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重症冠心病的外科治疗

小肠黏膜下层-骨髓间充质干细胞移植-治疗陈旧性心肌梗死

摘要: 目的 探讨自体骨髓间充质干细胞(MSCs)小肠黏膜下层(SIS)支架复合物移植于陈旧性心肌梗死区域后细胞的存活、支架的降解情况及其对心功能的影响。 方法 将16只黑山羊按随机数字表法分为两组，每组8只。实验组：建立心肌梗死模型，抽取自体骨髓,经体外分离MSCs,进行培养、传代、BrdU标记、与SIS支架复合，并于心肌梗死6周时将MSCs-SIS复合物补片移植至陈旧性心肌梗死区；对照组：建立心肌梗死模型。于移植后6周行超声心动图、HE染色及免疫组织化学检测。 结果 MSCs-SIS植入心肌梗死区2周时在补片区可见大量炎性细胞浸润；6周时淋巴细胞浸润消失，SIS部分降解，移植区见大量移植细胞存活。MSCs-SIS植入体内后6周时，实验组每搏输出量(42.81±4.91 ml vs. 37.06±4.75 ml)、射血分数(59.20%±5.41% vs. 44.56%±4.23%)、室壁增厚率（54.51%±8.60% vs. 43.36%±8.91%）、舒张期E峰 (54.85±6.35 cm/s vs. 43.14±4.81 cm/s)显著高于对照组(Plt;0.05)，左心室收缩期末容积(29.75±5.98 ml vs. 46.25±6.68 ml)、舒张期末容积(72.55±8.13 ml vs. 83.31±8.61 ml)显著低于对照组(Plt;0.05)。 结论 SIS作为支架移植MSCs有利于移植细胞存活，对陈旧性心肌梗死后心功能有明显的改善作用。

体外循环冠状动脉旁路移植术围手术期血浆脑钠肽的变化及其临床意义

目的 观察体外循环冠状动脉旁路移植术(CABG)围手术期血浆脑钠肽（brain natriuretic peptide,BNP）的变化规律。 方法 2005年7～10月我院收治20例CABG患者，分别于麻醉诱导后，主动脉开放前，开放后20 min，进入ICU，术后12 h，24 h和48 h测量血浆BNP浓度，分析围手术期BNP的变化规律，以及BNP与心功能、血流动力学指标及术后血浆肌酸激酶同工酶(CKMB)、肌钙蛋白(TNT)等的相关关系。 结果 麻醉诱导后BNP与左心室射血分数（LVEF）呈明显负相关（r=-0.912，P=0.000），与左心室舒张期末内径（r=0.714，P=0.000），肺毛细血管楔压(PCWP，r=0.809，P=0.000），中心静脉压(r=0.787，P=0.000）呈明显正相关。手术前后BNP浓度的差异有统计学意义（F=42.259,Plt;0.01），从主动脉钳开放后逐步上升，并在术后24 h达峰值。进入ICU，术后12 h，24 h的BNP浓度与PCWP呈明显正相关（r=0.602，P=0.005；r=0.554，P=0.011；r=0.631，P=0.003），与CK-MB浓度呈明显正相关(r=0.528，P=0.017；r=0.638，P=0.002；r=0.882，P=0.000)；但与TNT浓度的相关性不明显。 结论 冠心病患者术前血浆BNP浓度能正确反映术前的心功能状态；心肌缺血再灌注损伤是术后BNP大量释放的原因；术后BNP监测能正确及时地反映患者的心功能状态，特别是前负荷状态。

三房心外科治疗六例

Combined Coronary Artery Bypass Grafting and Valve Replacement: Report of 80 Cases

Abstract: Objective To summarize the experience of combined coronary artery bypass grafting(CABG) and valve replacement. Methods From May 1997 to March 2006, the results of 80 consecutive patients undergone valve replacement (MVR) and CABG were analyzed. CABG were performed withtotal grafts in 159 grafts (mean 1.99 grafts), with mitral valve replacement (MVR) in 49 patients, with aortic valve replacement (AVR) in 18 patients, with MVR+AVR in 13 patients(mechanical valve replacement in 68 and biological valve replacement in 12). Results The hospital time after operation was 19.2±13.4d. The hospital mortality rate was 12.5% (10/80). The primary cause of death included low cardiac output yndrome, acute renal failure, nervous system complications ,ventricular fibrillation and cardiac arrest. Multivariate testing of preoperative and operative description identified that preoperative myocardial infarction, worse cardiac function, radiographic cardiac enlargement and low ejection fraction were associated with an increase of hospital mortality (P＜0.05). There were postoperative complications including bleeding, severe ventricular arrhythmia, nervous system complications and incision infection. Followup of 58 patients (82.86%, range 6 to 60 months) showed the symptoms of angina pectoris and heart failure were significantly relieved. There were 2 longterm deaths (cerebral infarction and lung infection). Conclusion Combined CABG and valve replacement is an effective way for treatment of coronary artery and valvular heart disease. Improving the heart function preoperatively, strengthening myocardial protection, shortening operation and myocardial ischemia time, and complete revascularization are the key factors for success operation.

