目的:高龄冠心病合并糖尿病患者行冠状动脉旁路移植(CABG)围术期新发心房颤动的危险因素分析目前尚不明确,因此,本研究旨在探讨这些患者术后新发心房颤动的危险因素.方法:本研究回顾性分析了 2017年至2019年我科行CABG术且合并糖尿病的高龄(＞70岁)患者68例,将术后持续超过5min或需要抗心律失常或心电复律治疗的心房颤动定义为术后新发心房颤动.结果:在接受CABG术且合并糖尿病的高龄患者中以男性患者居多,为51例75％,平均年龄为(76.2±3.4岁),具有吸烟史的患者为29(42.6％)例,6(8.8％)例患者在手术前进行过冠状动脉支架治疗;术后新发心房颤动患者为23例(33.8％).经过多因素回归分析,并经过性别、年龄、BMI校正后发现,只有LAD(OR=3.04,95％CI:1.12～5.84,P=0.04)、心功能分级(OR=1.13,95％CI:1.03～1.24,P=0.01)和吸烟史(OR=1.13,95％CI:1.03～1.24,P=0.01)与这部分患者术后新发心房颤动的发生呈独立相关.此外,我们对左心房直径预测术后新发心房颤动的截断值进行了受试者工作特征曲线分析,曲线下面积为0.74,95％CI:0.58～0.89;此外,当LAD为42mm时是这部分患者术后新发心房颤动发生危险因素.结论:在进行CABG术的高龄且合并糖尿病患者中,LAD、术前心功能和吸烟史是这部分患者术后新发心房颤动发生的独立危险因素.

[目的]探讨阿托伐他汀钙对高脂血症兔模型主动脉瓣膜病理改变的影响.[方法]选择39只健康雄性新西兰白兔,根据随机数字表法将其分为阿托伐他汀钙干预的饮食高脂组(AI组)、正常饮食的对照组(N组)、单纯高脂饮食组(HC组).分别于实验开始4周、8周、12周后,取静脉血测定血浆脂质水平,于实验开始后8周、12周行主动脉瓣膜超声心动图检查,分析各组瓣膜形态改变情况,同时取主动脉瓣膜标本行组织学检测.[结果]HC组血清总胆固醇(TC)、C反应蛋白(CRP)、三酰甘油(TG)、低密度脂蛋白胆固醇(LDL-C)水平显著高于AI组、N组,差异有统计学意义(P＜0.05);AI组8周、12周的血清TC、TG、CRP、LDL-C水平高于N组、低于HC组,差异有统计学意义(P＜0.05).12周时,HC组超声心动图主动脉瓣膜出现增厚、回声增强,且随着高脂饮食时间延长,出现瓣膜钙化倾向,活动度下降;AI组超声心动图瓣膜改变程度较HC组减轻;N组主动脉瓣膜超声心动图前后无明显改变.HC组主动脉瓣膜的HE染色出现内皮损伤、脂质钙盐沉积、纤维组织的增生及巨噬细胞浸润引起的炎症反应等,AI组病变程度较HC组明显减轻.[结论]阿托伐他汀钙能够明显延缓因高脂血症而诱发的主动脉瓣膜病变进程.

BACKGROUND AND AIM OF THE STUDY:The midterm clinical outcomes of patients with latent left ventricular outflow tract (LVOT) obstruction who undergo septal myectomy are unclear. Therefore, this study aimed to evaluate the clinical outcomes of patients with latent LVOT obstruction who underwent septal myectomy.METHODS:We studied 34 patients with hypertrophic cardiomyopathy (HCM) and latent LVOT obstruction who underwent septal myectomy in 2011-2019 at Anzhen Hospital. After 2:1 propensity score matching, the study cohort included 34 patients with latent LVOT obstruction and 68 patients with resting LVOT obstruction.RESULTS:Compared to patients with resting LVOT obstruction, patients with latent LVOT obstruction had a thinner interventricular septal thickness (18.2 ± 3.2 mm vs. 20.4 ± 5.6 mm; p = .01), while the proportion of moderate or severe mitral regurgitation was significantly higher (26.5% vs. 5.9%; p = .003). Moreover, the proportion of mitral valve procedures (26.5% vs. 5.9%; p = .004) was significantly higher in patients with latent LVOT obstruction. However, there was no intergroup difference in cardiovascular death (5.9% vs. 1.5%, p = .26). Furthermore, the 5-year survival rates after sudden cardiac death (100.0% vs. 91.7%; p = .26) and cardiovascular death (95.5% vs. 89.0%; p = .32) were similar between HCM patients with latent versus resting LVOT obstruction.CONCLUSIONS:Midterm clinical outcomes were similar and excellent in a matched cohort of HCM patients with latent versus resting LVOT obstruction after septal myectomy.

