目的:分析生物瓣主动脉根部置换术(Bio-Bentall手术)后远期行经导管主动脉瓣"瓣中瓣"置换术(ViV-TAVR)的冠状动脉阻塞风险,并讨论冠状动脉阻塞风险与主动脉根部解剖结构、冠状动脉开口与人工血管的吻合方式、人工血管直径等因素之间的关系,为改良Bio-Bentall手术方法提供依据.方法:回顾性分析 2017 年 1 月至 2021 年 6 月期间中国医学科学院阜外医院血管外科中心由 3 位术者完成Bio-Bentall手术的患者的临床资料,筛选出其中能获取清晰、可用CT资料的患者 39 例.通过 3mensio软件分析患者Bio-Bentall术前及术后的CT资料,评估术后远期行ViV-TAVR的冠状动脉阻塞风险及相关影响因素.结果:术后平均随访(4.7±8.8)个月,门控增强心脏CT提示,39 例患者术后右冠状动脉开口高度较术前明显降低[18.9(14.8,24.4)mm vs.22.0(18.4,27.4)mm,P=0.028],其中 22 例(56.4％)为冠状动脉阻塞高风险患者.术后生物瓣与人工血管的同轴性夹角对术后远期右冠状动脉阻塞风险有显著影响(HR=0.55,95％CI:0.37～0.83,P=0.013),冠状动脉开口与人工血管的吻合方式对术后远期冠状动脉阻塞风险无明显影响(HR=1.10,95％CI:0.83～1.40,P=0.648).结论:在现有手术策略下,Bio-Bentall手术患者术后远期行ViV-TAVR的冠状动脉阻塞风险极高.目前的Bio-Bentall手术方法亟需改进,以降低术后远期因生物瓣衰败行ViV-TAVR的冠状动脉阻塞风险,最大限度地提高未来行ViV-TAVR的可行性.

Objective To observe the curative effect of phase Ⅰ cardiac exercise rehabilitation for patients after heart valve operation. Methods From November 2019 to November 2020,a total of 120 patients who were admitted to cardiac surgery in a third-class A hospital in Xiamen, Fujian Province and underwent cardiac valve surgery under general anesthesia and cardiopulmonary bypass were randomly divided into control group and intervention group with 60 cases in each group. The control group was given routine rehabilitation intervention, and the intervention group was given phase I cardiac exercise rehabilitation program on the basis of routine rehabilitation intervention. The distance of 6 min walking test, the degree of conscious exertion,cardiac function and complications, the incidence of re-admission to ICU and the incidence of re-admission were compared between the two groups. Results There was no significant difference in the distance of 6 minutes walk test（6MWT） and Borg score between the control group and the intervention group one day before operation（P ＞ 0.05）, and the clinical comparison had no statistical value. On the day of discharge, the distance of 6MWT in the intervention group was significantly longer than that in the control group, and Borg score was significantly lower than that in the control group（P ＜ 0.05）. The clinical comparison has statistical value. The first two groups were treated with left ventricular end diabetic diameter（LVEDD）, left ventricular end systemic diameter（LVESD）, left ventricular injection fraction（LVEF） and brain natural peptide（BNP） were not statistically significant（P ＞ 0.05）.After the intervention, LVEDD, LVEF and BNP in the intervention group were significantly better than those in the control group, with significant differences（P ＜ 0.05） The incidence of complications,second admission to ICU and second admission in the intervention group were significantly lower than those in the control group（P ＜0.05）. Conclusion Phase I cardiac exercise rehabilitation method for patients after heart valve surgery can improve their exercise endurance, promote their cardiac function rehabilitation, reduce the degree of conscious exertion and complications, the incidence of secondary admission to ICU and secondary admission, and promote the patients to return to life and society earlier.

