Atrial myxoma in children is rare, with vision loss and cerebral metastasis seldom reported. We present the case of a 12-year-old girl who experienced sudden vision loss and acute infarction, with a left atrial myxoma identified and surgically resected. One year later, she was readmitted with severe neurological symptoms. Imaging revealed multiple hypometabolic brain lesions, which were confirmed as metastatic myxoma through surgical resection and pathology. This case underscores the critical need for long-term follow-up in patients with cardiac myxoma to monitor potential delayed neurological complications.

目的 探究氯沙坦对内皮细胞增殖以及YAP活性的影响.方法 本实验于2020年5月至2021年8月在上海交通大学医学院附属新华医院实验室完成.氯沙坦与血管紧张素Ⅱ(AngⅡ)分别或共同刺激人脐静脉内皮细胞,观察内皮细胞增殖变化,分析细胞内YAP磷酸化与胞内分布情况,检测YAP下游基因的表达水平.结果 AngⅡ刺激内皮细胞明显增殖,氯沙坦的作用与之相反.同时,氯沙坦显著抑制由AngⅡ诱导的细胞增殖,呈现剂量依赖性以及时间依赖性作用.此外,AngⅡ可显著降低细胞内YAP磷酸化水平,促进YAP向细胞核内转移,还促进YAP下游促增殖基因的表达升高.相反,氯沙坦增加YAP磷酸化水平,抑制YAP的核内转移.共刺激实验发现,氯沙坦抑制了由Ang Ⅱ诱导的YAP去磷酸化与核易位,以及下游基因表达.结论 氯沙坦可以抑制内皮细胞中YAP活化,下调YAP下游靶基因表达,抑制内皮细胞增殖.

目的 总结我院近15年儿童主动脉瓣手术经验.方法 回顾性分析2007年至2022年上海交通大学医学院附属新华医院收治的16岁以内所有包含主动脉瓣手术的患儿55例,总结疾病特点,整理手术资料,并分析预后.结果 本组男性39例,女性16例.平均年龄(10.8±4.5)岁.主动脉瓣病因包括36例原发性病变,4例感染性心内膜炎,9例心脏术后相关,3例合并先心病,3例风湿性心脏病.本组病例置换主动脉机械瓣44例,其中7例患者行根部加宽;修复11例(交界切开6例,交界悬吊1例,瓣叶穿孔修补3例,瓣叶置换1例).全组主动脉阻断时间(79.4±43.2)min,体外循环时间(128.2±59.6)min.围术期死亡1例(1.8％),死亡原因循环衰竭.随访0.2～15.0年,修复患者中2例于4年、5年后接受了主动脉瓣置换.全组随访中2例死亡,Kaplan-Meier曲线分析提示5年生存率92.5％.存活患者心功能良好.结论 主动脉机械瓣置换可在儿童中安全开展,合适病例选择主动脉瓣成形疗效良好,能延缓再手术时机.

Background Intracardiac septal defect is repaired using median sternotomy in most centers; however, there are several reports using minimally invasive surgery in both children and adults. This study summarized our strategy of minimally invasive therapy using various lateral mini-thoracotomies in patients with congenital septal defect. Methods In this study, 472 patients who underwent minimally invasive repair of intracardiac septal defects (atrial septal defect, (ASD), ventricular septal defect, (VSD), and atrioventricular septal defect, (AVSD)) from January 2012 to June 2020 were retrospectively reviewed. Those who underwent device closure were excluded. The minimally invasive strategy included three groups: the right sub-axillary vertical incision (RSAVI) group (N = 335, including192 ASDs, 135 VSDs and 8 AVSDs); the right anterolateral thoracotomy (RALT) group (N = 132, including 77 ASDs, 51 VSDs and 4 AVSDs); and the left anterolateral thoracotomy (LALT) group (N = 5, all subpulmonary VSDs). Results Concomitant surgeries included nine cases of right ventricular outflow tract obstruction relief, nine cases of mitral repairs and 37 cases of tricuspid repairs. There was one transition from thoracotomy to sternotomy. Three patients required second pump run for residual lesions (two residual VSD shunts and one mitral regurgitation). The age and body weight of the RSAVI group were significantly lower than those of the RALT and LALT groups (all P < 0.01). No postoperative death was observed. Postoperative complications included one case of chest exploration for bleeding, one case of reoperation due to patch dehiscence during the same admission, one case of transient neural dysfunction, three cases of diaphragmatic paresis and 13 cases of atelectasis. The median stay in the intensive care unit was two days, while the median postoperative hospitalization duration was six days. The echocardiography results before discharge indicated no significant residual lesions. No reoperation, no new onset of chest deformities and no sclerosis were observed during the follow-up. Conclusions Intracardiac septal defects can be safely and effectively repaired by minimally invasive surgery with good cosmetic results. RSAVI is suitable in infants and children, while RALT is more commonly used in adolescents and adults. LALT is an alternative incision to repair subpulmonary VSD.

