AIM To analyze risk factors for repeat sternotomy (RS) in adult cardiac surgery (CS) and to identify the impact on outcomes.METHODS A retrospective study was conducted by analyzing the data of 242 patients with RS of CS from September 2009 to September 2015 at the 55th Ward of Adult Cardiac Center in Fuwai Hospital.Continuous variables were analyzed using 2-sample t tests and categorical variables were compared using 2-or Fisher's exact test.RESULTS Among the 242 patients,major injury (MI) occurred in 5 cases (2.1％) and no significant difference was found between the MI group and the nonMI group related to the interval since last sternotomy (8.3 ± 5.0 years vs.2.5 ± 8.8 years,P =0.286).Occurrence rate of MI was not statistically different between the primary coronary artery bypass graft and other operations (6.3％ vs.1.8％,P =0.292),or between the pericardium had closed or not (0％ vs.7.4％,P =0.275).The operative mortality rate was 1.7％ (4/242) and the operative mortality among the patients with MI during RS was not statistically different with those without MI (0％ vs.1.7％,P =0.919).CONCLUSION RS in adult CS is relatively safe and MI during RS is not a dangerous predictor of operative mortality.

Objective To summarize the clinical effect of mitral valve replacements with all subvalve structures preserved. Methods A total of 28 patients,including 17 males and 11 females,underwent mitral valve replacements with preservation of all subvalve structures,both of which suffered from mitral incompetence. Preoperatively,12 cases were in NYHA function class Ⅱ and 16 cases in classⅢ. Results There was no operative death and no postoperative complications( low cardiac output,severe arrhythmia and reoperation for hemostasis following open-heart surgery). Follow-ups showed that all the cases were successfully recovered,with heart function in class Ⅰ ~ Ⅱ. Conclusions Mitral valve replacements with preservation of all subvalve structures is a safe and effective surgical technique,which can reduce the risk of post-operative left ventricle rupture and improve the left ventricular ejection fraction.

目的：探讨主动脉根部———右心房分流术在带主动脉瓣人工血管升主动脉替换和冠状动脉开口移植手术（ Bentall手术）中的效果。方法回顾性分析22例在Bentall手术中预防性应用主动脉根部—右心房分流术患者的临床资料，观察其疗效。结果22例患者中无术中死亡病例，手术时间（226±33）min，术中体外循环时间（131±25）min，阻断时间（83±12）min，术中失血量（326±106）mL，术后总引流量（610±219）mL，术后住院时间（13．7±5．0）d。出院前常规超声心动图检查提示主动脉根部与右心房间无血流流动，64排CT检查显示主动脉根部有血栓形成，术后随访6～12个月，无早期及远期出血，无右房血栓、肺栓塞、心肌梗死等情况发生。结论主动脉根部—右心房分流术在并行循环复温过程中，可缩短体外循环及手术时间，改善手术效果，减少出血相关并发症，提高手术成功率。

Objective To summarize the experience of Bentall operation for aortic root aneurysm .Methods 21 patients with ascending aortic root aneurysm underwent Bentall operation .Among the 21 cases,there were 14 cases of ascending aortic aneurysm and over moderate and severe aortic valve regurgitation ,1 case of ascending aortic aneurysm and over moderate and severe aortic valve stenosis,3 cases of Marfan syndrome,and 3 cases of acute dissecting aortic aneurysm.Before operation,2 cases were ranked in NYHA function class I , 14 cases in class II and 5 cases in class III.Results One patient died in hospi-tal.No postoperative complications ( low cardiac output , severe arrhythmia and reoperation for hemostasis following open-heart surgery)occurred in the others.Follow-ups showed that 20 patients successfully recovered,with heart function improving to classes I-II.Conclusion Bentall procedure should be the optimal option for ascending aortic root aneurysm .Furthermore,to improve surgical technique ,reduce CPB time , decrease myocardial injury and ensure coronary artery blood flow are the essen-tial factors for surgical success .

目的 探讨成人Ebstein's畸形的临床特征及外科治疗策略. 方法 2008年1月至2011年12月阜外心血管病医院手术治疗成人Ebstein's畸形78例,其中男24例,女54例;年龄18～54(33.0±9.5)岁.术前心功能分级(NYHA)Ⅰ～Ⅱ级72例,Ⅲ级以上6例.临床表现主要为运动耐力下降和活动后心累.术前二维超声心动图示三尖瓣隔瓣下移20～60 (34.8±12.7)mm,隔瓣严重发育不良或缺如3例;后瓣下移20～70(46.8±11.6)mm,后瓣缺如1例;三尖瓣瓣环明显扩大为37～70 (60±10)mm;平均房化心室占右心室约40％;三尖瓣中量反流18例,中大量反流60例.75例行三尖瓣成形术.除2例未处理房化心室外,余均进行了房化心室折叠(56例)或房化心室去除(20例).32例应用了人工三尖瓣瓣环.3例行三尖瓣置换术. 结果 术后死亡2例,死亡率2.5％.患者术后恢复尚可,无严重房室传导阻滞等其他并发症.出院前常规检查提示三尖瓣功能良好,无三尖瓣中度以上反流.平均随访时间26个月,无1例需要再次手术. 结论 成人Ebstein's畸形患者急性心功能衰竭发生率低.外科治疗以成形为主,术后可达到外科治疗的主要目的,即改善心功能、增加患者的远端耐力和改善生活质量.

