Background:There are many techniques to reduce anastomotic bleeding for the total arch replacement, but hemostasis is sometimes difficult to achieve after surgery for acute dissection, especially in patients with abnormal coagulation (AC). This study aimed to investigate the hemostatic effect and early efficacy of a pre-set bovine pericardium wrapper in the right heart system shunt for total arch replacement in patients with type A aortic dissection (TAAD) and preoperative AC.Methods:A retrospective analysis was conducted on 85 patients with TAAD and AC who underwent total arch replacement between January 2018 and December 2022. The patients were divided into two groups: the preset pericardium group (n=30) and the control group (n=55).Results:There were no significant differences between the two groups in terms of Bentall surgery (ascending aorta replacement with an aortic valve artificial vessel) and cardiac arrest time. However, compared to the control group, the preset pericardium group exhibited a shorter duration of cardiopulmonary bypass (CPB) and operation (P<0.001). Additionally, the preset pericardium group required fewer transfusions of blood products and hemostatic drugs (P<0.05). Moreover, the preset pericardium group had lower 24-hour postoperative mediastinal drainage volume (P<0.001), a lower proportion of bedside hemofiltration (P=0.039), and a shorter duration of mechanical ventilation and stay in the intensive care unit (P=0.014). Although the preset pericardium group showed reductions in in-hospital mortality, re-exploration for bleeding, and neurologic dysfunction, these differences were not statistically significant compared to the control group.Conclusions:This study represents the first investigation into the application of the preset wrapping technique in total arch replacement for TAAD with AC. The results demonstrate that this method can reduce the duration of CPB and operation, decrease postoperative bleeding, and minimize the need for blood transfusion and hemostatic drugs. Consequently, this technique may contribute to early postoperative recovery.

完全性肺静脉异位引流(total anomalous pul-monary venous connection,TAPVC)是一种罕见的紫绀型先天性心脏病,缺氧和充血性心力衰竭可导致明显症状,通常患者在出生后几个月内需要手术矫正,成人病例在临床上比较少见,尤其是生存至中老年更是罕见.我们成功为1例53岁心内型TAPVC合并房间隔缺损、肺动脉高压患者实施手术.通过回顾该病例的临床及影像学资料,并进行文献回顾,探讨成人TAPVC的临床特点、围术期治疗及预后,以提高对该类成人病例的诊治水平,相关内容报道如下.

目的:探讨在心脏围手术期使用乌司他丁联合沐舒坦治疗气管狭窄是否获益.方法:回顾性分析2012年6月—2018年6月于南部战区总医院诊断为先天性心脏病(先心病)合并气管狭窄(TS)患儿42例,其中男28例,女14例;年龄1～132(17.2±13.8)个月;体重4.5～38(9.8±3.9)kg,所有患儿均未切开气道,并根据是否采用乌司他丁联合沐舒坦治疗分为治疗组22例与对照组20例.对比分析两组入监护室时气道压力峰值(Ppeak)和动脉血气分析指标、肺部感染指标、抗生素使用时间、呼吸机辅助时间和ICU时间.结果:所有心脏手术均顺利完成,全组术后死亡2例,术后14例发生肺部感染经积极治疗后均顺利恢复.全组随访29例(72.9％),随访6～72个月,平均(35±14)个月,随访期间无死亡.与对照组比较,治疗组患儿入监护室时动脉血氧分压(PaO2)和氧合指数低(OI)高,二氧化碳分压(PCO2)和乳酸(LAC)低、Ppeak低,术后再次气管插管例数少(均P＜0.05),呼吸机辅助时间及ICU时间缩短(均P＜0.05),抗生素使用时间较短(P＜0.05).结论:绝大多数先心病合并TS患儿可采用不切开气道保守手术方式,围手术期使用乌司他丁联合沐舒坦可加快此类患儿术后康复.