目的 探讨腺苷蛋氨酸作为预充液对乙型肝炎病毒(HBV)携带者行体外循环心脏手术后肝功能的影响.方法 选取2016年5月至2019年5月于首都医科大学附属北京安贞医院行体外循环心脏手术的HBV携带患者88例,通过随机数字表法分为对照组和观察组,各44例.对照组患者术后给予0.9％氯化钠注射液静脉注射,观察组患者术后给予腺苷蛋氨酸+0.9％氯化钠注射液静脉注射,2次/d,连续治疗7d.观察2组患者术前及术后1、3、7d肝功能指标、炎症因子及不良反应发生情况.结果 2组患者术前肝功能指标及炎症反应指标差异均无统计学意义(均P＞0.05).术后1d,2组血清总胆红素、直接胆红素、天冬氨酸转氨酶(AST)水平均高于本组术前,但观察组低于对照组[(20±16) μmol/L比(29±20) μmol/L,(9.6±6.2)μmol/L比(19.2±7.6)μmol/L,(52±32)U/L比(79±22) U/L];胆碱酯酶水平均低于本组术前,但观察组高于对照组[(4 555 +1 123) U/L比(3 936±864) U/L](均P＜0.05).观察组术后1、3、7d患者总胆红素、直接胆红素、丙氨酸转氨酶、AST水平均低于同时点对照组,胆碱酯酶水平高于同时点对照组(均P＜0.05).观察组术后1、7d患者肿瘤坏死因子α、白细胞介素8、肌酸激酶同工酶、肌钙蛋白水平均低于同时点对照组,白细胞介素10水平均高于同时点对照组,差异均有统计学意义(均P＜0.05).观察组患者不良反应发生率与对照组比较,差异无统计学意义[11.4％ (5/44)比4.5％ (2/44),x2 =2.920,P=0.085].结论 HBV携带者体外循环心脏手术后肝功能均有一定程度的损伤,术后短期应用腺苷蛋氨酸,能够改善HBV携带者肝功能,对患者的预后康复效果有积极作用.