目的 探讨心血管外科术后ICU院内感染的发生情况及其危险因素.方法 回顾性分析2020年1月1日至12月31日中国医学科学院阜外医院心血管外科ICU收治的720例全麻气管插管下心脏大血管手术后成年患者的临床资料,根据入住ICU期间是否发生院内感染(包括肺部感染、导管相关性感染、泌尿系感染、纵隔感染及切口感染)分为院内感染组(41例)和无院内感染组(679例),采用多因素logistic回归分析探讨心血管外科术后ICU院内感染的独立危险因素,并分析主要致病菌的分布情况.结果 720例全麻气管插管下心脏大血管手术后患者中41例发生院内感染,占5.7％,其中肺部感染39例(5.4％),中心静脉导管相关性感染2例.多因素logistic回归分析显示,NYHA心功能分级(OR=1.592,95％CI 1.074～3.042,P=0.026)、慢性阻塞性肺疾病(OR=2.555,95％CI 1.743～95.099,P=0.012)、吸烟史(OR=2.310,95％CI 1.898～53.443,P=0.007)及呼吸机使用时间(OR=1.016,95％CI 1.009～1.024,P<0.001)是心血管外科术后ICU院内感染的独立危险因素.最常见的致病菌为肺炎克雷伯菌(23.6％),其后依次为嗜麦芽寡养单胞菌(10.1％)、光滑假丝酵母菌(8.8％)、白假丝酵母菌(8.1％)、金黄色葡萄球菌(6.1％).结论 心血管外科术后发生的ICU院内感染以呼吸系统感染为主,致病菌以革兰氏阴性杆菌为主;其独立危险因素包括心功能NYHA分级、慢性阻塞性肺疾病、吸烟史及呼吸机使用时间.

许多临床研究表明肾囊肿与主动脉瘤的发生有密切的相关性,其中基质金属蛋白酶家族及PKD基因在两种疾病中显示出相关性,现就肾囊肿与主动脉瘤相关病理及病因学研究进展做一综述.

Objective:To evaluate the safety and effectiveness of adventitial inversion technique for root repair in patients with acute type A aortic dissection(ATAAD).Methods:Between 2015 and 2018, ATAAD patients with dissected root and underwent open surgery were included. The exclusion criteria were as follows: previous root intervention, traumatic dissection and patient underwent root replacement(Bentall or David procedure). 490 ATAAD patients were included, 366(74.69%) male and 124(25.31%) female, aged(51.28±10.99) years(range 24-77 years). The clinical data were retrospectively analyzed with ANOVA/ nonparametric test and Chi- square test. Follow-up mortality and reoperation were displayed with Kaplan- Meier curve. Results:All patients were technically divided into three groups: adventitial inversion(A), direct suture(B) and Cabrol-shunt(C). The mean age in group A was(53.05±11.09) years, whereas worse cardiac and renal function occurred in group C. The mean duration of HCA, CPB and ACC were shortest, with a highest average of minimum rectal temperature during surgical interval in group A. Postoperative complications and early mortality were similar among groups. There were no significant differences of mid-term mortality and reoperation among these three techniques. Though no late reintervention for aortic root was found in both group A and B, the root diameter was more stable in group A during follow-up period[(33.14±3.74)mm vs.(34.51±3.83)mm vs.(33.89±3.89)mm, P=0.008]. Conclusion:Adventitial inversion technique is safe and effective for root repair in patients with ATAAD, achieving satisfactory short- and mid-term effects.

Objective:To evaluate the short-term outcomes of cuff wrapping technique using remnant aortic wall in modified Bentall procedure.Methods:Between January 2018 and December 2018, 23 patients underwent modified Bentall procedure with the remnant aortic wall as a cuff to cover the sewing area of composite valved graft and the aortic annulus for proximal hemostasis. After the sewing ring of the composite valved graft was sutured to the aortic annulus by continuous suture, the remnant aortic wall was sutured to the graft just distal to the sewing ring by continuous suture. There were 21 males and 2 females, aged from 22 to 72 with a mean of(50.96±13.23)years. Short-term outcomes were assessed by cardiopulmonary bypass time, clamp aorta time, mechanical ventilation time, ICU time, postoperative stay time, effusion drainage till the first postoperative day, Left ventricular end diastolic diameter(LVEDD), left ventricular ejection fraction(LVEF), and follow-up results.Results:There were no postoperative and follow-up death. Cardiopulmonary bypass time was(157.74±39.85)min, ranged from 114 to 275 min; clamp aorta time(122.61±30.25)min, ranged from 84 to 212 min; mechanical ventilation time(11.65±3.08)h, ranged from 7.87 to 20.33 h; ICU time(81.43±45.88) h, ranged from 15.18 to 184.77 h; postoperative stay time(8.73±2.80)days, ranged from 6 to 15 days. Effusion drainage was(336.82±117.65)ml, ranged from 200 to 670 ml till the first postoperative day. Follow-up was performed from 19 to 30 months, with a mean of(23.17±3.17)months. There were significant differences between preoperative LVEDD and postoperative LVEDD before discharge[(49.78±6.21)mm vs.(58.78±10.54)mm, P<0.05]; There were a little decrease of follow-up LVEDD compared with postoperative LVEDD, but no significant difference between them[(48.87±4.63)mm vs.(49.78±6.21)mm, P>0.05] . There were a little decrease of postoperative LVEF compared with preoperative LVEF, but no significant difference between them(0.57±0.07 vs. 0.59±0.05, P>0.05). There were significant differences between follow-up LVEF and preoperative LVEF(0.62±0.04 vs. 0.57±0.07, P<0.05), postoperative LVEF before discharge( P<0.05). Conclusion:Cuff wrapping technique using remnant aortic wall in modified Bentall procedure has got good short-term results. This modification may be a simple, effective way in controlling proximal bleeding.