目的:回顾性总结295例急性Stanford A型主动脉夹层围术期治疗效果,分析术后感染发病率、种类及相关影响因素,探究急性Stanford A型主动脉夹层术后感染的主要危险因素及预防策略.方法:回顾性分析本中心2007年7月-2019年7月收治的急性Stanford A型主动脉夹层患者295例,根据围术期感染标准将术后患者分为感染组(111例)与非感染组(184例),总结围手术期的各项数据及资料,采用单因素分析筛选危险因素并纳入多因素logistic回归以明确独立危险因素.结果:围术期死亡60例(20.33％),其中感染组死亡36例(32.43％),非感染组死亡24例(13.04％),两组死亡率差异有统计学意义(P＜0.001).死亡原因包括多器官功能衰竭31例,低心排综合征15例,脑出血9例,呼吸衰竭5例.围术期感染111例(37.6％),包括肺部感染81例(73％),泌尿系感染8例(7.2％),切口感染7例(6.3％),感染性心内膜炎5例(4.5％),肠道感染5例(4.5％),脓毒血症3例(2.7％),纵隔感染2例(1.8％).感染组与非感染组年龄、吸烟、糖尿病、术前氧分压、术前肌酐水平、术前乳酸值、术后呼吸机辅助时间、纵隔及心包引流管留置时间、体外循环时间、ICU时间、围手术期RRT及人工主动脉瓣植入均差异有统计学意义(均P＜0.05).经logistic回归分析进一步明确糖尿病(OR:8.960;P=0.017)、术前乳酸值(OR:1.461;P=0.004)、围手术期RRT(OR:29.238;P＜0.001)、术后呼吸机辅助时间(OR:2.442;P＜0.001)、纵隔心包引流管留置时间(OR:2.054;P＜0.001)、ICU时间(OR:1.051;P=0.02)为术后感染的独立危险因素.ROC曲线分析显示,术后呼吸机辅助时间预测术后感染的效能最高.结论:围术期感染是急性Stanford A型主动脉夹层术后常见并发症;明确糖尿病、术前乳酸值、围手术期RRT、术后呼吸机辅助时间、纵隔心包引流管留置时间、ICU时间是急性Stanford A型主动脉夹层术后感染独立危险因素;围手术期对患者实施有效评估并采取对应措施,可降低术后感染风险、提高患者的预后及减轻患者家庭的经济负担.

目的 分析急性A型主动脉夹层(acute type A aortic dissection,AAAD)伴灌注不良综合征(malperfusionsyndrome,MPS)患者术后死亡的危险因素,为更合理制定临床治疗策略提供参考.方法 回顾性分析2006年8月至2018年9月期间海军军医大学附属广州临床医学院连续手术的299例AAAD患者的临床资料,诊断合并MPS110例,其中术后死亡28例,纳入死亡组,82例存活患者纳入存活组.比较死亡组及存活组患者的围术期资料,将单因素分析有统计学意义的结果(P<0.05)纳入多因素Logistic回归,明确术后死亡独立危险因素,并采用受试者工作特征(receiver operating characteristic,ROC)曲线对所得危险因素的预测效能进行判断.结果 单因素分析可得两组间患者的术前肌酐浓度、动脉血氧分压、急诊手术、肾脏灌注不良、2个以上脏器灌注不良、体外循环时间、主动脉阻闭时间、低流量脑灌注时间、脓毒症、连续肾脏替代治疗、恶性心律失常发生率比较,差异有统计学意义(均P<0.05).将单因素比较有统计学意义的指标纳入二项分类Logistic回归分析,得出:2个以上脏器灌注不良、体外循环时间>240 min、主动脉阻闭时间>120 min和急诊手术是AAAD伴MPS患者术后死亡的独立危险因素.ROC曲线分析结果显示,联合预测概率的曲线下面积为0.896,有统计学意义(P<0.01),预测敏感性为92.9％,特异性为51.2％.结论 AAAD患者术前伴MPS危害大,手术死亡率高.2个以上脏器灌注不良、体外循环时间>240 min、主动脉阻闭时间>120 min、急诊手术是AAAD伴MPS患者术后死亡的独立危险因素.

