患儿男,1岁4个月,12 kg。体检发现心脏杂音1年。超声心动图诊断"先天性心脏病,法洛四联症,房间隔缺损"。64排CT示"主动脉骑跨、室间隔缺损、房间隔缺损、右心室肥厚、右心室流出道及肺动脉狭窄"。2014年8月在全麻体外循环下行"法洛四联症纠治、房间隔缺损修补术"。术中跨瓣自体心包补片扩大右心室流出道至左肺动脉。术后第3天顺利撤除呼吸机。当日患儿血氧饱和度(SpO 2 )进行性下降,双肺闻及大量湿罗音,再次插管。二次

Objective To introduce a new technique:minimally invasive transthoracic closure of ventricular septal defects (VSD) without cardiopulmonary bypass (CPB) under guidance of transepicardial echocardiography (TECE).Methods A total of 41 patients with VSD,5 months to 6 years,averaging (15.1 ± 18.5) months,underwent transthoracic device closure.The weight of these patients ranged from 5 to 26.0 kg with an average weight of (10.78 ± 6.87) kg.The diameter of their VSD ranged from 3 to 8.5 mm with an average of (5.2 ± 1.13) mm.After small median sternotomy incision,an appropriately sized VSD occluder was inserted into the left ventricle via VSD,then the occluder was released and the VSD was closed.TECE was used to monitor the whole procedure to guide the device positioning and evaluate the cursive effect instantly after operation.Results The procedure was successful in 38 patients.Three cases failed,including two cases whose guiding wire could not pass through VSD and one case whose occluder could not fix well.Three patients had tiny residual shunt after operation,two vanished during the follow-up period,and one case still had small amount residual shunt because of the occluders shifting.In 6 to 36 months follow-up,neither complete atrioventricular heart block nor aortic insufficiency was found in any patient.Conclusions The transthoracic closure of ventricular septal defects without cardiopulmonary bypass under guidance of transepicardial echocardiography is easy,safe,and efficient.

对先天性心脏病术后肺动脉高压采用西地那非进行治疗，观察分析其临床效果。将接受治疗的22例先天性心脏病术后肺动脉高压患者按照随机投掷的方法分成治疗组与对照组，每组11例，对照组采用常规药物治疗，治疗组在对照组的基础上联合西地那非治疗。治疗后，治疗组总有效率（90.91%）明显高于对照组（54.55%），差异具有统计学意义（P＜0.05）；治疗后治疗组PAP、PaO2与氧合指数均优于对照组，差异具有统计学意义（P＜0.05）。采用口服西地那非治疗先天性心脏病术后肺动脉高压的临床效果优于常规治疗，可有效控制肺动脉压，提高患者的生活质量，建议广泛应用。

A 61-year-old man was referred with palpitation. Transesophageal echocardiography demonstrated a ventricular septal defect, severe regurgitation of the aortic valve, and a saccular aneurysm of the anterior mitral valve leaflet (Figure 1). The aneurysm was resected. The mitral valve leaflet was retained in repair of the ventricular septal defect and aortic valve replacement (Figure 2). The patient was doing well 1 year later, without any mitral valve disease.

<正>先天性心脏病合并气管狭窄是危及婴幼儿及儿童生命的急重症[1],但先天性心脏病伴气管狭窄诊断较为困难,往往被心脏疾病掩盖气管狭窄的症状,而在心外科手术中行气管插管或术后脱离呼吸机困难时被发现[2]。目前螺旋CT血管造影被越来越多应用于婴幼儿先天性心脏病的术前检查。本科最近应用64层螺旋CT血管造影诊断1例先天性心脏病合并多发气管狭窄并右上肺支气管异常起源患儿,现报道如下。病例男,6月,以"自幼口唇发绀,加重伴呼吸困难1月"为主述入院。查体:口唇发绀,胸骨上窝可闻及喘鸣音,胸

aortic dissection Peng Zhu*, Qian Yang and Tao Shu Department of Cardiovascular Surgery, The Affiliated Zhongshan Hospital of Xiamen University, Xiamen Heart Center, Xiamen, China * Corresponding author. Department of Cardiovascular Surgery, The Affiliated Zhongshan Hospital of Xiamen University, Xiamen Heart Center, The South of Lakeside, 201, Xiamen, China. Tel: +86-0592-2292349; fax: +86-0592-2292303; e-mail: doctff@hotmail.com (P. Zhu). Received 18 January 2013; received in revised form 20 February 2013; accepted 27 February 2013

