膜炎复发。结论 正确把握手术时机和使用有效抗生素是提高治愈率的关键，应强调对先天性心脏畸形的早期治疗，以防止严重并发症。

Effect of Alltrans Retinoic Acid on Proliferative Artery Disease after Heart Transplantation

Objective To investigate the effect of alltrans retinoic acid (atRA) on proliferative artery disease after heart transplantation. Methods Heterotopic heart transplantation model was established by Ono model with 16 inbred healthy male Wistar rats as donors and 16 SD rats as recipients. The rats were divided into chronic rejection group and atRAtreated group by complete random design, and there were 8 rats in each group. Rats in chronic rejection group were given Cyclosporine A 10 mg/(kg·d) by subcutaneous injection after operation, and those in atRAtreated group were given Cyclosporine A 10 mg/(kg·d) in the same way and atRA 10mg/(kg·d) by gavage. The transplanted hearts of rats were taken out 60 days after the transplantation. HE stain, masson stain and Van Gieson were done to analyze the rejection of transplanted hearts, the degree of vascular stenosis and myocardial fibrosis respectively.Immunohistochemistry was used to test proliferating cell nuclear antigen (PCNA). Results The area of myocardial fibrosis in chronic rejection group was obviously larger than that in atRAtreated group（63.99%±11.91% vs.34.68%±6.34%）, and there was significant difference between two groups（t=8.377，P=0.000）. The index of vascular stenosis in chronic rejection group was higher than that in atRAtreated group（62.86±17.18 vs. 40.10±8.20）. Vascular stenosis in atRAtreated group alleviated significantly, and there was significant difference between two groups（t=3.913, P=0.006）. The PCNA positive cells in chronic rejection group were obviously more than that in atRAtreated group（60.17±17.74 vs. 33.96±8.65）, and there was significant difference between two groups（t=5.387, P≤0.001）. There was a positive correlation between the PCNA positive cell ratio and the index of vascular stenosis（r=0.854, P=0.007）. Conclusion Alltrans retinoic acid can inhibit vascular disease after heart transplantation by cell proliferative pathway.

Effect on the Expression of C-myc and Proliferating Cell Nuclear Antigen of Vein Grafts Transferred by C-myc Antisense Oligodeoxynucleotides of Soluble Stent

Objective To investigate the effect on expression of c-myc and proliferating cell nuclear antigen （PCNA） of vein grafts transferred by c-myc antisense oligodeoxynucleotides（ODN） of soluble stent. Methods A rabbit model of common carotid arteries grafted by external jugular veins was constructed in 50 New Zealand rabbits and were randomly divided into five groups, 10 rabbits each group. Control group： no stents ; group 1： soluble stent ; group 2： soluble stent with sense-ODN; group 3： soluble stent with antisense-ODN; group 4.. soluble stent with mismatch-ODN. At 7 d, 28 d and 90 d after surgery, vein grafts were harvested. The expression of c-myc and PCNA were identified by immunochemistry methods. Results At 7d, 28d, 90d after surgery, the expression of c-myc and PCNA of the intima and media of vein grafts in control group, group 1, group 2, group 4 were higher significantly than that in group 3 （P〈0. 01）. At 28d, 90d after surgery, the expression of c-myc in five groups were higher than that in the same group at 7d after surgery （P〈0. 01）. Conclusion Soluble stent can transfer ODN effectively. C- myc antisense-ODN transferred by soluble stent can inhibit significantly the expression of c-myc and PCNA in the intima and media of vein grafts.