OBJECTIVES: Pectus excavatum (PE) can be secondary in patients who underwent sternotomy for cardiac surgery. Retrosternal adhesions increase the complexity and risk of traditional Nuss repair. Thus, we summarized the outcomes of our modified Nuss procedure using a newly designed bar. METHODS: A retrospective analysis was performed on 35 patients who underwent modified PE repair after open heart surgery from January 2011 to July 2019. The surgery was performed using a novel bar with no need for intraoperative reshaping and rotation, assisted by thoracoscopy and subxiphoid incision when necessary. RESULTS: There were 19 males and 16 females with a median age of 5.3 years (interquartile range, 4.1-10.9) at PE repair. All patients underwent the modified procedure uneventfully with no death. The median operating time was 70 min. Twenty-nine (82.9%) patients required subxiphoid incision assistance. There was 1 case (2.8%) with unexpected sternotomy due to intraoperative bleeding. The median length of postoperative hospital stay was 4 days. During the median 3.5 years of follow-up, no bar dislocation was found and 30 (85.7%) patients had their bars removed with no recurrence recorded. After PE repair, the Haller index improved significantly (2.6 +/- 0.4 vs 4.9 +/- 1.3, P < 0.05) and further decreased till the time of bar removal (2.5 +/- 0.4 vs 2.6 +/- 0.4, P < 0.05). All patients were satisfied with the cosmetic outcome. CONCLUSIONS: The novel bar can be placed and removed easily with a low rate of adverse events. This modified Nuss procedure seems to be a safe, effective and convenient approach for the management of PE after cardiac surgery.

心房颤动(房颤)是临床最常见的心律失常.自主神经系统在房颤的发生及维持中起着重要作用.心脏受内外在自主神经的调节.外在自主神经中的交感神经纤维主要来源于椎旁神经节,特别是星状神经节,星状神经节与胸腔内的多条神经和结构相连,是心脏交感神经支配的最重要来源.心脏内在的自主神经是一个由轴突和神经节丛组成的网络,包含各种交感和副交感神经元,它们与外在自主神经相互影响,共同维持心脏搏动速率及节律.目前通过调节自主神经活性的方法控制房颤的心室率及心脏节律已被广泛研究并逐步应用于临床治疗,常用自主神经调控方法包括皮下神经刺激、心脏神经节丛消融、去交感神经化、刺激迷走神经和星状神经节消融及部分切除等.本文就影响房颤相关神经机制及神经调控方法进展进行综述.

Background Diffuse pulmonary vein stenosis (PVS) is an intractable congenital heart disease for which the underlying mechanism remains unclear. In this study, we investigated the effect of losartan and the role of the Hippo pathway in PVS. Methods A total of 19 neonatal piglets were divided into 3 groups: a sham group (n=7), a banded group (n=6) with the left upper pulmonary vein and common trunk of both lower pulmonary veins banded, and a losartan group (n=6) with losartan treatment (1 mg/kg/d) after the banding operation. After 8 weeks, the piglets underwent hemodynamic measurement and harvesting. The upstream pulmonary veins were collected for histological staining and molecular biological analysis. Losartan and/or angiotensin II (stepwise concentrations from 0.1 to 100 µmol/L) were added to a human umbilical vein endothelial cell culture to investigate the potential mechanism in vitro. Results The modified model demonstrated the main characteristics of patients with PVS, including pulmonary hypertension and intimal hyperplasia in the upstream veins. Upregulation of yes-associated protein (YAP) and angiotensin II type 1 receptor was observed in the neointima (P<0.01). Losartan treatment improved the pathological changes in piglets and decreased YAP expression in the neointima (P<0.01). In vitro, losartan suppressed angiotensin II-induced cell proliferation by inhibiting dephosphorylation and nuclear translocation of YAP in human umbilical vein endothelial cells (P<0.05). Conclusions Losartan treatment ameliorates intimal hyperplasia and inhibits YAP activation. The activation of the Hippo-YAP pathway is involved in the vasculopathy of progressive PVS. These findings may contribute to the development of new approaches for treating PVS.