Objective:To compare the early and mid-term results of thoracic endovascular aortic repair (TEVAR) with covered stent and simple medication in treating uncomplicated acute type B aortic dissection (ATBAD).Methods:The clinical data of 203 patients (118 males and 85 females) with uncomplicated ATBAD admitted to the First Affiliated Hospital of Xiamen University from January 2012 to December 2018 were collected and analyzed. The patients were divided into two groups based on the ways of treatment: simple medication group (Med group, 67 cases) and TEVAR group (136 cases). The operative and follow-up data of the patients in two groups were analyzed to evaluate the incidence rate of postoperative complications and the reintervention rate.Results:The follow-up time was (3.7±1.8) years (range: 3-84 months). During the follow-up period, the overall incidence rate of complications was 15.3% (31/203), the reintervention rate was 10.3% (21/203), and the mortality rate was 6.4%(13/203). The incidence rate of aortic-related complications (26.9% vs. 9.6%; P<0.05), the reintervention rate(19.4% vs. 6.6%; P<0.05), and the mortality rate (13.4% vs. 2.9%; P<0.05) in the TEVAR group were significantly lower than those in the Med group, and the differences were statistically significant. Compared with the Med group, the TEVAR group did not show a higher incidence of aortic dissection rupture (7.5% vs. 1.5%; P<0.05) and retrograde type A aortic dissection (4.5% vs. 1.5%; P>0.05). Conclusion:For the treatment of uncomplicated ATBAD, TEVAR is effective and safe. Compared with simple medication, TEVAR can achieve better early and mid-term results in treating uncomplicated ATBAD.

Objective:To compare the mid-term result of two different valve-sparing root replacement techniques in acute type A aortic dissection: including reimplantation and remodeling.Methods:From March 2009 to December 2019, 41 patients with acute type A dissection and root involvement, who underwent a valve-sparing root replacement using reimplantation(36 cases) or remodeling(5 cases) were retrospectively analyzed in current study. The average age was(44.63±11.34) years old, 36 males. The differences of perioperative variables, postoperative aortic insufficiency and postoperative survival were compared between the two groups.Results:Thirty-day mortality for two groups was 2.8% and 20%( P=0.23). Remodeling group was significantly inferior to reimplantation group in terms of blood consumption(red blood cells, plasma and platelets), postoperative mechanical ventilation time, reoperation for bleeding and hemofiltration for acute renal failure. The median follow-up time of 39 discharged survivors was 34.56(3-121) months, and the follow-up rate was 100%. There was no follow-up death, no bleeding or embolism events, and no cardiovascular reoperation. Grade 2 or sever aortic regurgitation in remodeling group was significantly higher than that in reimplantation group( P=0.02). A Cox regression analysis identified that the remodeling technique was the independent risk factors of postoperative aortic regurgitation. Conclusion:Compared with remodeling technique, reimplantation technique has better perioperative and mid-term results in patients with acute type A aortic dissection. The rate of reoperation for bleeding, the blood consumption and the postoperative aortic regurgitation are significantly reduced. The long-term results need further follow-up.