目的:总结主动脉瓣环扩大联合环上型生物瓣膜替换策略,治疗老年小瓣环主动脉瓣狭窄的近中期结果,探讨老年小瓣环主动脉瓣狭窄的治疗策略.方法:2010年1月至2017年1月,28例老年小瓣环主动脉瓣狭窄患者应用主动脉瓣环扩大联合环上型生物瓣替换策略进行治疗,主动脉瓣关闭不全或多个瓣膜病变等排除在本研究之外.男性8例,女性20例,年龄65～ 77岁,平均(70.5±3.48)岁,体表面积1.55～ 1.72 m2,平均(1.63±0.05) m2.按病因分类,退行性主动脉瓣狭窄17例,先天性二叶畸形6例,风湿性改变4例,其他病变1例.患者术前心功能分级(NYHA分级):Ⅱ级6例,Ⅲ级20例,Ⅳ级2例.同时合并疾病包括冠心病5例,2型糖尿病8例,高血压病7例,慢性肾功能不全5例,慢性阻塞性肺疾病3例,心房颤动7例,既往卒中史6例.手术前超声心动图测主动脉瓣环径(17.5±1.02) mm,平均跨瓣压差(59.8± 10.2)mmHg(1 mmHg=0.133 kPa).结果:体外循环时间(105.O±18.8)min,心肌血运阻断时间(71.0±17.1)min.实测主动脉瓣环径(18.1±0.87)mm,应用Nick法扩环25例,Nu(n)ez法3例,扩环后主动脉瓣环径(22.2±0.93) mm,平均增加(4.13±0.78)mm,平均替换瓣膜尺寸(21.8±0.99)mm,预期有效瓣口面积指数(1.10±0.07) cm2/ m2.同期行冠状动脉旁路移植术5例,心房颤动射频消融术7例,左心耳切除术7例.围手术期死亡1例(3.6％),死因为低心排血量综合征.开胸止血术1例,急性肾衰竭1例,肺部感染2例,切口并发症1例,临时起搏治疗6例.出院时平均跨瓣压差(13.14±2.14)mmHg,超声实测有效瓣口面积指数(1.12±0.07) cm2/m2,仅1例发生轻度患者-人造瓣膜不匹配.手术后2年,常规超声心动图检查及临床评估.24例患者心功能Ⅰ级,3例Ⅱ级.患者平均跨瓣压差及左心室质量指数较术前明显改善[(59.8±10.18)vs.(13.8±1.93) mmHg,P＜0.01;(151.3±9.95)vs.(110.6±6.95)g/m2,P＜0.01].5例患者主动脉瓣听诊区可闻及2/6级收缩期杂音,19例患者左心室肥厚得到逆转,8例患者仍存在轻度左心室肥厚.随访时平均有效瓣口面积指数(1.09±0.09) cm2/m2,1例发生轻度患者-人造瓣膜不匹配.结论:主动脉瓣环扩大联合环上型生物瓣替换策略治疗老年小瓣环主动脉瓣狭窄近中期疗效良好,既有效避免患者-人造瓣膜不匹配现象,又避免了长期抗凝所致的血栓栓塞及出血风险.

Objective: To investigate the indication and midterm outcomes of surgical treatment of traumatic tricuspid insufficiency. Methods: Totally 19 patients with traumatic tricuspid insufficiency who underwent surgical treatment at Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University from January 2002 to January 2018 were included in this retrospective study. There were 12 male and 7 female patients, aged (43.1±12.9) years (range: 17-68 years). The main causes of traumatic tricuspid insufficiency included blunt chest trauma following high-speed vehicle accidents (17 patients) and high-fall trauma (2 patients). The preoperative New York Heart Association functional class was class Ⅱ in 5 patients, class Ⅲ in 12 patients, and class Ⅳ in 2 patients. The mechanism of tricuspid insufficiency included anterior chordal rupture in 9 patients, anterior papillary muscle rupture in 3 patients, anterior and posterior chordal or papillary muscle rupture in 4 patients, laceration of leaflet combined with chordal rupture in 2 patients and infection combined with anterior papillary muscle rupture in 1 patient. Anular dilation and enlargement of the right ventricle were observed in all the patients. Paired t test was used to evaluate the echocardiogratic results at preoperation, postoperation and follow-up. Independent sample rank sum test was used to evaluate the intervals between trauma and surgery in tricuspid valve repair group and tricuspid valve replacement group. Results: Tricuspid valve repair was successful in 8 patients, and 11 patients underwent valve replacement. Among the patients who underwent valve replacement, 6 patients received mechanical valve and 5 received bioprosthetic valve. The interval from trauma to surgery of the valve repair group and valve replacement group were 8.5(10.0) months (range: 0.1-13.0 months) and 72.0 (108.0) months (range: 2.0-228.0 months), respectively. Concomitant procedures included debridement in scalp trauma (1 patient), internal fixation of femoral fracture (1 patient). One patient died from liver failure 10 days after operation and the remaining patients survived. Eighteen patients were followed up for (94±50) months, 15 patients were in New York Heart Association functional class Ⅰ and 3 patients in class Ⅱ. One patient received redo-tricuspid valve replacement because of mechanical valve failure at the 11 years of follow-up. Conclusions: The midterm outcomes of surgical treatment of severe traumatic tricuspid insufficiency were satisfactory. Early diagnosis and surgical invention were recommended to achieve successful valve repair.