目的 探讨感染性心内膜炎(IE)患者围术期死亡的危险因素及各指标的预测效能.方法 收集2012年4月至2019年4月中国人民解放军南部战区总医院收治的91例IE患者的临床资料,围术期死亡6例(死亡组),顺利出院85例(存活组).2组患者术前均应用抗菌药物控制感染,体温正常、血常规正常2～4周后手术治疗.其中行单纯主动脉瓣置换13例,主动脉瓣置换+二尖瓣置换7例,主动脉瓣置换+二尖瓣成形5例,主动脉瓣置换+二尖瓣成形+三尖瓣成形5例,主动脉瓣置换+肺动脉瓣置换+三尖瓣成形1例,单纯二尖瓣成形20例,二尖瓣置换+三尖瓣成形11例,二尖瓣置换+三尖瓣置换1例,单纯三尖瓣成形4例,单纯心内赘生物清除24例.合并冠状动脉多支病变行冠状动脉旁路移植术4例,合并先天性心脏病行一期修复,包括室间隔缺损9例,动脉导管未闭2例,卵圆孔未闭1例.比较2组患者的基线资料和术中、术后资料,应用多因素Logistic回归方法分析围术期死亡的危险因素,绘制受试者工作特征曲线评价各指标的检验效能.结果 死亡组合并糖尿病、既往心肌梗死病史、术前肝功能不全、围术期肾功能不全和术后神经系统症状、肺部并发症比例均高于存活组,术前纽约心脏病协会心功能分级劣于存活组,升主动脉阻断时间和气管插管时间、重症监护病房(ICU)停留时间、住院时间均长于存活组[(113±38) min比(75±33) min、(3.8±1.0)d比(1.9±1.4)d、(12±8)d比(5±4)d、(52±29)d比(29±14)d](均P＜0.05).多因素Logistic回归分析结果表明,ICU停留时间长、围术期肾功能不全是IE患者术后死亡的独立危险因素(均P＜0.05),二者预测IE患者术后死亡的曲线下面积分别为0.861(95％置信区间:0.760～0.962,P=0.003)和0.792(95％置信区间:0.563～1.000,P=0.017),二者联合预测IE患者术后死亡的曲线下面积为0.922(95％置信区间:0.851～0.992,P=0.001).结论 ICU停留时间长和围术期肾功能不全是IE患者术后死亡的独立危险因素,缩短患者ICU停留时间及维持患者围术期肾功能和循环的稳定,有助于降低患者围术期的死亡风险.

目的:探讨先天性冠状动脉瘘手术治疗的最佳时机、方法及疗效,努力提高手术成功率.方法:我院2013年10月-2019年10月共收治19例冠状动脉瘘患者,其中男11例,女8例,年龄4.5(1～61)岁,体重16.25(7～69) kg.右冠状动脉右房瘘3例,右冠状动脉右室瘘7例,右冠状动脉左室瘘1例,左冠状动脉右房瘘2例,左冠状动脉左房瘘2例,左冠状动脉右室瘘2例,左冠状动脉肺动脉瘘2例;合并先天性二尖瓣发育不良2例,房间隔缺损、室间隔缺损、卵圆孔未闭、三尖瓣关闭不全各1例.所有患者均胸正中切口体外循环下行动脉瘘矫治术,同期矫治其他心脏畸形,围术期常规监护治疗,术后1、6个月及每年随访复查.对所有患者临床资料进行统计、分析及总结.结果:升主动脉阻断时间(61.330±11.479)min,体外循环时间(99.940±15.206) min,手术时间(140.610±19.150) min,呼吸机使用时间(33.000±19.275)h,ICU时间(2.220±1.215)d,住院时间(20.940±8.795)d.患者术前左室射血分数(63.167±8.031)％,术后当日左室射血分数(69.390±8.389)％,术后左室功能明显改善(P＜0.05).患者术前心胸比0.506±0.0769,术后当日心胸比0.479±0.060 3,手术前后心胸比差异显著(P＜0.05).19例患者围手术期无严重并发症及死亡,均痊愈出院.术后随访6个月～5年,未见残余瘘及严重心血管症状.结论:冠状动脉瘘发病率低,出现心悸、呼吸困难等症状应尽早手术治疗,外科手术治疗疗效较好,并发症少.

目的 探讨Tei指数在定量比较经胸微创封堵(MITO)与体外循环(CPB)心内直视修补室间隔缺损(VSD)术后早期左心室(LV)功能变化的应用价值.方法 97例VSD儿童根据手术方式分为A组(MITO组,n=47例)、B组(CPB组,n=50例),分别于术前12～24 h及术后第1、3、5天,1、3个月用脉冲多普勒超声心动图测量LV-Tei指数,应用电化学发光免疫学法测定血浆NT-proBNP.结果 (1)组间比较:A组LV-Tei指数术后第1、3、5天、1个月显著小于B组(P<0.01).(2)组内比较:A组、B组LV-Tei指数术后均呈先升高后降低趋势,术后第1天达峰值.A组术后第3～5天恢复至术前水平,且术后1、3个月小于术前(P<0.05).B组术后第3、5天维持高水平,术后第5天～1个月恢复至术前,且术后3个月小于术前(P<0.05).(3)儿童LV-Tei指数与血浆NT-proBNP呈正相关,其中A组(r=0.74,P<0.01)、B组(r=0.65,P<0.01).结论 Tei指数是定量评估儿童VSD术后左室功能变化的良好指标.MITO与CPB关闭VSD早期会造成一定儿童左室功能损伤,但CPB损伤较MITO严重.