目的 探索主动脉窦成形在修复急性StanfordA型主动脉夹层受累根部中的可行性、有效性和效果的持久性.方法 从2014年1月至2017年7月,共43例急性StanfordA型主动脉夹层患者在我院接受了主动脉窦成形术修复受累的主动脉根部,其中男34例、女9例,年龄32～65(50.1±8.1)岁.回顾性分析患者的围术期和随访资料,对术前、术后和随访时的超声指标进行统计分析.结果 全部患者30 d死亡率为4.7％(2例),5例患者行连续性肾脏替代治疗,1例患者因出血行再次开胸手术.无患者因脆弱的主动脉根部组织出血而接受再次手术.所有患者术前的主动脉瓣反流在术后即刻得以纠正,假腔同时被完全消除.随访时间为18～45 (27.9±6.7)个月,随访期间无远期死亡,2例失访.接受随访的39例患者中,无主动脉根部及主动脉瓣的再次干预,未发现根部存在残余夹层,无显著的根部扩张.比较出院时和随访时的主动脉根部直径和主动脉瓣反流程度,差异无统计学意义.结论 修复在急性Stanford A型主动脉夹层中严重受累的主动脉根部,主动脉窦成形术是一种简便可靠的方法,近期效果优异.

Objective:To evaluate the safety and efficacy of balloon occlusion technique combined with total arch replacement and frozen elephant trunk in the treatment of complex aortic arch diseases.Methods:The clinical data of 100 patients undergoing balloon occlusion technique combined with total arch replacement and frozen elephant trunk surgery in Fuwai Hospital from August 2017 to September 2018 were retrospectively reviewed, and the early clinical results were analyzed.Results:The average circulatory arrest time was(5.2±3.1) min. The lowest nasopharyngeal and bladder temperature was(27.9±1.0) ℃ and(29.2±1.2) ℃, respectively. One patient died in hospital due to multiple organ failure caused by acute liver failure, and a total of 4 patients died within 30 days. Other postoperative complications included cerebral infarction in 3 cases, paraplegia in 2 cases, low cardiac output syndrome requiring IABP assistance in 1 case, renal failure requiring continuous dialysis in 5 cases, redo for bleeding in 4 cases, reintubation in 3 cases, recurrent laryngeal nerve injury in 1 case, and osteofascial compartment syndrome in 1 case.Conclusion:Balloon occlusion technique combined with total arch replacement and frozen elephant trunk is safe and feasible in the treatment of complex aortic arch diseases. Its organ protection effect still needs to be confirmed by large sample comparison study.

目的 探讨急性A型主动脉夹层和壁内血肿患者的早期临床转归.方法 回顾性分析2020年1月23日至3月10日于我院就诊的61例急性A型主动脉夹层和壁内血肿患者的临床资料,其中男43例、女18例,年龄22～ 81(52.1±13.0)岁.对患者的就诊时间、临床特点、早期生存情况进行分析.生存分析使用Kaplan-Mier生存曲线以及log-rank检验.结果 急性A型主动脉夹层患者48例(78.7％),壁内血肿患者13例(21.3％).34例患者接受手术,其中11例在24 h内接受急诊手术,手术死亡率2.9％.全组61例患者中存活48例、死亡13例.所有患者术后1d、3d和7d累积生存率分别为93.4％、86.4％和77.5％;夹层患者术后1d、3d和7d的累积生存率分别为95.7％、88.7％和79.4％,血肿患者术后1d、3d和7d的累积生存率分别为92.3％、84.6％和84.6％,经log-rank检验,生存率差异无统计学意义(P＞0.05).所有患者术后14d生存率为74.5％,夹层和血肿患者术后14d生存率差异无统计学意义(P＞0.05).对比存活患者和死亡患者,两组血流动力学不稳定状态的患者占比差异有统计学意义(P＜0.05).结论 存活至就诊的急性主动脉夹层和壁内血肿患者在积极药物治疗下仍有死亡风险,夹层破裂是该类患者死亡的首要原因,特别是血流动力学不稳定的患者.