目的 总结使用主动脉根部全间断褥式缝合联合内引流技术治疗A型主动脉夹层的早中期结果.方法 回顾2018年6月至2020年12月我科行A型主动脉夹层手术患者46例.根据主动脉根部处理方式分为三组:根部间断缝合组18例,根部置换组(Bentall和Cabrol术组)17例,根部连续缝合组11例.对比三组间术前资料、围术期及随访结果.结果 全组男性32例(69.6％),年龄(57.2±11.9)岁,发病24 h内急诊手术29例(63％).三组之间性别、年龄无明显差异,手术时机、术前心功能无差异,主动脉根部替换组术前窦部直径显著高于其他两组[置换组(44.2±8.3)mm,间断组(35.9±3.2)mm,连续组(35.9±4.0)mm,P<0.01)],主动脉瓣反流程度也更严重.35例患者全弓置换,8例行半弓置换,3例未行弓部手术.主动脉阻断时间(121.5±23.7)min,体外循环时间(262.2±78.8)min,根部置换组时间较长.存活39例(84.8％),三组之间死亡率、术后ICU停留天数、输血量、术后住院时间无显著差异.随访3月～3年,无轻度以上主动脉瓣反流,心功能良好;随访CTA结果良好.结论 主动脉根部间断缝合联合内引流的方法操作简单、可复制性强,近期手术效果与其他方法相当,可作为现有手术方法的一种补充.

Abstract Background: Intracardiac septal defect tends to be repaired by minimally invasive surgery in both children and adults. This study summarized our strategy of minimally invasive therapy using various lateral mini-thoracotomies in patients with congenital septal defect. Methods: Four hundred and seventy-two patients who underwent minimally invasive repair of intracardiac septal defects (Atrial septal defect, ASD; ventricular septal defect, VSD; atrioventricular septal defect, AVSD) between January 2012 and June 2020 were retrospectively reviewed. Those who underwent device closure were excluded. The minimally invasive strategy included three groups. First, right sub-axillary vertical incision group (RSAVI group, N=335, 192 ASDs, 135 VSDs and 8 AVSDs; Second, right anterolateral thoracotomy group (RALT group, N=132, 77 ASDs, 51 VSDs and 4 AVSDs; Third, left anterolateral thoracotomy group (LALT group, N=5, all of them were sub-pulmonary VSDs). Results: Concomitant surgeries included 9 cases of right ventricular outflow tract obstruction relief, 9 mitral repairs and 37 tricuspid repairs. There was one transition from thoracotomy to sternotomy. Three patients required second pump run for residual lesions (2 residual shunts and 1 mitral regurgitation). The age and body weight of RSAVI group were significantly lower than those of RALT and LALT groups. The mean cardiopulmonary bypass time was 67.3±11.3 min and cross clamp time was 38.1±8.9 min. There was no post-operative death, and complications included 1 chest exploration for bleeding, 1 redo operation due to patch dehiscence during the same admission, 1 transient neural dysfunction, 3 diaphragmatic paresis and 13 atelectasis. The median stay in ICU was 2 days, while the median post-operative hospitalization was 6 days. The echocardiography results before discharge indicated no significant residual lesions. There was no reoperation, no new onset of chest deformities and no sclerosis during the follow up. Conclusions: The commonly seen intracardiac septal defects can be safely and effectively repaired by minimally invasive surgery with good cosmetic results. Right sub-axillary vertical incision is suitable in infants and young children, while right anterior mini-thoracotomy is more commonly used in adolescents and adults. Left anterior mini-thoracotomy is an alternative incision to repair sub-pulmonary artery VSD.