目的 研究大动脉转位(TGA)患儿行一期大动脉调转术(ASO)后应用大剂量血管活性药物的有效性及安全性.方法 选取2009年1月至2019年1月在中国人民解放军南部战区总医院心脏外科行ASO并术后使用血管活性药物的82例TGA患儿为研究对象,根据术后血管活性药物(肾上腺素和去甲肾上腺素)的使用剂量将其分为A组[20例,0.01～0.10μg/(kg·min)]、B组[32例,0.11～0.20μg/(kg·min)]及C组[30例,0.21～0.40μg/(kg·min)].比较三组患儿的并发症发生情况、用药时间、手术时间、术后住院时间、体外循环时间及应用血管活性药后的不良反应发生情况.结果 A、B、C组患儿早期死亡率分别为15.0％(3/20)、15.6％(5/32)、10.0％(3/30),差异无统计学意义(P>0.05).三组患儿并发症总发生率、用药时间和手术时间比较,差异具有统计学意义(P<0.05),其中,C组的并发症总发生率最低.A、B、C组使用血管活性药物后分别有13、8、5例发生不良反应,三组低心排征、乳酸>4.0 mmol/L的发生率比较,差异具有统计学意义(P<0.05).结论 TGA患儿ASO术后早期死亡率仍较高;为维持患儿生命体征平稳,大剂量使用血管活性药物是安全、有效的,且未增加患儿的早期死亡率和术后并发症发生率.

目的 比较应用牛颈静脉带瓣管道与自体心包管道重建右心室流出道的中期疗效差异.方法 回顾性分析2013年5月至2016年7月接受外管道重建右心室流出道术的18例先天性心脏病患者的临床资料,患者年龄为2～16(5.22±4.12)岁,男11例、女7例,肺动脉闭锁合并室间隔缺损7例、右心室双出口合并肺动脉瓣狭窄4例、永存动脉干3例、永存动脉干合并右肺动脉缺如1例、矫正型大动脉转位合并肺动脉瓣狭窄1例、完全大动脉转位合并肺动脉瓣狭窄2例.术中采用完整国产牛颈静脉带瓣管道重建右心室流出道11例(牛颈静脉管道组),采用自体心包管道重建右心室流出道7例(自体心包管道组),记录围手术期情况.术后随访4～56个月,应用心脏超声及心脏计算机断层扫描血管成像(CTA)评估疗效.结果 牛颈静脉管道组11例患者无围手术期死亡;自体心包管道组7例患者死亡2例,其中1例死于术后肺动脉高压危象,1例死于低心排出量综合征.牛颈静脉管道组右心室压/桡动脉压比值、术后机械通气时间、重症监护病房(ICU)时间均小于自体心包管道组,差异均有统计学意义(P均<0.05);两组患者体外循环时间、主动脉阻闭时间、停机后右心室流出道跨瓣压差、输血量及住院总费用差异均无统计学意义(P均>0.05).两组随访期间均无死亡病例,牛颈静脉管道组无再次手术病例,自体心包管道组1例因严重右心功能不全于术后2年行机械瓣膜带瓣管道植入术.超声测量结果显示,牛颈静脉管道组术后最后一次随访时右心室流出道跨瓣压差与出院前相比差异无统计学意义[(22.91±7.31)mmHg(1 mmHg=0.133 kPa)vs(20.45±6.70)mmHg,P>0.05],自体心包管道组术后最后一次随访时右心室流出道跨瓣压差高于出院前[(29.20±18.09)mmHg vs(16.14±4.02)mmHg,P<0.05];牛颈静脉管道组术后最后一次随访时发现轻度反流8例、中度反流3例,自体心包管道组发现轻度反流1例、中度反流2例、重度反流2例,两组间差异有统计学意义(P<0.05).术后超声检查显示牛颈静脉管道内瓣叶组织均有不同程度的增厚,但未见钙化,瓣叶活动良好,无血栓形成及感染性心内膜炎发生;自体心包管道未见钙化、血栓形成及感染性心内膜炎发生.术后随访期间心脏CTA检查发现牛颈静脉管道有1例中段、1例近端吻合口出现瘤样扩张情况,自体心包管道均未见扩张.结论 国产牛颈静脉带瓣管道适用于各类复杂先天性心脏畸形患者右心室流出道重建术,中期随访显示牛颈静脉管道抗反流性能良好,无严重梗阻或钙化发生,优于自体心包管道.但部分国产牛颈静脉带瓣管道术后中期随访有瘤样扩张发生,制备工艺有待进一步改进.