Clinical Analysis of 1405 Patients Undergoing Coronary Artery Bypass Grafting and Transmyocardial Laser Revascularization

Objective To summarize the essential of perioperative therapy and improve the prognosis of coronary artery bypass grafting （CABG） and transmyocardial laser revascularization （TMLR） through analyzing 1405 patients with coronary atherosclerotic heart disease. Methods From May 1997 to January 2006, 1 405 patients were treated in our hospital. On-pump CABG were performed in 825 patients, single CABG were performed in 666 patients, CABG with cardiac valvular operation in 98 patients, CABG with cardiac ventricular aneurysm resection in 55 patients, CABG with ventricular septal defect repairment in 2 patients; CABG with left atrium gelatinous tumor resection in 2 patients, CABG with ascending aorta repairment in 1 patient, and mediastinal septum tumor resection in 1 patient. Off-pump coronary artery bypass grafting （OPCAB） were performed in 500 patients; single TMLR were performed in 30 patients, CABG＋TMLR were performed in 50 patients. Results The number of bridge vessel was 2.9±1.0. Forty-two patients（3.0%） died of bleeding, myocardial infarction, low cardiac output syndrome, renal failure, multiple organ failure（MOF） and so on. Various complications were occurred in 70 patients（5.0%）, including bleeding, low cardiac output syndrome, myocardial infarction, renal failure and so on. All of them were recovered after treatment. There were 1 177 patients of angina in grade Ⅲ-Ⅳ （CCS） before operation, 1 154 of them （98.0%） changed in grade 0-Ⅰ （CCS） postoperatively. There were 857 patients （62.9%） in follow-up for 8.3±2.9 months postoperatively. There was no angina in 788 patients（91.9%） 6 months after surgery. The ultrasonic graphic showed that left ventricular ejection fraction was 0.66±0.10 and raised 7.9% than that before operation. The quality of life was better than before. Conclusion CABG has become the most potent routine operation in the therapy of coronary artery disease. It can extend the applications of CABG and improve the operative prognosis, if the indications are correctly mastered and the perioperative management are enhanced.

Surgical Treatment for Patients with Stanford Type A Aortic Dissection

ObjectiveTo summarize our clinical experience of surgical treatment for 51 patients with Stanford type A aortic dissection (AD). MethodsClinical data of 51 patients with Stanford type A AD who received surgical treatment in Shanghai Yuanda Heart Hospital between February 2009 and January 2013 were retrospectively analyzed. There were 29 males and 22 females with their age of 35-63 (47.2±11.1)years. The diagnosis of all the patients was confirmed by enhanced CT scan and Doppler echocardiography. Surgical procedures included Bentall procedure and Sun's procedure in 29 patients, Bentall procedure, mitral valve replacement and Sun's procedure in 2 patients, ascending aorta replacement and Sun's procedure in 17 patients, valsalva sinus plasty, ascending aorta replacement and Sun's procedure in 2 patients, ascending aorta replacement (stage 1), Sun's procedure (stage 2)and endovascular exclusion of the thoracic aorta (stage 3)in 1 patient. ResultsMean operation time was 320.6±77.3 minutes, cardiopulmonary bypass time was 190.4±63.4 minutes, aortic cross-clamp time was 123.2±45.1 minutes, duration of circulatory arrest with hypothermia was 28.2±11.1 minutes, and mean length of hospital stay was 13.4±4.2 days. Two patients (3.9%)died perioperatively including 1 patient with intraoperative bleeding and another patient with delayed bleeding after operation. Postoperative complications included bleeding, paraplegia, perivalvular leak and sternal dehiscence in 1 patient respectively, and endoleak in 2 patients. Forty-nine patients were followed up for 3-48 (25.3±10.5)months and no late death occurred. ConclusionSurgical treatment is effective for patients with Stanford type A AD.

Uniportal Procedure for the Correction of Pectus Excavatum in 203 Patients

ObjectiveTo summarize the clinical experience and investigate the safety and reliability of uniportal procedure for the correction of pectus excavatum (PE). MethodsFrom November 2010 to November 2015, 203 PE patients (164 males, 39 femalzs average age of 5.7±3.0 years, ranging from 2 to 19 years) underwent the correction operation with only single 2 cm incision on right lateral chest. There were 188 patients under 12 years of age and 15 patients above 12 years. According to Park classification, 176 patients were symmetric and 27 were asymmetric. ResultsAll operations were performed successfully. The average operating time was 16.1±5.2 min with a range of 4-65 min and the average postoperative hospital stay was 6.4±1.3 d, ranging from 4-14 d. A single incision was made on the right chest and only one bar was inserted in the patients. Postoperative follow-up was 1-56 months (mean, 27.6 months). There was no complication occurred such as bar turnover, displacement and redepressed sternum. Totally, 84 patients received bar removal procedure. ConclusionIn terms of operation time and surgical trauma, uniportal procedure for PE is superior to Nuss procedure. And there is no significant difference in the safety and effectiveness between two procedures. Uniportal procedure is especially suitable for the treatment of PE children under 12 years of age.