Objective:To explore the clinical application of Fuwai aortic dissection classification, including comparing the difference between the diverse types, and its meaning of aortic surgery selection.Methods:Retrospectively collected 1 570 aortic dissection surgery patients from January 1, 2010 to December 31, 2015 in Fuwai Hospital. Fuwai classification includes four types. Type A restricted to the ascending aorta. Type B refers to the descending aorta dissection below the left subclavian artery. Type C refers to dissection involve the aortic arch. Type D refers to the dissection restricted to the abdominal aorta below the diaphragm. The subtype of the type C include type Cp, type Ct and type Cd. Type Cp refers to the proximal aortic arch is involved (at least the left subclavian artery was not implicated). Type Ct refers to total aortic arch is involved. Type Cd refers to the distal aortic arch is involved (at least the innominate artery was not implicated). We compared the differences among the four types (A/B/C/D) and three subtypes (Cp/Ct/Cd) aortic dissection in preoperative, intro and postoperative characteristics.Results:There were 78 cases (4.96%) Fuwai type A, 421 cases (26.82%) Fuwai type B, 1063 cases (67.71%) Fuwai type C, and 8 cases (0.51%) Fuwai type D. The operative mortality was 5.41%. The average age of the patients in type D was the oldest, which was (58.02 ± 11.93) years. The preoperative renal insufficiency in type C was the highest, (14.96%). Type A had the largest aortic sinus diameter (45.92 ± 12.88 mm). Type C had the highest mortality(7.71%), followed by 0.71% of type B, and no surgical deaths occurred in type A and type D. Among type C patients, 54 patients were type Cp, 832 patients were type Ct, 177 patients were type Cd. Surgery mortality between type Ct and type Cd was significant difference (9.38% vs. 1.69%, P<0.01). Type Ct had higher surgery mortality than type Cp, there was no difference (9.38% vs. 1.85%, P=0.06). Type Cp and type Cd had no significant statistical difference in surgical mortality (1.85% vs. 1.69%, P=0.94). Simply ascending aorta replacement accounted for 64.1% in type A , TEVAR accounted for 81.53% in type B , partial arch replacement accounted for 62.96% in type Cp, total aortic arch replacement accounted for 98.56% in type Ct, debranch+ TEVAR/TEVAR accounted for 70.62% in type Cd, EVAR accounted for 100% in type D. Conclusion:The Fuwai classification is more comprehensive and practical for clinical application than the traditional classification. Different classification had different clinical characteristics and prognosis. The classification was helpful for surgical methods selection.

目的 分析覆膜支架腔内修复术(TEVAR)中支架锚定于Zones 2或Zone 3的并发症发生情况.方法 回顾性分析2013年6月至2018年7月117例Stanford B型主动脉夹层患者行TEVAR的治疗及随访资料(出院随访期间意外死亡除外),随访期间,患者均行主动脉CT血管造影检查,了解覆膜支架位置、远端真假腔血栓化程度、主动脉重要分支血流灌注情况、有无内瘘、是否新发主动脉夹层及其他的并发症.结果 术中所有覆膜支架释放成功,27例支架锚定于Zone 2,90例支架锚定于Zone 3.117例随访患者中有14例发生并发症,其中Zone 2发生8例,Zone 3发生6例.随访发现内瘘发生率为6.84％,Ⅰa型内瘘3例,锚定于Zone 2的2例,Zone 3的1例;Ⅰb型内瘘1例,锚定于Zone 3;Ⅱ型内瘘3例,锚定于Zone 2的2例,Zone 3的1例;Ⅳ型内瘘1例,锚定于Zone 3.8例患者接受再次手术干预治疗,包括Zone 2的5例(其中2例行腔内修复术,3例行开放手术)和Zone 3的3例(其中2例行腔内修复术,1例行开放手术).结论 TEVAR治疗Stanford B型主动脉夹层患者将支架锚定于Zone 2,随访期间并发症发生率较高,因此对于支架只能锚定于Zone 2的患者需谨慎选择TEVAR治疗.