目的 探讨急性A型主动脉夹层患者术后死亡的危险因素.方法 回顾性分析2006年8月至2018年9月期间连续手术的299例急性A型主动脉夹层患者,将患者按是否术后死亡分为死亡组(61例)和存活组(238例),详细统计两组患者围术期资料并进行对比,将单因素分析有统计学意义的结果(P<0.05)纳入多因素Logistic回归明确独立危险因素,并采用受试者工作特征曲线(ROC)对所得危险因素的预测效能进行判断.结果 单因素分析结果经Logistic回归分析进一步明确:年龄≥50岁、术前伴灌注不良综合征、全弓置换手术方式(孙氏手术)、术后并发低心排是患者院内死亡独立危险因素.ROC曲线显示,联合预测概率的曲线下面积(AUG)为0.949,且各独立危险因素曲线下面积均>0.6,差异有统计学意义(P<0.01),预测敏感性为98.4％,特异性为51.5％.结论 年龄≥50岁、术前伴灌注不良综合征、全弓置换手术方式(孙氏手术)、术后并发低心排为急性A型主动脉夹层患者术后死亡的独立危险因素.

目的:探讨以内膜破口位置为导向的非全主动脉弓置换术治疗急性Stanford A型主动脉夹层的策略.方法:入选2010年3月至2017年6月我院手术治疗急性Stanford A型主动脉夹层患者275例,179例为主动脉弓部无破口的Stanford A型主动脉夹层,其中,65例以内膜破口位置为导向行升主动脉或近端半主动脉弓置换手术(AAR组),114例行全主动脉弓置换孙氏手术(TAR组).记录两组围术期临床数据和并发症,术后随访3个月～7年,记录生存率和再次手术干预情况,进行生存分析比较.结果:TAR组和AAR组比较,体外循环时间[(208.62±57.82)min vs(114.71±26.22)min]、心脏停灌注时间[(95.55±27.92)min vs(77.32±17.89)min]、停循环时间[(21.27±7.28)min vs 0 min]、术后有创通气时间[(71.86±68.06)min vs(35.86±17.03)min]、重症监护病房时间[(7.33±3.73)d vs(4.46±1.48)d],差异均有统计学意义(P<0.05);AAR组术后血制品的消耗、急性肾损害及一过性脑功能障碍发生率均低于TAR组,差异有统计学意义(P<0.05);两组患者的围术期死亡率(9.65％vs 4.62％)差异无统计学意义(P>0.05);随访时间3个月至7年,两组患者的远端血管残余夹层发生率、远期生存率差异均无统计学意义.两组60岁以上患者的术后30天死亡率(12.50％vs 8.70％)、远期全因死亡率(14.29％vs 6.25％)和远期血管病变再干预率(0％vs 0％),差异均无统计学意义(P>0.05).结论:以内膜破口位置为导向的非全主动脉弓置换术有较高的围术期安全性,远期疗效与全主动脉弓置换术接近,适用于治疗破口位于升主动脉的Stanford A型主动脉夹层和老年患者.

目的 分析一马凡综合征(Marfan syndrome,MFS)家系的临床特征,进行原纤维蛋白-1基因(FBN1)突变分析,明确该家系的致病基因,以加强对此病的认识,提高早期诊断率,并对1例MFS孕妇进行产前诊断.方法 描述一家系8例患者的临床表现,提取先证者及其家族成员外周血DNA,用PCR和DNA测序技术检测FBN1基因外显子中的潜在突变.提取MFS孕妇羊水细胞DNA和培养后羊水细胞的RNA,RT-PCR扩增RNA检测该家系所发现的阳性位点.结果 该家系的遗传方式为常染色体显性遗传,4代共有8例患者,其中4例在47～59岁猝死,先证者和其他3例存活患者均具有心血管系统的异常(主动脉根部夹层或主动脉根部扩张)、晶状体脱位、高度近视及MFS的特征性骨骼改变,并随着年龄的增长而逐步加重.基因检测显示先证者FBN1基因54号外显子存在c.6554T>C(p.Ile2185Thr)错义突变,其他3例存活患者均发现该位点突变,而表型正常的成员未发现该突变.胎儿羊水细胞的DNA与羊水培养细胞RNA均发现该位点的突变.结论 FBN1基因错义突变c.6554T>C(p.Ile2185Thr)为该家系致病的分子基础,基因检测有助于早期明确诊断以便尽早干预治疗,避免夹层动脉破裂导致猝死的不良结局.该MFS孕妇的胎儿遗传有该FBN1的致病突变,给双亲决定是否终止妊娠提供参考,有助于患病家族的优生优育.