目的 研究应用吸入一氧化氮(iNO)治疗急性A型主动脉夹层(acute typeA aortic dissection,ATAAD)手术后严重低氧血症的疗效.方法 回顾性分析2015年1月至2020年12月我院手术的ATAAD患者资料,排除术后72h内病死、术后卒中和截瘫患者,共48例严重低氧血症(氧合指数＜100 mm Hg)患者入组.2018年9月之前采用常规疗法,共28例,归入CON组;2018年10月之后应用吸入一氧化氮治疗共20例,归入iNO组,该组除了常规方法外给予吸入体积分数为5×10-6的一氧化氮.结果 两组术前资料、术中手术方式、时间和输血量等均无统计学差异.术后CON组低氧血症改善缓慢,iNO组氧合指数上升明显加快.术后早期病死率iNO组(10％)与CON组(10.7％)相比差异无统计意义.iNO组机械通气时间(87.3±13.1)h低于CON组(128.5±16.6)h,ICU停留时间iNO组(12.1±1.57)d低于CON组(14.4±1.93)d,术后住院时间iNO组(19.8±1.64)d短于CON组(21.4±1.93)d.结论 iNO治疗ATAAD术后严重低氧血症安全有效,可显著促进患者氧合功能改善和缩短气管插管呼吸机使用时间.

Objective:Unilateral thoracotomy with selective partial pulmonary vein banding was used to establish a modified piglet model of pulmonary vein stenosis (PVS). We explored the alterations of hemodynamics, the pathomorphological change of upstream pulmonary vein, and the effect of losartan treatment in this model.Methods:A total of Nineteen Yorkshire piglets were selected and allocated into three groups, seven in sham operation group, six in pulmonary vein banded group, and six in losartan treatment group. The chest was entered through left thoracotomy. The left upper pulmonary vein and the common trunk of bilateral lower pulmonary veins were banded with Goretex vascular stripes. The treatment group had oral losartan [1 mg/(kg·d)] since the second day after the surgery. At 8th week after the operation, hemodynamic data were obtained and the pulmonary veins of the piglets were harvested for hematoxylin-eosin (HE) staining, Masson staining and immunofluorescence staining to observe the pathological alterations of upstream pulmonary veins.Results:In contrast to the sham group, pulmonary venous flow and mean pulmonary artery pressure (PAP) and PAP/aortic blood pressure (ABP) ratio significantly increased [(209.33±17.44) cm/s vs. (54.13±13.22) cm/s, (29.0±4.7) mmHg vs. (14.0±1.3) mmHg, 0.43±0.09 vs. 0.21±0.04, t=10.030, 8.143, 5.859, P<0.05] in banded group, and they also significantly increased [(163.00±14.70) cm/s vs. (54.13±13.22) cm/s, (20.1±6.2) mmHg vs. (14.0±1.3) mmHg, 0.30±0.07 vs. 0.21±0.04, t=7.789, 2.556, 2.905, P<0.05] in losartan group. As compared with banded group, these indices were significantly decreased [(163.00±14.70) cm/s vs. (209.33±17.44) cm/s, (20.1±6.2) mmHg vs. (29±4.7) mmHg, 0.30±0.07 vs. 0.48±0.09, t=2.873, 2.802, 2.739, P<0.05] in losartan group. The banding procedure led to intimal hyperplasia, decreased expression of CD31 and increased expression of α-SMA. The changes of intimal hyperplasia and the expression of markers were suppressed by losartan treatment, but they were still higher than in the sham group. Conclusion:This modified piglet model of PVS can be used to investigate the molecular mechanisms related to PVS. Losartan can improve the pathological changes of PVS, yet the underlying mechanism requires further study.

目的 比较主动脉夹层手术中应用del Nido心脏停搏液和传统心脏停搏液的心肌保护效果.方法 回顾性总结分析2017年7月至2019年12月上海交通大学医学院附属新华医院63例主动脉夹层手术的临床资料,根据应用的心脏停搏液不同分两组,应用del Nido心脏停搏液(DN组)33例,应用传统心脏停搏液(传统组)30例.DN组用del Nido晶体液与氧合血按4:1混合(4份晶体1份血),灌注量20 ml/kg,最大不超过1L.主动脉阻断时间超过90 min再次灌注300ml.传统组应用4:1含血冷晶体改良St.Thomas液(4份血1份晶体),灌注量15 ml/kg.每隔20～30 min灌注一次(7.5ml/kg).结果 两组术前一般资料差异无统计学意义.术中体外循环时间、主动脉阻断时间传统组较长,但差异无统计学意义.停搏液灌注次数和灌注耗时传统组显著高于DN组.自动复搏率两组相近,DN组94％,传统组97％.术后早期(30天内)病死率DN组(6.1％)与传统组(6.7％)无差异.术后第1天血清肌钙蛋白Ⅰ DN组(4.10±0.65)ng/ml与传统组(4.25±0.61)ng/ml无差异.术后低心排发生率、术后1天和出院前LVEF两组之间差异均无统计学意义.结论 主动脉夹层术中应用del Nido心脏停搏液可以达到满意的心肌保护效果.