Objective:To analyze the effects of thoracic endovascular aortic repair (TEVAR) with stents deployed in different landing zones on early to mid-term results in patients with type B aortic dissection.Methods:The data of 147 patients with type B aortic dissection receiving TEVAR in the First Affiliated Hospital of Xiamen University from January 2012 to December 2017 were reviewed retrospectively. All of the patients were divided into two groups based on the distance between proximal entry tear and left subclavian artery: (1) ≤2 cm, the stent was deployed in Zone 2 (Zone 2 group, 40 cases); (2) >2 cm, the stent was deployed in Zone 3 (Zone 3 group, 107 cases). CTA data of the two groups at 1-, 3-month and annually thereafter were analyzed to assess the postoperative complication rates (mainly the incidences of endoleak) and reintervention rates.Results:The age of the Zone 2 group was younger than that of the Zone 3 group [(57±9.3)years vs (61±10)years, t=2.04, P=0.04]. The follow-up period was (37.8±20.5) months (range: 6-77 months). In total, there were 18 cases presented with postoperative complications during follow-up, and the complication rate of Zone 2 group was higher than that of Zone 3 group [27.5% (11/40) vs 6.54% (7/107), χ2=11.90, P=0.001]. A total of 10 cases appeared with endoleak, and the incidence of endoleak in the Zone 2 group was higher than that in the Zone 3 group [15%(6/40) vs 3.74%(4/107), χ2=5.82, P=0.025]. A total of 12 patients were treated with reintervention, and the reintervention rate of Zone 2 group was higher than that of Zone 3 group [20%(8/40) vs 3.74%(4/107), χ2=10.27, P=0.003]. Conclusion:For type B aortic dissection, stent landing in Zone 2 is associated with higher rates of complications and reintervention than that in Zone 3.

目的 总结右房黏液瘤的临床特征和外科治疗结果.方法 2007年1月至2012年12月共28例右房黏液瘤患者行黏液瘤切除术,女性16例,男性12例;年龄8～79岁,平均(46.3±14.8)岁.合并病变:中重度三尖瓣关闭不全4例,冠心病5例,肺动脉栓塞1例,同期外科手术.对27例(96.43％)患者随访70～138个月,平均(95.8±31.1)个月.总结右房黏液瘤在心脏黏液瘤中的比率、附着部位、近期及中期疗效.结果 右房黏液瘤占心脏黏液瘤的7.89％.最常见的附着部位是房间隔.所有患者术后早期无死亡.1例术后死于肺癌,余患者心功能(NYHA分级)Ⅰ-Ⅱ级.结论 右房黏液瘤外科治疗中期结果满意,远期疗效需进一步随访.

目的 探讨晚期妊娠合并严重心脏瓣膜病患者围产期综合治疗方法及其临床效果.方法 回顾性分析2007年12月-2017年12月间在厦门大学附属第一医院心脏外科与妇产科联合治疗的32例晚期妊娠合并心脏瓣膜重度狭窄和(或)关闭不全患者的临床资料,对其产前治疗、围产期抗凝策略、麻醉和分娩方式选择、围产期并发症等进行总结分析.结果 32例患者均在有体外循环的条件下,于全身麻醉下行剖宫产结束妊娠.其中,按术前计划行剖宫产同期心脏手术患者11例;2例患者分别于麻醉过程中和娩出胎儿挤压子宫时出现心室颤动,遂紧急开胸于体外循环下继续完成剖宫产术,同期行心脏手术;1例重度二尖瓣狭窄患者剖宫产术后早期出现急性左侧心力衰竭、肺水肿,积极药物治疗效果不理想,紧急返回手术室行心脏瓣膜置换+三尖瓣成形术;18例患者单纯行剖宫产术,顺利度过围产期,另择期行心脏手术.无一例产妇死亡,母婴均,顺利恢复后出院.结论 晚期妊娠合并严重心脏瓣膜病的患者应在全身麻醉、体外循环准备下选择剖宫产做为结束妊娠的方式.并由产科、心脏外科、麻醉科等经验丰富的专家共同协作,根据孕妇心脏基础疾病、心功能状态、胎儿状况等决定分娩时机,以及是否同期行心脏手术.