目的 二尖瓣成形术被广泛应用于先天性及继发性二尖瓣病变的手术治疗中.文中探讨二尖瓣成形术后并发机械性溶血的机制及治疗策略.方法 回顾性分析2010年8月至2018年6月解放军南部战区总医院行二尖瓣成形术(含房室管畸形病例)451例患者临床资料.其中16例(3.5％)术后出现机械性溶血(血红蛋白尿、黄疸、贫血),心脏超声检查显示二尖瓣少量返流3例、中量返流9例、大量返流4例,其中12例二尖瓣返流束为高流速(Vmax>4m/s).根据溶血治疗策略将患者分为2组:再手术组(n=10)确诊溶血后1周内接受再次二尖瓣成形术;保守治疗组(n=6)予以血液透析、输血、利尿、碱化尿液、护肝、口服美托洛尔等对症治疗.所有患者接受随访2～36个月,平均(16.0±7.5)个月,对比患者术后心脏超声结果、溶血症状改善程度、心功能水平等.结果 两组术后均无死亡病例.再手术组全部患者症状迅速消退,痊愈出院;保守治疗组4例患者因治疗效果不佳于术后3～11周接受再次手术治疗(行二尖瓣成形1例、二尖瓣机械瓣膜置换3例),术后痊愈出院,另外2例患者长期保守治疗.接受再次手术患者心功能维持在I～II级,复查心脏超声显示二尖瓣微量返流10例,少-中量返流3例,无机械性溶血复发;2例长期保守治疗患者,轻中度贫血,尿胆原1+～2+,二尖瓣返流中量,心功能II级,处于亚临床溶血状态.再手术组患者治疗1周后血红蛋白水平、总胆红素水平、二尖瓣返流量均显著优于保守治疗组,差异有统计学意义(P<0.05);再手术组的再次干预发生情况(0 vs 66.7％)及溶血/亚临床溶血发生情况(0 vs 100％)均显著低于保守治疗组,差异有统计学意义(P<0.05).结论 机械性溶血多发生在二尖瓣成形术后早期,超声可发现具有高剪切力的二尖瓣残余返流,可结合临床血管内溶血症状进行诊断.手术是影响溶血的重要因素.术后出现溶血基本可判定手术失败,应尽早再次行二尖瓣成形手术是最佳选择,保守治疗通常效果不佳.

Objective:To retrospectively analyzed the infection rate, infection type and other related influencing factors of 444 cases of valvular replacement surgery, and identify the risk factors for infection after valve replacement surgery.Method:A total of 444 patients (209 males and 235 females, at a mean age of (49.62±12.92) years with valve replacement surgery at the cardiovascular surgery department of Guangzhou General Hospital of Guangzhou Military Command from July 2013 to July 2018, were collected and retrospectively analyzed.The 71 patients infecting after receive valve replacement surgery were assigned into the infection group, and the other patients (n=373) were included in the non-infection group.Risk factors were identified by univariate analysis and further confirmed by Logistic regression.Result:Our study had 7 patients died in perioperative period (1.6％).Infection group had 5 cases (7.0％), non-infection group had 2 cases (0.5％), and the mortality of the two groups was statistically significant (P＜0.001).The causes of death include:5 cases withlow cardiac output syndrome (LCOS) and 2 cases with multiple organ dysfunction (MODS).There were 71 patient infected (15.9％) during the perioperative period.Among them, 61 patients were pulmonary infection (85.9％), 3 cases were intestinal infection (4.2％), 2 cases were urinary tract infection (2.8％), and 5 cases were endocardial infection (7.1％).Univariate analysis identified old age, male, obesity, diabetes, smoking, hyperlipidemia, preoperative infection, abnormal liver and kidney function, cardiac function, course of the disease, total operation time, extracorporeal circulation time, aorta blocking time correlation, intubation time were risk factors for infection after valve replacement surgery.Logistic regression analysis further identified obesity (OR:5.777;P＜0.05), diabetes (OR:7.071;P＜0.05), Preoperative infection (OR:29.953;P＜0.01), Abnormal liver function (OR:20.546;P＜0.01), Course of the disease＞10 year (OR:5.091;P＜0.01), total operation time (OR:1.969;P＜0.01), aorta blocking time correlation (OR:1.070;P＜0.05), Intubation time were (OR:3.989;P＜0.01) as independent risk factors for infection after valve replacement surgery.The predictive values of identified risk factors were evaluated based on the area under the receiver operating characteristic (ROC) curve.Conclusion:Perioperative infection is a common complication after valve replacement, and severe infection seriously affects the prognosis of patients.According to independent risk factors, Comprehensive evaluation and intervention during perioperative period can efficiency reduce the risk of infection.