目的 总结自制带单瓣管道重建右心室-肺动脉连接治疗复杂先天性心脏病的经验,探讨术中操作要点,评估该疗法的近中期结果.方法 回顾性分析我科2006年1月至2018年6月利用自制带单瓣管道外科治疗的65例复杂先天性心脏病患者的临床资料.其中男42例、女23例,年龄5～23(9.9±4.2)岁,体重15～65(26.2±9.9)kg.根据所使用带单瓣管道将患者分为两组:带单瓣人工血管组19例,带单瓣牛心包管组46例.其中室间隔缺损(VSD)合并肺动脉闭锁(PA)48例,矫正性大动脉转位合并肺动脉狭窄10例,法洛四联症合并单支冠状动脉畸形5例,右室双出口合并肺动脉狭窄及单支冠状动脉畸形2例.结果 术后早期死亡2例,均为VSD/PA行人工血管外管道根治患者.术中测右室流出道压差:人工血管组13～ 37(25.2 ±4.9)mm Hg,牛心包管组5～23(10.5 ±3.3)mm Hg.出院时心脏彩超显示外管道内无明显反流.术后失访1例,随访时间8个月至13年.随访期间,三尖瓣中度反流5例,管道内中度反流32例,右室流出道重度梗阻7例,中度梗阻11例,轻度梗阻25例.无中晚期死亡.心功能分级(NYHA)Ⅰ～Ⅱ级,活动耐量良好.结论 自制带单瓣外管道重建右心室-肺动脉连接临床效果良好,牛心包管道术中流出道压差小于人工血管,我们更推荐牛心包管用于低龄、低体重患者.

Photodynamic therapy (PDT) has the advantages of low toxicity and specificity, but photosensitizers usually fail to accumulate efficiently at the tumor site. In this study, a new multifunctional nano-drug delivery system was exploited by a biomimetic strategy to improve the PDT effects. The self-assembled methoxy poly(ethylene glycol)-poly(lactide-co-glycolide) (mPEG-PLGA) nanoparticles encapsulated with the photosensitizer chlorin e6 (Ce6) by microfluidics were employed as the nano-core, followed by coating red blood cell (RBC) membranes as the biomimetic agent to prolong the circulation time in vivo. In order to boost the therapeutic effect, doxorubicin (Dox) was preloaded into RBC nanovesicles. The cell membrane surface was modified with folic acid (FA) to further enhance the tumor targeting efficiency. The prepared biomimetic nanoparticles with a homogeneous size (70 nm) can trigger sufficient reactive oxygen species (ROS), leading to significant tumor ablation without side effects. In addition, the system had high tumor targeting efficiency, with an increase of 25% compared with no FA-modified nanoparticles. Therefore, this biomimetic multifunctional nanodrug delivery system possesses a prolonged circulation time and higher tumor targeting efficiency and can exert better tumor cytotoxicity for improved PDT due to homophilic targeting in vivo.

Primary cardiac tumors are rare and the majorities are benign. Conventional surgical treatment uses median sternotomy, while minimally invasive surgery from right anterolateral minithoracotomy has become an alternative method in recent years. In this study, we summarized the surgical outcomes of both approaches. From January 2008 to August 2018, 50 patients with primary benign cardiac tumors underwent either conventional or minimally invasive surgery in our department. The baseline data were collected. The peri-operative data and follow up results were compared between the two groups. There were19 men and 31 women enrolled in this study with a mean age of 55.0 ± 17.5 years. The most common site of the tumor was left atrium (n = 40, 80%), followed by right atrium (n = 8, 16.0%), right ventricle (n = 1, 2.0%) and left ventricle (n = 1, 2.0%). All patients underwent surgery uneventfully, including 33 cases (66.0%) of median sternotomy and 17 cases (34.0%) of right anterolateral minithoracotomy. No significant differences were found between the two groups in terms of cardiopulmonary bypass time, aortic cross-clamp time, postoperative intubation time, intensive care unit days and length of the hospital stay. Patients with right anterolateral minithoracotomy had less post-operative chest drainage (536 ± 159 vs 773 ± 255 ml, P < 0.01) and transfusion rate (5.9% vs 33.3%, P = 0.033) than those who had sternotomy. There was no peri-operative death, and all the patients were alive and free of recurrence at the latest follow-up. Surgical resection of primary benign cardiac tumors is safe, effective and durable. The right anterolateral minithoracotomy provides the same postoperative recovery as standard median sternotomy, but less transfusion. It can be considered as a promising alternative approach.