Objective The presence of alloreactive memory T cells in recipient is a critical handicap to achieve transplantation tolerance.To make a mouse model which mimics the present transplant patient is important for research at this subject.Thus,we developed a novel re-transplant model and compared the alloresponse in this model with that in the conventional memory T cellstransfer model (transfer control).Methods The re-transplant model was established via microsurgery and vessel cannula techniques,and the experiment was composed of three groups:the re- transplant group,memory T cell-transfer group (transfer control) and the conventional blank group (blank control).The research indexes included survival time of donor heart,rejection score of allograft,and detection of proliferation and differentiation of the alloreactive memory/effector T cells by by flow cytometry (FCM) and in vitro mixed lymphocyte reaction (MLR).Results The median survival time of allograft in re-transplant recipients was significantly shortened compared to that of transfer control,but there was no significant difference in rejection score of graft between them (the score in retransplant group was the most intense of the three groups). Moreover, proliferation and differentiation of the alloreactive effector T cells were more intensive in re- transplant recipients than in the transfer control,which was confirmed by in vitro MLR and by FCM of the splenocytes for detecting CD44highCD62L-memory/effector phenotype cells.Conclusion The recall alloresponse in retransplantation is more intensive than that in memory-transfer setting and this re-transplant model is more close to the clinic situation than the memory-transfer model in rodents.

AIM To evaluate the curative effects of diltiazem on postoperative hypertension after surgical closure of patent ductus arteriosus(PDA)when sodium nitroprusside failed to control.METHODS A retrospective study was performed in 51 patients with postoperative hypertension after surgical closure of PDA in our center.Thirty-one patients,who received sodium nitroprusside for postoperative hypertension,were enrolled in the sodium nitroprusside group.Twenty patients,who received diltiazem when sodium nitroprusside failed to achieve satisfactory blood pressure control,were included in the diltiazem group.Clinical data,the mean blood pressure,heart rates before and 0,1,2,4,6 hours after the surgery,the drug doses and adverse drug reactions were compared between the two groups.RESULTS There were no significant differences in gender,age,weight,height,operation time and perioperative infusion volume between the two groups(P 0.05).The diameter of PDA in the diltiazem group was larger than that in the sodium nitroprusside group((7.4 ± 2.5)mm vs.(4.4 ± 1.4)mm,P 0.01).The heart rates at different time points in the diltiazem group were lower than those in the sodium nitroprusside group(P 0.01).The overall incidence of adverse drug reactions in the diltiazem group was lower than that in the sodium nitroprusside group(52% vs.20%,P 0.05).There was significant difference(P 0.01)in drug doses at different time interval in the sodium nitroprusside group with time-dependent trend,while there was no significant difference in the diltiazem group(P 0.05).CONCLUSION Intravenous diltiazem is effective and safe in postoperative hypertension after surgical closure of PDA when solium nitroprusside failed to control.

房间隔缺损(ASD)是最常见的先天性心脏病,内科介入治疗目前已是成熟的治疗方法.但巨大房间隔缺损的内科介入治疗还存在一定难度,一般认为ASD内科介入治疗适应证为ASD最大伸展内径小于30 mm[1].2005年3月至2011年3月,我们使用非体外循环下经胸微创封堵术治疗97例巨大ASD,取得良好效果,现报告如下.

<正>患者女,27岁。因胸闷、腹胀伴下肢水肿2个月,于2008年11月2日入院。本次入院前13 a,患者曾因风湿性心脏病行二尖瓣、三尖瓣机械瓣置换术,4 a前及1 a前曾2次因胸部正中切口处巨大瘢痕疙瘩而行瘢痕切除、植皮术。入院查体:颈静脉怒张,胸部正中可见陈旧性瘢痕,长约13cm,高出皮面约12 mm。心前区机械瓣启闭音清晰。

目的 探讨运用双向腔静脉-肺动脉分流术(BCPS)治疗复杂先心病的疗效及安全性.方法 47例复杂先心病患者,21例在体外循环下,26例在非体外循环下完成BCPS手术.共行单侧BCPS术30例,双侧BCPS术17例.结果 术后围术期死亡3例,病死率6.38%.随访35例,有7例术后2年左右进行二期根治手术,2例术后2年死亡,余26例心彩超复查无吻合口狭窄,发绀得到不同程度的缓解,心功能改善,生活质量明显提高.结论 双向腔静脉-肺动脉分流术对于不能一期矫治的功能性单心室类复杂先心病患者是一种有效的姑息手术方法,非体外循环下行腔肺吻合术有助于心、肺功能的早期恢复,还可减少患者的住院开支,是安全、可行且有利的.

患者男,61岁.当地医院因体检发现心脏杂音转我院进一步诊治.既往无明显不适,否认家族中有心脏病史.查体:发育正常,口唇无发绀,颈动脉搏动正常,颈静脉充盈.血压16/6 kPa,心率79次/min,窦性心律,心尖搏动位于左锁骨中线处,心界扩大,胸骨左缘第3肋间可闻及Ⅳ级收缩期杂音,并触及收缩期震颤,无心包摩擦音,无杵状指、趾,双下肢无水肿.