Objective To observe the surgical outcome and survival of patients with tricuspid valve mechanical prosthesis replacement.Methods Clinical data of 36 patients receiving tricuspid mechanical valve replacement in Beijing Anzhen Hospital,Capital Medical University between January 2010 and December 2017 was retrospectively reviewed.There were 14 females and 22 males,with a mean age of (52 ± 9) years (28-64 years old).Among the patients,22 cases were in New York Heart Association(NYHA) functional class Ⅱ,12 cases were in NYHA class Ⅲ[and 2 cases were in NYHA class Ⅳ.Tricuspid valvular lesion of all patients was confirmed by echocardiography and surgical findings.There were 28 cases of rheumatic heart disease,4 cases of tricuspid valvular hypoplasia,3 cases of congenital heart disease (Ebstein's anomaly) and 1 case of tetralogy of Fallot.Mechanical valve replacement of tricuspid valve or multi-valve replacement was implemented and 45 mechanical prostheses were used.Results Three patients died of right heart insufficiency,infection and multiple organ dysfunction,the postoperative in-hospital mortality was 8.3％ (3/36).One patient was discharged 97 days after surgery;32 patients were discharged in 8-21 days after surgery.The mean follow-up interval was 3-42 months in 33 patients(91.7％).During follow-up,1 patient developed paravalvular leakage 3 months after surgery and underwent reoperation of bioprosthetic valve replacement;other patients survived without any valve-related events.Conclusions Tricuspid valve replacement has high risks of mortality and morbidity and requires rigorous indications.Patients with no indication of tricuspid valve repair or failure in repair can have valve replacement and the surgical effect is valid.

Objective To summarize the short and mid-term outcome of adult patient suffered with aortic stenosis and small aortic root treated by aortic root enlargement with supraannular prostheses replacement or supraannular prostheses replace-ment.Methods From January 2005 to January 2017, 223 patients with aortic stenosis and small aortic root who underwent i-solated aortic valve replacement(AVR) were included in this retrospective study cohort.Patients with aortic insufficiency who underwent isolated AVR or those who underwent combined valve replacement were excluded from the study cohort .Aortic root enlargement with supraannular prostheses replacement was performed in 98 patients(ARE), and supraannular prostheses re-placement was performed in the remaining 125 patients as a control group(SP).The mean age and other baseline characteristics were compared between the two group, except that body surface area(BSA) in ARE were higher than that in SP[(1.62 ± 0.04)m2 vs(1.61 ±0.04)m2, P=0.015].Results Operative mortality occurred in 6 patients(2.7%), the cause of death including low cardiac output syndrome(LCOS, 3 patients), multiple organ failure(MOF, 2 patients) and stroke(1 patient). Reoperation for bleeding occurred in 5 patients and acute renal failure in 9 patients, pneumonia in 5 patients.The other nonfa-tal operative complications included wound complication(8 patients), temporary pacing therapy(24 patients), and new onset of acute mitral regurgitation(1 patient).The operative mortality and nonfatal complication were not statistically different be-tween the two groups.Patients in ARE received more bioprotheses and iEOA was higher than those in SP .Transvalvular pres-sure gradients and incidence of patient-prostheses mismatch were lower in ARE.At the 2 years of follow-up, transvalvular pres-sure gradients and left ventricular mass index were statistically lower in ARE compared with SP .The iEOA of ARE was higher than that in SP(1.22 ±0.13 vs 0.87 ±0.13, P<0.01).However, during the mid-term follow up(mean duration of follow-up was 6.31years), the overall survival rate was not statistically different between the two groups.Conclusion The strategy of aortic root enlargement with supraannular prostheses to treat adult patients with aortic stenosis and small aortic root can provide more optimal hemodynamic effect , effectively avoid PPM and was not associated with increased risk of mortality or adverse event when compared with strategy of supraannular prostheses replacement.However, the mid-term survival rate was not statistically different between the two strategies.