目的:探讨术前伴凝血功能异常的A型主动脉夹层(AAD)手术方式及相关治疗策略.方法:回顾性分析2014-01-2018-06于南部战区总医院心脏外科中心治疗的230例AAD患者,根据临床病史及检查结果判断术前是否伴有凝血功能异常并进行分组,其中试验组伴凝血异常患者43例,对照组未发现明确凝血异常患者187例.全组患者入院后积极完善术前检查后均行急诊外科手术治疗,凝血异常治疗策略在实验室凝血相关检查结果指导下进行,凝血异常患者优先考虑采用自体主动脉或人工血管补片行吻合口覆盖性包裹治疗.比较两组患者术前一般情况、手术情况、输血相关指标及术后恢复情况.结果:全组AAD患者均完成外科手术操作.与对照组比较,试验组患者术前肝功能异常比例及凝血相关指标异常的发生率较高,全弓置换率较低,手术时间相对较长,围手术期浓缩红细胞、新鲜冰冻血浆、血小板和凝血成分如凝血酶原复合物、重组人凝血因子Ⅶ和纤维蛋白原输注较多,且术后24 h引流量较多,ICU滞留时间较长,再次开胸止血、血滤治疗、纵膈感染及院内死亡比例相对较多(均P＜0.05).两组患者体外循环时间、主动脉阻闭时间及术中最低温度、术后肺部感染率均无明显统计学差异.结论:伴凝血功能异常的AAD患者急诊手术风险高,术后并发症多,对此类患者应给予针对性的相关药物治疗,同时选择相对简易的手术方式,手术效果尚可接受.

目的 总结高龄高危心脏瓣膜置换术患者的体外循环(Cardiopulmonary bypass,CPB)管理经验.方法 2008年8月至2017年8月广州军区广州总医院对54例高龄(年龄>70岁)高危心脏瓣膜患者行瓣膜置换术.CPB中:心肌保护采用1:4(晶:血)冷灌注液,每隔30 min以冷血半钾停搏液重复灌注,常规监测患者的心电图、动脉压、中心静脉压和混合静脉血氧饱和度,定时行血气分析、活化全血凝固时间(activated clotting time of whole blood,ACT)、电解质以及尿量监测,保持动脉血pH值7.35~7.45,静脉血氧饱和度65%以上, ACT 维持在480 s以上,术中灌注流量2.0~2.6 L/(min·m2),灌注压维持在60~80 mmHg(1 mmHg=0.133 kPa).结果 全组CPB时间112(87~258)min,主动脉阻断时间74(54~174)min,术毕心脏自动复搏率78%,围术期死亡3例,余均痊愈出院.结论 高龄高危心脏瓣膜置换术风险大,对术中管理要求高,在CPB中选用性能良好的材料如膜肺,合理的预充,充分的组织灌注,有效的心肌保护,适度的辅助循环,以及改良超滤,可降低并发症发生率和病死率,是手术成功的保证.

Objective To identify the risk factors for renal replacement therapy (RRT) following total arch replacement.Methods A total of 258 patients (215 males and 43 females,at a mean age of 47.78-±8.81 years) with type Ⅱ aortic dissection undergoing total arch replacement at the cardiovascular surgery department of Guangzhou General Hospital of Guangzhou Military Command from March 2007 to March 2017 were collected and retrospectively analyzed.Forty-six patients having to receive RRT due to severely damaged renal function were assigned into the RRT group,and the other patients were included in the nonRRT group (n =212).The perioperative data were reviewed.Risk factors were identified by univariate analysis and further confirmed by Logistic regression.The predictive values of identified risk factors were evaluated based on the area under the receiver operating characteristic (ROC) curve.Results Univariate analysis identified preoperative sepsis,bilateral renal artery dissection,preoperative serum creatinine level,operation time,cardiopulmonary bypass time,intraoperative red blood cell infusion ＞ 10 units were risk factors for RRT after total arch replacement.Logistic regression analysis further identified preoperative serum creatinine level (OR =1.018,95％ CI:1.008 ～ 1.027,P ＜0.001),operation time (OR =1.034,95％ CI:1.005 ～ 1.064,P =0.020) and intraoperative red blood cell infusion ＞ 10 units (OR =3.426,95％ CI:1.573 ～7.458,P =0.002) as independent risk factors.ROC curve analysis showed that the area under the curve of the 3 risk factors was 0.839,and 95％ confidence interval was 0.786 to 0.892 (P＜0.001).Conclusion Preoperative creatinine level,operation time and intraoperative red blood cell infusion are independent risk factors for RRT after total arch replacement.