目的 研究中度低温停循环联合单侧顺行脑灌注应用于主动脉弓部替换手术的疗效.方法 回顾性分析2008年1月至2018年6月上海交通大学医学院附属新华医院收治的229例行主动脉弓部替换手术患者的临床资料,平均年龄(61.4±6.9)岁,男性166例(72.5％).其中全弓替换152例(66.4％),同时行主动脉根部替换144例(62.9％).应用的循环管理和脏器保护方法是中度低温停循环(moderate hypothermic circulatory arrest,MHCA)联合单侧顺行性脑灌注(unilateral antegrade cerebral perfusion,UACP).右侧腋动脉插灌注管,温度降至(23.5±1.4)℃停循环,开始单侧顺行脑灌注,灌注液温度18℃～22℃、流量5～10ml·kg-1·min1,脑灌注压力50～60 mm Hg.结果 体外循环时间(229±41)min,主动脉阻断时间(152±29)min,停循环时间(45.1±13.3)min.手术死亡17例(7.4％).主要术后并发症包括永久性神经功能障碍(permanent neurologic dysfunction,PND)、一过性神经功能障碍(temporary neurologic dysfunction,TND)、需要透析的急性肾损伤(acute kidney injury,AKI)和延迟拔管(机械通气时间＞72 h),发生率分别为2.6％、6.9％、3.9％、17.9％.结论 主动脉弓部替换手术应用MHCA+UACP方法病死率和并发症发生率低,疗效满意.

目的 心房颤动(房颤)有致残、致死风险,微创外科房颤消融手术近年来获得良好疗效,但仅在大型医疗中心开展,本研究旨在总结基层医院开展该手术的经验,验证其可推广性.方法 回顾性分析2018年1月至2019年1月泰州市第四人民医院15例经左侧胸腔镜辅助微创外科房颤射频消融手术(梅氏微创消融术)患者,总结围手术期和随访资料.结果 本组患者男性9例(60％),年龄(64.3±7.1)岁,其中12例持续性房颤、3例阵发性房颤.5例患者术前有卒中病史,术前CHA2S2-Vasc评分(2.5±1.8)分.术前超声心动图检查测量左心房内径(38.1±7.2)mm,显著低于CT平扫测量的左心房最大前后径(46.5±7.3)mm(P=0.004).所有患者顺利完成手术,无中转开胸,手术时间(128.7±30.8)min.术后呼吸机辅助时间(2.3±1.3)h,术后ICU停留时间(1.1±0.4)d,术后住院天数(11.7±3.5)d,全组无死亡.随访3个月至1年,无再入院,无新发脑梗,大部分患者恢复窦性心律,3例患者仍存在房颤.结论 梅氏微创外科房颤消融手术安全可行,并发症发生率低;该术式效果良好,完整切除左心耳,降低了患者卒中风险,可在基层医院推广开展.

目的 评价del Nido心脏停搏液在成人心脏外科手术中的安全性及有效性,为成人心脏手术选择合适心肌保护液提供参考.方法 回顾性分析2018年1月至2019年1月我科95例应用del Nido心脏停搏液的临床资料.结果 本研究中男性47例(49.5％),年龄(55.0±17.6)岁,病因以心脏瓣膜病(64例,67.4％)为主,术前合并心房颤动26例(27.4％).体外循环时间(138.6±65.4)min,主动脉阻断时间(75.8±32.0) min,灌注次数(1.14±0.43)次,顺行灌注94例(98.9％),自动复跳86例(90.5％).转流最低肛温(33.3±2.7)℃,转流结束时乳酸值1.7(1.4～2.3) mmol/L.术后第2天cTnⅠ浓度3.3(1.8～5.7)ng/ml.呼吸机辅助时间24(18～67)h,ICU停留时间4(3～7)d,术后住院13(9～16)d.术后无卒中和新发心肌梗死,新发心房颤动26例(37.7％),胸腔积液14例(14.7％),二次开胸2例(2.1％),急性肾衰竭2例(2.1％),感染3例(3.2％).出院前最后一次LVEF较术前稍降低[(59.6±9.0)％比(62.4±8.7)％,P＜0.01],围手术期死亡2例,与心脏停搏液无关.结论 del Nido心脏停搏液灌注次数少,未发现其对心肌的额外损伤,适合多种疾病的心肌保护.近期安全性、有效性良好,提高了手术操作的简便性.