目的:观察高脂血症能否直接诱导兔主动脉瓣膜发生退行性的改变,以及阿托伐他汀对瓣膜病变进程的影响.方法:选择健康新西兰纯种雄性,白兔,45只,随机平均分配为对照组(N组)、高脂组(HC组)和高脂加阿托伐他汀干预组(AI组).并分别于实验开始4、8、12周后,取静脉血测定血浆脂质及hs-CRP水平,取主动脉瓣膜标本行组织学检测,经HE和免疫组织化学染色,观察钙化性主动脉瓣组织学改变及各炎性指标的变化,分析比较各组间是否存在差异.结果:第8、12周HC组和AI组血浆中TC、TG、LDL-C及高敏C反应蛋白(hs-CRP)的浓度较第4周及N组均升高,同期AI组的各项血脂水平低于HC组,差异有统计学意义(P＜0.05).与正常主动脉瓣比较,HC组光镜下组织学改变与钙化性主动脉瓣疾病早期病理改变相似,AI组较HC组病变减轻;免疫组织化学染色示:因子TNF-α、IL-6在HC组中表达明显,在AI组中的表达较HC组显著下降,N组中则无表达.结论:高脂饮食能够诱导兔主动脉瓣膜发生早期钙化并存在慢性炎症,阿托伐他汀通过降血脂及抗炎作用,能够抑制钙化性主动脉瓣疾病病变发展进程.

目的:探讨二尖瓣置换术中乳头肌悬吊固定技术重建瓣下连续性的方法,在二尖瓣关闭不全合并左心室功能严重受损的患者中临床应用效果.方法:回顾性分析2013年6月至2016年7月,在我院心外科,因二尖瓣关闭不全合并左心室功能严重受损,需行二尖瓣置换术且应用乳头肌悬吊固定技术,作为重建瓣下结构连续性的方法的患者临床资料22例,男性15例,女性7例;年龄36 ～75岁,平均年龄(59.18±11.5)岁;心功能(NYHA分级)Ⅲ级17例,Ⅳ级5例,心房颤动18例.病因包括感染性心内膜炎(4例)、退行性变(13例)、缺血性二尖瓣返流(3例)及风湿性改变(2例).结果:22例患者在二尖瓣置换术中,全部切除二尖瓣前叶及瓣下腱索、大部分后叶及腱索,保留后叶基底部及与之相连的基底部腱索,再将前后乳头肌分别悬吊固定于后瓣环相应的位置以重建瓣下结构的连续性,最后以间断或连续缝合法置入人造瓣膜.本组置入机械瓣12枚,生物瓣10枚,同期行左心耳缝闭及左心房折叠术17例,心房颤动射频消融术15例,冠状动脉旁路移植术3例,三尖瓣成形15例.1例死于术后严重肺部感染,其余均顺利出院,21例患者随访,随访时间12～40个月,平均(26.14±8.16)个月.随访期间1例发生感染性心内膜炎,其余患者心功能改善,人造瓣膜功能良好,无瓣膜功能障碍及抗凝治疗导致的出血或栓塞并发症.术后及随访期间心胸比、左心室舒张期末径及收缩期末径、球形指数较术前明显改善,左心室收缩功能在术后早期得到改善,表现为左心室射血分数明显提高,随访期进一步改善.结论:应用乳头肌悬吊固定技术重建二尖瓣下结构连续性的方法,在二尖瓣关闭不全合并左心室功能受损的二尖瓣置换术中安全有效,与传统的保留二尖瓣下结构的技术相比,简单易行,易于掌握,近中期疗效满意.

目的 分析乳头肌瓣环再固定 (papillary muscle repositioning,PMR) 技术在二尖瓣置换术中应用的可行性.方法 回顾性分析2016年3月至2017年3月,以二尖瓣病变为主并实施PMR技术的瓣膜置换术 (均置换的机械瓣膜) 19例患者的临床资料,其中男10例、女9例,年龄 (52.46±11.22) 岁.分析其心功能改善情况及左心室形态等手术效果.结果 患者围手术期死亡0例;开胸止血1例,低心排血量综合征 (低心排) 1例,强心利尿后好转,并顺利出院.术后仅1例出现大量血管活性药物的应用.心脏超声随访结果显示术后6个月左心室射血分数 (LVEF) 均较术前改善,出院前较术前降低;左心室舒张末期内径 (LVEDD)、左心室收缩末期内径 (LVESD) 较术前减小,差异具有统计学意义 (P＜0.05).结论 实施PMR技术的二尖瓣置换术在维持左心室乳头肌-二尖瓣环的张力和完整性,改善左室容积、左室形态和射血分数方面效果良好.