Objective To evaluate the multidetector-row computed tomography angiography (MUCTA) used in diagnosis and treatment of children with Tetralogy of Fallot (TOF).Methods Between December 2004 and December 2008,38 patients with TOF were assessed using eeho-doppler (TTE) and MUCTA.Three dimensional images were constructed to assess the pulmonary artery anomalies,anomalies of the coronary artery and aorta-pulmonary collateral arteries.McGoon and Nakata indiees were obtained in preparation for corrective surgery.Results A total of 38 patients were scanned using MUTCA and anomalies were diagnosed as TOF with ventricular septal defects (VSD).Two of these patients also had atrial septal defects (ASD) and three had patent ductus arteriosus (PAD).Seven had right ventricular outlet stenosis.Thirty-one patients with arterial stenosis including pulmonary arterial branch stenosis,six with left sided and eight with right sided stenosis all of which developed pulmonary arterial branch enlargement.Two had coronary artery anomalies,nineteen had aorta-pulmonary anomalies which three of these had enlarged collaterals.With the use of MUCTA and TTE,we were able to plan the surgieal procedures pre-operatvely.This was otherwise not possible.Thirty-five of the patients recovered while the remaining three patients died peri-operatively.Conclusions MUCTA is a more accurate imaging than other modalities for the assessment of pulmonary artery.

Objective To review and sum up the experience of diagnosis and surgical treatment of cardiac myxoma. Methods 133 patients with cardiac myxoma of different locations from January 1990 to May 2007 admitted in Qilu Hospital of Shandong University and Department of Cardivovascular Affdiafed Zhong shan Hospital of Xiamen Unversity were clearly diagnosed by two dimensional echecardiography. The tumors of 109 patients were located in left atrium ,22 in right atrium and 2 in both cardiac atria. All the patients underwent tumor extirpation under extracor-poreal circulation. Atrioventricular valve plasty was performed when necessary. 11 underwent bicuspid valvuloplasty and 6 underwent tricuspid valvuloplasty at the same time. All the minors were sent to histopathology examination. Re-suits Two patients died of low cardiac output syndrome in early postoperative period. Cerebral embolism happened in 6 cases,left lower extremity embolism and pulmonary embolism in 1 ease respectively. Other patients' symptoms were improved and the physical sign disappeared. All the tumors were demonstrated to be benign cardiac myxoma. Conclusions Most cardiac myxoma is benign but its clinical consequence is severe. So tumor extirpation should be performed as soon as possible and the following-up is important after operation. Prevention of tumor defluvium is im-portant. Two dimensional echocardiography is preferred in the diagnosis of cardiac myxoma.

A 7-year-old boy was hospitalised because of sudden back pain 7 years after surgery for interruption of the aortic arch.A computed tomography angiography demonstrated a large pseudo-aneurysm between the left carotid artery and the previously implanted vascular prosthesis (Figs. 1 and2).

目的探讨超声心动图在经胸小切口直视封堵房间隔缺损（ASD）及室间隔缺损（VSD）术中的应用价值。方法对31例ASD和2例VSD患者,术前采用经胸超声筛选合适的病例及封堵器;术中采用经胸超声或经食管超声指导封堵术,经右心房插入特制推送器,将封堵器嵌入ASD或VSD处;术后即刻及1~9个月随访观察封堵器的位置及有无分流。结果31例ASD患者中,29例封堵术成功,2例失败;2例VSD患者均获得成功。术后随访1~9个月,无一例发生严重并发症。结论超声心动图在小切口直视封堵ASD、VSD术前病例筛选、术中闭合器放置指导、术后疗效评价中起到重要作用。

微创是当前外科手术的发展趋势,2005年3月至2006年3月,我们使用微创封堵术对14例房间隔缺损（ASD）患儿进行治疗,取得良好效果。

二尖瓣置换术后左心室破裂是一种少见而致死率极高的并发症.其发生率为0.43%～2.00%,病死率高达65%～100%[1].自1996年以来,我们共发生3例,抢救成功2例,死亡1例,结合文献报道,分析如下.

Objective To investigate the effectiveness of concomitant microwave ablation of atrial fibrillation in heart valve surgery.Methods In heart valve surgery,concomitant microwave ablation was performed in 90 patients suffering from persistent atrial fibrillation with heart valvular disease.Results The mean time for microwave ablation was 14.3(2.9 min.All patients had been followed up for 1～24 months.Fourteen patients recurred and others kept normal sinus rhythm without interrelated complications.The curative rate was 84.4%.Conclusion Concomitant microwave ablation of atrial fibrillation in heart valve surgery is safe and effective.