目的 研究中低温停循环(MHCA)联合单侧顺行性脑灌注(UACP)应用于急诊主动脉弓部置换手术的疗效.方法 回顾性分析2008年1月至2018年6月我院146例急诊应用MHCA+UACP方法行主动脉弓部置换手术患者的临床资料,其中男111例、女35例,平均年龄(60.3±7.2)岁.按手术方式不同将患者分为全弓置换组(n=104)和半弓置换组(n=42).右侧腋动脉插灌注管,停循环温度(23.4±1.4)℃,单侧顺行性脑灌注,灌注液温度18℃ ～ 22℃,流量5～10 mL/(kg·min),脑灌注压力50 ～ 60 mm Hg.结果 全组体外循环时间(235.0±42.0) min,主动脉阻断时间(154.0±29.0)min,停循环时间(48.1±13.0)min.全弓置换组体外循环时间、停循环时间长于半弓置换组.手术死亡率9.6％.术后并发症包括永久性神经功能障碍(PND)、一过性神经功能障碍(TND)、需要透析的急性肾损伤(AKI)和延迟拔管(机械通气时间＞72 h).PND、TND发生率分别是2.7％和6.8％,需要透析的AKI发生率为4.1％,延迟拔管发生率21.9％.两组死亡率和并发症发生率差异无统计学意义.平均随访(63.0±33.1)个月,术后5年生存率全弓置换组72.6％、半弓置换组85.5％,两组差异无统计学意义.结论 应用MHCA+UACP方法行急诊主动脉弓部置换手术疗效满意.

The variable anatomy of Ebstein’s anomaly leads to its various surgical procedures. The long-term outcomes of different operations were not well established. Thirty-five patients with Ebstein’s anomaly who underwent operations from 2006 to 2018 in our department were retrospectively reviewed. Individualized surgical plans were performed according to the preoperative echocardiography and surgeons’ preference. Tricuspid repair, either Danielson’s or Carpentier’s technique, was the primary choice in patients who had sufficient tricuspid leaflets and adequate right ventricle, while tricuspid replacement was used when a reliable repair is not achievable. Additional bidirectional cavopulmonary shunt was performed in those who had unstable hemodynamics despite of high central venous pressure after separation from cardiopulmonary bypass. The perioperative and follow-up data were collected. The age was 26.9 (0.6–54) years [16 children (age < 14, and 19 adults (age ≥ 14)]. Preoperative tricuspid regurgitation was severe in 30, moderate in 4, and mild in the remaining 1 patient. Preoperative cardiac-associated malformations include 20 atrial septal defects, 2 ventricular septal defects, 2 pulmonary stenosis, and 1 sub aortic ridge, and these were operated simultaneously. Among all the surgical patients, 2 needed additional reoperation during the same admission, and ultimately, 29 patients had biventricular repair, including 21 tricuspid repair and 8 replacements. The other 6 patients had cavopulmonary connection and achieved 1.5 ventricular repair (3 tricuspid repair and 3 replacements). In all the 24 tricuspid repair patients, Danielson’s procedure was used in 17, while Carpentier’s technique was used in the other 7 patients. The average cardiopulmonary bypass time was 90 ± 28 min and cross-clamp time was 48 ± 24min. There were 2 perioperative deaths (5.7%) and no third-degree atrioventricular block. The postoperative in hospital stay was 13.7 ± 9.6 days. In the 33 survivors who were followed up at a median of 29.2 months, 6 patients had severe tricuspid regurgitation, and 2 of them underwent tricuspid replacement. The 5-year freedom from severe tricuspid dysfunction or reoperation was 78.5%, and no difference was found between children and adults, neither between different surgical choices. The surgeries of Ebstein’s anomaly were variable, and individualized operation achieved reasonable short- and mid-term results. However, severe tricuspid regurgitation during the follow-up was not neglectable, and reoperation in such cases also achieved good outcomes. New repair strategy such as cone repair may be considered.