近年来,随着我国研究生教育事业的蓬勃发展,研究生培养规模不断扩大,学位层次体系逐渐完善.加之对研究生教育改革和结构调整的深入及社会对研究生能力要求的改变,研究生教育的形势发生了巨大的变化.新时期下心脏外科作为一个专业化强,技术精尖且学科发展迅速的学科,心脏外科硕士的培养应以临床实践能力、科研能力及教学能力为重点的"三条腿走路",基础、医德及人文等多方面共同发展为原则.基于国内外不同培养模式及我院近几年来在研究生培养方面的经验,将以问题为中心的教学法(problem-based learning,PBL)、循证医学等理念融入教学培养,进一步探讨研究生临床实践能力及科研思维等多方面的培养的效果及可行性,进而推进我国心脏外科研究生培养模式的完善.

目的:建立实验性高脂血症动物模型,观察高脂血症能否直接诱导兔主动脉瓣膜发生退行性主动脉瓣疾病(DAVD)的病理改变,以及他汀干预对瓣膜病变的影响.方法:选择健康新西兰纯种雄性白兔39只,随机平均分配为正常对照组(N组),高脂饮食组(HC组),高脂饮食加阿托伐他汀干预组(AI组).分别于实验开始,4,8,12周后,取静脉血测定血浆脂质水平,分析比较各组间是否存在差异,同时取主动脉瓣膜标本行组织学检测.结果:HC组和AI组血浆中胆固醇(CHOL)、TG、LDL-C、C反应蛋白(CRP)的浓度第8,12周,较4周及N组均升高,同期AI组的各项血脂水平低于HC组,差异有统计学意义(P＜0.05);HDL-C、CK、ALT实验前后及三组间,差异无统计学意义(P＞0.05).HC组主动脉瓣膜的光镜HE染色及电镜病理表现与DAVD早期病理组织学改变相似,AI组病变程度较HC组减轻.结论:高脂饮食能够诱导兔主动脉瓣膜发生与早期DAVD相似的病理组织学改变.阿托伐他汀能够明显延缓DAVD病变发展.

心脏外科专业学位硕士研究生的培养是以临床为重点，基础、临床、科研、医德、人文等全方位的培养。首都医科大学附属北京安贞医院心外科从培养目标、人生观建立、基础知识、临床能力培养、科研能力、医德医风、医患沟通等多方面系统总结了近几年在研究生教育方面的一些经验。

目的 总结双侧腋下小切口直视下肺静脉隔离及左心耳切除治疗孤立性心房颤动的临床经验.方法 对28例孤立性心房颤动患者通过腋下小切口径路,直视下用Atricure双极射频消融系统行双侧肺静脉隔离及左心耳切除、Marshall韧带切断.结果 无围术期死亡、Ⅲ度房室传导阻滞、脑卒中及大出血等严重并发症,气管插管时间(4.2±2.6)h,平均住院时间(5.8±3.2)d.24例患者术毕转复窦性心律,1例电复律后转复,3例5d内转复.平均随访16.5个月,1例心房颤动复发,2例出现阵发性房性早搏.结论 双侧腋下小切口直视下射频消融治疗孤立性心房颤动效果良好,无需特殊器械辅助,易于推广.