目的 总结本中心A型主动脉壁内血肿(intramural hematoma,IMH)的外科治疗经验,分析近期和远期临床结果.方法 选取2012年2月至2018年4月在阜外医院接受手术治疗的A型IMH患者共106例.手术策略:出现心包填塞或其他严重并发症的患者接受急诊手术,对病情稳定的患者采取初始药物治疗和择期手术治疗.临床终点包括手术死亡和复合临床终点,复合临床终点为死亡、永久性神经损伤(卒中和截瘫)和新发的需血液滤过治疗的肾损伤.采用Logistic单因素和多因素回归分析手术死亡和复合临床终点的危险因素,采用Kaplan-Meier生存曲线评估患者的远期生存率和免于主动脉事件生存率.结果 本组患者中,急性IMH 79例,亚急性IMH 27例.平均年龄(57.9±10.6)岁,58例(54.7％)为女性.1例因心包填塞行急诊手术,其余患者接受初始药物治疗和择期手术.9例患者行升主动脉置换术,18例患者行部分主动脉弓置换术,45例患者行全主动脉弓置换术及支架象鼻术,34例患者行杂交全主动脉弓置换术.其中23例患者同时合并其他手术.平均体外循环时间和主动脉阻断时间分别为(138.7±41.6) min和(79.3±27.8) min.55例(51.9％)患者术中进行低温停循环,平均持续时间为(18.5±6.1) min.手术死亡率为1.9％(2/106),7例患者出现复合临床终点.多因素回归分析显示:体外循环时间≥200 min和慢性肾脏病是复合临床终点的独立危险因素.共97例患者完成随访,平均随访时间为(30.8±16.2)个月.随访期间,3例死亡,5例发生主动脉事件.1年、3年和5年生存率分别为97.0％、95.3％和79.4％,而1年、3年和5年免于主动脉事件生存率分别为97.7％、95.3％和89.4％.急性IMH组和亚急性IMH组之间生存率和免于主动脉事件生存率均无统计学差异.结论 对出现心包填塞或其他严重并发症的患者采取急诊手术,对病情稳定的患者采取初始药物治疗和择期手术治疗.该治疗策略对于A型IMH,死亡率低,远期结果满意,适合于中国人群.

心脏脂肪瘤是一种罕见的心脏良性肿瘤,大多数缺乏特征性的临床表现,常于死亡后的尸解及病理检查得以确诊.其症状主要取决于脂肪瘤的位置及大小,可出现呼吸困难、胸痛、心律失常,甚至猝死等.外科手术干预通常获得良好的效果.由于心脏脂肪瘤的发病率低,目前尚无大规模的随机对照试验及相关的治疗指南,手术指征通常取决于临床表现及肿瘤对血流动力学的影响,通过外科手术达到缓解症状及预防进展的目的.因此,早期发现心脏脂肪瘤并定期随诊,有助于患者得到及时的治疗.本文旨在总结心脏脂肪瘤的多种影像学检查手段,包括超声、电子计算机断层扫描及磁共振成像中的特征及优势,以期达到更好的诊疗目的.

目的 分析心脏脂肪瘤的临床特征和外科治疗结果.方法 回顾性分析我院2002～ 2012年间582例行外科手术的心脏肿瘤病人的临床资料.其中,共10例心脏脂肪瘤病人接受外科手术切除,女5例,男5例;年龄7～62岁,中位年龄46.5岁.7例在体外循环下手术,3例在非体外循环下手术.合并房间隔缺损1例,同期外科手术修补.结果 心脏脂肪瘤占总体心脏肿瘤的1.72％.老年病人占所有脂肪瘤病人的10％(1/10).10例中完全切除8例(80％),部分切除2例(20％),无早期死亡.老年心脏脂肪瘤病人的手术体外循环时间、主动脉阻断时间长于非老年病人;术后呼吸机辅助时间、ICU时间及术后住院时间长于非老年病人.9例(9/10,90.00％)病人随访72～193个月,平均(126.10±44.46)个月,无远期死亡,心功能(NYHA分级)Ⅰ级或Ⅱ级.结论 本组心脏脂肪瘤占总体心脏肿瘤的1.72％.老年病人占脂肪瘤病人的10％.老年心脏脂肪瘤病人的手术时间及手术后恢复时间长于非老年病人,外科治疗远期结果良好.

急性主动脉夹层手术技术难度大,术后死亡多与吻合口相关并发症有关,因此安全有效的端端血管吻合至关重要.血管吻合有直接吻合、动脉外膜内翻技术、“三明治”技术3种方法,其中后两种吻合方法均可有效止血,降低术后并发症发生.最近有相关文献报道动脉外膜内翻技术可以促进假腔血栓性闭合,提高患者远期生存率.本文同时还介绍2种改良吻合法,对急性Stanford A型主动脉夹层手术中不同血管吻合技术的应用及效果进行比较,探讨最值得临床推荐使用的血管吻合技术.