OBJECTIVES:The effect of antegrade pulmonary blood flow (APBF) has never been studied in the bidirectional Glenn (BDG) procedure performed late.METHODS:Records of 112 consecutive patients who had a BDG procedure during a 10-year period were reviewed retrospectively. The patients were divided into 2 groups based on whether APBF occurred following the BDG procedure (APBF group, n = 81) or not (non-APBF group, n = 31). The median age at the BDG procedure was 6.16 ± 3.93 years in the APBF group and 6.12 ± 4.40 years in the non-APBF group.RESULTS:Demographics and pre- and intraoperative variables were comparable for both groups. Follow-up data were obtained for patients at the BDG stage and for those who had undergone the Fontan completion. Both oxygen saturation levels (81.72 ± 1.976% vs 78.32 ± 2.344%, P < 0.01) and pulmonary pressure (13.59 ± 1.376 mmHg vs 12.90 ± 0.978 mmHg, P = 0.012) were higher in the APBF group immediately after the BDG procedure. Both the duration of chest tube drainage and the total length of stay were longer in the APBF group. The pre-Glenn measurements showed a mean McGoon ratio of 1.68 ± 0.114 in the APBF group and 1.67 ± 0.098 in the non-APBF group (P = 0.474). The McGoon ratios measured before the Fontan procedure were also comparable (1.669 ± 0.726 vs 1.685 ± 0.669, P = 0.576). At the pre-Fontan measurement, there was no significant difference in mean pulmonary artery pressures between the groups (13.72 ± 1.368 vs 13.50 ± 1.265, P = 0.653). Fifty-nine patients underwent the Fontan completion (43 from the APBF group and 16 from the non-APBF group) procedure with a median of 1.2 (APBF group) and 1.4 (non-APBF group) years after the BDG procedure. No significant differences between groups were observed in arterial oxygen saturation levels, incidence of systemic atrioventricular valve regurgitation or ventricular dysfunction in survivors at the last follow-up visit.CONCLUSIONS:The BDG procedure can be safely performed at a relatively older age (∼6 years). APBF increases oxygen saturation but also prolongs pleural effusion and hospital stay. Medium-term outcomes and the Fontan completion rate in the APBF and the non-APBF groups are comparable. Further large studies and long-term follow-up are needed to clarify the effect of APBF in patients who have the late BDG.

目的 评价自主研制的超微孔膨体聚四氟乙烯(ePTFE)自膨式介入主动脉瓣膜绵羊体内原位置换的可行性和早期效果.方法 选用厚度0.1 mm的超微孔ePTFE材料制作成三叶自膨胀型介入主动脉瓣膜.采用雄性绵羊10只,体质量(23.4±1.8) kg.全身麻醉,左侧开胸,经心尖入路行经导管主动脉瓣原位置换术.术后通过心血管造影、经胸心脏超声对介入瓣膜功能进行早期评价.结果 死亡3只,另外7只羊手术成功.术后即时心血管造影和心脏超声提示人工瓣膜位置满意,开闭良好,冠状动脉供血良好,无明显瓣周漏.3只羊无或仅有微量反流,4只羊少量反流,峰值跨瓣压差为(2.38±0.60) kPa[(17.9±4.5) mmHg].术后随访4周无死亡或Ⅲ°房室传导阻滞等严重并发症,心脏超声提示4只羊微量反流,3只羊少量反流;人工瓣膜峰值跨瓣压差平均(2.67±0.64) kPa[(20.1±4.8) mmHg],与术后即刻结果比较,差异无统计学意义(P=0.066),二尖瓣功能未受影响.结论 超微孔ePTFE自膨式介入主动脉瓣绵羊体内原位置换安全可行,早期效果良好.