Objective To summarize surgical experience and explore the best treatment strategy for the management of complicated mediastinitis after cardiac surgery. Methods Clinical data of 18 patients who received vascularized muscle fl ap transposition combined with negative pressure wound therapy(NPWT) for the treatment of complicated mediastinitis after cardiac surgery in one stage in the Department of Cardiac Surgery of Beijing Anzhen Hospital,Capital Medical University between June 2006 and December 2012 were retrospective analyzed. There were 12 male and 6 female patients with their average age of 65.5±8.2 years. The average interval between cardiac surgery and vascularized muscle flap reconstruction was 12.5±5.8 days. Results Postoperatively,1 patient died of recurrent mediastinitis,sepsis and multiple organ dysfunction syndrome. Seventeen patients had an uneventful postoperative recovery and one-stage wound healing. Postoperative hospital stay was 18.6±7.2 days and wound healing time was 4.5±2.4 weeks. All the 17 patients were followed up for over 6 months, no recurrent mediastinitis was observed, and they had a good quality of life. Conclusion Vascularized muscle fl ap transposition combined with NPWT is a simple and effective surgical strategy for the treatment of complicated mediastinitis after cardiac surgery in one-stage.

目的 总结线圈法人工腱索植入治疗二尖瓣脱垂导致的瓣膜关闭不全的临床经验.方法 北京安贞医院心外科2008年1月至2011年8月应用线圈法人工腱索植入治疗二尖瓣关闭不全的患者共22例,男15例、女7例,年龄26～69(53.1 ±8.5)岁.心功能分级(NYHA)Ⅱ级6例,Ⅲ级16例.前叶腱索断裂14例,前叶腱索延长2例,前后叶腱索均有断裂4例,后叶腱索断裂2例.均合并重度以上二尖瓣反流,1例合并三房心,1例合并冠心病.左心室舒张期末内径49～67(58.1±3.9) mm,射血分数(EF) 58％～69％ (61.8％±6.1％),心胸比率0.53±0.16.应用自制的腱索测量器,测量病变腱索邻近正常腱索的长度作为人工腱索的长度,根据瓣叶脱垂的范围,在测量器上制作人工腱索线圈数根,然后将其固定在相应乳头肌和脱垂瓣叶游离缘,常规进行瓣环成形.同期行三房心矫治术1例,冠状动脉旁路移植术1例.所有患者出院后华法林抗凝治疗3个月.结果 无手术死亡,术后出现血红蛋白尿1例,伤口感染1例,经治疗后均痊愈.出院前超声心动图提示无反流或微量反流1例,微量反流21例.术后左心室舒张期末内径43～53 (48.3±2.1)mm,较术前明显改善.术后门诊随访4～39(18.3±5.2)个月,少量反流5例,无或微量反流17例.心功能分级(NYHA)Ⅰ级17例,Ⅱ级5例,较术前明显改善.结论 线圈法人工腱索植入治疗二尖瓣脱垂所致的二尖瓣关闭不全,手术操作简单易行,近中期疗效满意.

Objective:To summarize the clinical outcomes and experiment of mitral valve replacement with different chordal-sparing technique and to improve the clinical therapeutic effects,reduce mortality and complication.Methods:Clinical data of 102 patients with mitral valve diseases who underwent total chordalsparing mitral valve replacement(all with mechanical valve prosthesis) from May 2005 to July 2013 were retrospectively analyzed.There were 48 male and 54 female with age from 22 to 67 years old(46 ± 10.1).Pre-operation diagnosis was mitral valve stenosis in 22 patients,mitral valve stenosis and insufficiency in 56 patients,regurgitation in 24 patients,combined with more than moderate tricuspid regurgitation in 38 patients,atrial fibrillation in 35 patients,left atrial thrombus in 3 patients.The preoperation left ventricular ejection fraction were 33% ~ 65%,mean(52 ± 8.2) %.7 patients were in New York Heart Association(NYHA) functional class Ⅱ,76 patients in class Ⅲ and 19 patients in class Ⅳ preoperation.At the same time,each 102 patients were chosen as control group which underwent mitral valve replacement with posterior chordal preservation and nonchordal preservation.There was no statistical difference in preoperative clinical characteristics between the three groups(P 0.05).Results:There was no perioperative death in total chordal-sparing group.In posterior chordal group,1 died for low cardiac output syndrome and 1 died for severe pulmonary infection.Five patients were died for left ventricular rupture(3 patients) and severe low cardiac output(2 patients) in nonchordal group after operation.Left ventricular ejection fraction(LVEF) 、end-diastolic dimension(LVEDD) and end-systolic dimension(LVESD) of total chordal-sparing group were improved than that of posterior chordal group and nonchordal group 6 months follow-up after surgery by echocardiography,and there was statistical difference in LVEF and LVESD between the three groups(P 0.05).Conclusion:Mitral valve replacement with total chordal preservation has a good result in short term,which is suited to various kinds of mitral valve diseases,especially to regurgitation valve diseases.Because of complicated manipulation,total chordal preservation is suited to experienced surgeon.Posterior chordal preservation is fit for predominant mitral valve stenosis with small annulus.

