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华法林抗凝过量致自发性后腹膜出血一例

Long-term outcomes of Aortic Valve Replacement for Patients with Severe Aortic Regurgitation and Severe Left Ventricular Dysfunction

ObjectiveTo analyze long-term outcomes of aortic valve replacement (AVR) for patients with severe aortic regurgitation (AR) and left ventricular dysfunction (LVD). MethodsWe retrospectively analyzed clinical data of 44 patients with severe AR and LVD who received AVR in Drum Tower Hospital from January 2002 to December 2012. Left ventricular ejection fraction (LVEF) of all the patients was lower than 35%. There were 29 male and 15 female patients with their age of 23-78 (44±6) years and LVEF of 22%-34% (29%±3%). ResultsTwo patients died because of heart failure postoperatively. Cardiopulmonary bypass time was 57-92 (73±8) minutes, aortic cross-clamping time was 33-61 (48±6)minutes, and length of ICU stay was 2-15 (8±3) days. All the patients were followed up for 1-11 (4.3±2.9) years. Two patients died during follow-up because of heart failure and stroke respectively. One-year survival rate was 93% and five-year survival rate was 91%. ConclusionAVR can significantly increase long-time survival of patients with severe AR and LVD.

Risk factors for sternal wound infection after various cardiac operations

Objective To evaluate the risk factors for sternal wound infections after various cardiac operations. Methods We retrospectively analyzed the clinical data of 2 924 consecutive patients (28% female) in our hospital from 2010 to 2014 year. Their median age was 69 years (interquartile range of 60 to 76 years). Procedures included isolated coronary artery bypass grafting (CABG), isolated valve repair or replacement, and valve procedures plus CABG. Results Sternal wound infection was detected in 110 (3.8%) patients among the 2 924 patients: 67 of 1 671 patients (4.0%) after CABG, 17 of 719 (2.4%) after valve operations, and 26 of 534 (4.9%) after valve+CABG operation. In the CABG patients, bilateral internal thoracic artery harvest procedure, operation time>300 minutes, diabetes, obesity, chronic obstructive pulmonary disease, and female were independent risk factors for sternal wound infection. In the valve operation patients, only revision for bleeding as an independent predictor for sternal infection. For combined valve plus CABG patients, revision for bleeding and operation time>300 minutes were independent risk factors for sternal infection. Conclusion Risk factors for sternal wound infections after cardiac operations vary with the type of surgical procedure. In patients undergoing valve operations or combined operations, procedure-related risk factors (revision for bleeding, operation time) independently predict infection. In patients undergoing CABG, not only procedure-related risk factors but also bilateral internal thoracic artery harvest and patient characteristics (diabetes, chronic obstructive pulmonary disease, obesity, female) are predictors of sternal wound infection. Preventive interventions may be justified according to the type of operation.

Stanford B 型主动脉夹层腔内修复术后并发 A 型夹层的外科治疗

目的总结 Stanford B 型主动脉夹层胸主动脉腔内修复术（TEVAR）后并发 A 型夹层的临床特点及外科治疗经验。方法自 2013 年 11 月至 2018 年 3 月，南京鼓楼医院外科治疗 Stanford B 型主动脉夹层 TEVAR 术后并发的 A 型夹层患者 14 例，其中男 13 例 、女 1 例，年龄 24～66（52±3）岁，合并高血压 13 例，糖尿病 2 例，马方综合征 1 例。所有患者在深低温停循环选择性脑灌注下施行手术，近心端 13 例行升主动脉置换术，1 例行 Bentall 术。共实施全弓置换加象鼻手术 13 例，弓部开窗支架植入术 1 例。结果全组无死亡，1 例术后右上肢单瘫，1 例术后血行感染，1 例出现右侧偏瘫及肾功能不全行肾脏替代治疗。随访 6～45 个月，随访期间 1 例患者术后 1 个月因原介入支架远端胸降主动脉发生新的夹层再次行 TEVAR，其余患者 CT 血管造影检查未见吻合口造影剂渗漏及人工血管扭曲。结论B 型主动脉夹层 TEVAR 术后并发 A 型夹层及时给予外科手术治疗可取得良好疗效。

右冠状动脉-右心室瘘致巨大冠状动脉瘤一例

Clinical Effect of Tricuspid Valve Re-operation after Left Cardiac Valve Surgery

ObjectiveTo evaluate the clinical efficacy of tricuspid valve re-operation after left cardiac valve surgery. MethodsWe retrospectively analyzed the clinical data of 23 patients underwent tricuspid valve re-operation in the Affiliated Drum Tower Hospital of Medical School, Nanjing University from January 2009 to November 2014. There were 3 males and 20 females with a mean age 53.48±10.79 years ranging from 34 to 71 years. The average body mass index of the 23 patients was 21.77±2.42 kg/m2. We followed up all the patients in outpatient department or through telephone for 3 months to 5 years. ResultsAll surgeries were operated under cardiopulmonary bypass. There were 15 patients underwent operation through medisternal incision and 8 patients underwent operation through the fourth intercostal incision of right anterolateral side. The mean operation time was 284.35±56.16 minutes and the mean time of cardiopulmonary bypass was 138.61±46.91 minutes. One patient died postoperatively and 2 patients chose to discharge automatically after operation. The other 20 patients recovered and discharged uneventfully. We followed up the patients for 3 months to 5 years. One patient underwent permanent pacemaker therapy for atrioventricular block, 3 patients accepted pharmaceutical therapy for atrial arrhyttmia, 1 patient underwent re-operation for infectious endocarditis of left cardiac artificial valve. and the follow-up conditions of the rest patients were well. Besides, the follow-up data showed that there was a mild regurgitation in 3 patients underwent tricuspid valve plasty. ConclusionTricuspid valve re-operation after left cardiac valve surgery can take multiple surgical pathways and strategies. The clinical effect has been proved and the midterm follow-up condition is well, but we still need the long-term follow-up for the further effect.

右侧腋下直切口在二次心脏瓣膜手术中的应用

目的 探讨右侧腋下直切口在二次心脏瓣膜手术中的应用效果。 方法 回顾性分析2014 年 1 月至 2016 年 12 月我院经右侧腋下直切口行二次心脏瓣膜手术 23 例患者的临床资料，男 9 例、女 14 例，年龄 37～67 岁，平均（54.0±9.1）岁，体重 43～73 （56.0±9.8）kg。手术方式包括二尖瓣置换（MVR）7 例，二尖瓣成形（MVP）1 例，主动脉瓣置换（AVR）3 例，三尖瓣成形术（TVP）4 例，三尖瓣置换术（TVR）2 例，MVR+TVP 2 例。 结果 本组平均手术时间 3～6（4.6±0.9）h，体外循环时间 55～140（104.8±22.3） min。心脏停跳术后自动复跳 17 例（17/23），气管插管时间 4～24（12.2±6.0）h，手术后住院时间平均（7.5±1.9）d。手术后首日引流量平均（404.3±204.0）ml。17 例患者术后无输血（17/23）。本组患者无围术期死亡，无明显并发症出现。出院时心功能 Ⅰ 级 13 例、Ⅱ 级 10 例。 结论 经右侧腋下直切口在二次心脏瓣膜手术中的近期手术效果良好，手术安全性高，适用于常见二次心脏瓣膜手术。

Outcome comparison of mitral valve disease patients aged 50 to 65 undergoing mechanical versus tissue prosthesis implantation: A propensity-score matched study

ObjectiveTo evaluate the in-hospital and long-term outcomes of patients receiving mitral valve replacement with mechanical or biological prosthesis.MethodsThe clinical data of patients undergoing mitral valve replacement in our center between January 2005 and August 2018 were retrospectively analyzed. Patients with emergency, reoperation, bleeding or embolic events or incomplete clinical data were ruled out.ResultsTotally 569 patients were enrolled, including 325 with mechanical prosthesis (a mechanical prosthesis group, 111 males and 214 females with a mean age of 55.54±4.09 years) and 244 bioprosthesis (a bioprosthesis group, 90 males and 154 females with a mean age of 60.02±4.28 years). There was no significant difference in the in-hospital mortality between the two groups (P=0.250). The survival rate at postoperative 15 years of the bioprosthesis group was higher than that of mechanical prosthesis group (78.69% vs. 66.25%, χ2=8.844, P=0.003). No remarkable differences were found in prosthesis failure (P=0.183) and thromboembolism events (P=0.505) between the two groups. Bleeding occurred more frequently in the mechanical prosthesis group (P=0.040). After the propensity-score matched analysis based on the age, the survival rate was still higher in the bioprosthesis group than in the mechanical prosthesis group (P=0.032).ConclusionBiological prosthesis can be considered as the preferable choice in mitral valve replacement procedure in order to improve the long-term survival and decrease the frequent of bleeding events.