Objective To summarize our clinical experience and improve clinical outcomes of chordal transfer and artifi cial chordae in mitral valvuloplasty(MVP). Methods Clinical data of 74 patients who received chordal transfer or artifi cial chordae in MVP for the treatment of anterior mitral leafl et prolapse [degenerative mitral regurgitation(MR)] from January 2008 to February 2013 were retrospectively analyzed. There were 34 male and 40 female patients with their age of 22-64(48.00±6.40)years. According to different surgical techniques,all the 74 patients were divided into 2 groups. In the chordal transfer group,there were 42 patients who received chordal transfer with posterior leafl et chordae transferred to anterior leafl et. In the artifi cial chordae group,there were 32 patients who received artifi cial chordae with loop technique. Postoperative mortality,morbidity and MR were analyzed. Left ventricular ejection fraction(LVEF),left ventricular end-diastolic diameter(LVEDD) and end-systolic diameter(LVESD) were examined by echocardiography during follow-up.Results There was no perioperative death in either group. Two patients underwent reexploration for postoperative bleeding.Nine patients had paroxysmal atrial f ibrillation postoperatively,and were cured by intravenous administration of amiodarone.Echocardiography before discharge showed mild MR in 5 patients,trivial MR in 12 patients,and none MR in 25 patients in the chordal transfer group,and mild MR in 6 patients,trivial MR in 15 patients and none MR in 11 patients in the artifi cial chordae group. Seventy patients[ 94.59%(70/74)] were followed up after discharge. In both groups,LVEF at 6 months after MVP was signif icantly higher than that before discharge( chordal transfer group:64.00%±4.20% vs. 55.00%±5.10%;artif icial chordae group:63.00%±3.50% vs. 56.00%±4.20%). LVEDD( chordal transfer group:47.00±2.20 mm vs. 58.00±6.90 mm; artifi cial chordae group:45.00±3.80 mm vs. 57.00±5.10 mm,P 0.05) and LVESD at 6 months after MVP were signifi cantly smaller than preoperative values. There was no statistical difference in LVEF,LVEDD or LVESD preoperatively,before discharge and 6 months after MVP respectively between the chordal transfer group and artifi cial chordae group( P 0.05). One patient in the chordal transfer group underwent mitral valve replacement for severe MR 14 months after MVP. One patient in the artifi cial choadae group underwent mitral valve replacement for persistent hemoglobinuria 6 months after MVP. Conclusion Chordal transfer and artifi cial chordae technique are both suitable for the treatment of complex anterior leafl et prolapse. Artifi cial chordae has wider range of application,and chordae transfer needs advanced and fl exible surgical skills. Both techniques have good short-term clinical outcomes and deserve clinical application.

目的:总结小切口直视下肺静脉隔离,及左心耳切除治疗孤立性心房颤动的临床经验及近中期疗效.方法:2005年9月至2013年8月,31例孤立性心房颤动患者通过腋下小切口径路,直视下用Atricure双极射频消融系统,行双侧肺静脉隔离及左心耳切除、Marshall韧带切断.结果:无围术期死亡、Ⅲ°房室传导阻滞、脑卒中及大出血等严重并发症,气管插管时间(4.3±2.4)h,平均住院天数(5.9±2.8)d.26例患者术毕转复窦性心律,2例电复律后转复,3例5d内转复.平均随访19.4个月,2例心房颤动复发,3例出现阵发性房性期前收缩.结论:小切口直视下射频消融治疗孤立性心房颤动,无需特殊器械辅助,易于推广,近中期效果良好.