目的 总结保留二尖瓣后瓣及瓣下结构的二尖瓣置换术的临床效果.方法 完成保留二尖瓣后瓣及瓣下结构的二尖瓣置换术310例,男112例,女188例,均为风湿性心脏病.术前心功能分级(NYHA)I级33例,II级119例,III级126例,IV级32例.结果 术后死亡2例,随访6个月~6年,无死亡病例,心功能I-Ⅱ级.结论保留二尖瓣后瓣及瓣下结构二尖瓣置换术可减少左心室破裂的危险,改善术后心功能.

目的：探讨左心瓣膜替换术后功能性三尖瓣反流外科治疗的手术时机和导致功能性三尖瓣反流出现的病因学特点。<br>　　方法：2005-01至2013-04阜外心血管病医院外科手术治疗73例，男21例，女52例。平均年龄（52.1±8.4）年，心功能Ⅱ级15例，Ⅲ级50例，Ⅳ级8例。风湿性心脏病71例，先天性心脏病1例，感染性心内膜炎1例。术前合并房颤心律40例。肺动脉高压轻度4例，中度9例，重度1例。

Objective To explore the cause of acute myocardial ischemia early after coronary artery bapass graft (CABG) and surgical management on it. Methods From 2001 to 2009, 28 patients underwent urgent reoperation early after CABG due to acute myocardial ischemia. The incidence of reoperation is about 0.02%. The cause of reoperation inclouded early graft occlusion (10 cases) ,IMA damage or injury during harvesting(9 cases), inexactitude distal anastomosis(2 cases)and radial artery spasm(4 cases). The mean interval time between two operations was 8 hours. Reoperation was done under offpump bypass in 2 patients and on-bypass used in other patients. Unsatisfactoey graft were substituted with new graft material and thrombotic was removed. If LIMA was the reson for myocardial ischemia, an additional vein graft was inserted. The spasm radial artery were substituted with new vein graft. Completely revascularization was used in re-do CABG. Results Two patients died during reoperation. 8 patients was died between 1 day and 14 days after reoperation. IABP was used in 16 patients,which 2 patients received ECMO suppord and 2 patient received LVAD suppord at mean time. Conclusion There have very high mortality in acute myocardial ischemia early after CABG. The early diagnosis and correct surgical management can improve the rates of survival. The active prevent should be emphasized during the first CABG.

Objective:To summarize the experience in repairing the atrioventricular dissociation defects by microtraumatic surgery with non-stop cardiac impulse.Methods:Twenty-four cases of congenital atrioventricular dissociation defects were repaired through the right subaxillay incision with extracorporeal circulation and the heart beating.The atria defects in 2 cases complicated with partial anomalous pulmonary venous connection(PAPVC) were enlarged and the right pulmonary vein which had been drained to the right atrium was isolated to the left atrium with a displaced septum;the valve junction incision was performed in 2 cases complicated with pulmonary valve stenosis,3 cases complicated with tricuspid valve incompetence received tricuspid valve plastic operation.Results:No deaths or complications such as residual shunt,gaseous emboli or low cardiac output were observed.The right atrium posterior wall and the right lower pulmonary veins in 2 of the cases were damaged separately;1 had transient hemoglobinuria and 1 arrhythmia.Conclusions:The procedure of right subaxillay incision with extracorporeal circulation and non-stop cardiac impulse causes little trauma,but it must be operated safely and accurately.

目的 应用牛颈静脉带瓣管道(BJVC)进行心脏右室流出道的重建,探讨BJVC对复杂先天性心脏病外科治疗的效果.方法 2005年10月至2009年5月共应用BJVC治疗复杂先天性心脏病15例.结果 BJVC重建右室流出道15例患者均痊愈出院.随访3～24个月,患者心悸、气促消失,活动耐力明显提高,心功能恢复至Ⅰ～Ⅱ级,超声检测发现15例置入的管道通畅,无扩张,未见血栓形成,瓣叶活动良好,无明显反流,肺动脉跨瓣压差不大,吻合口无狭窄.结论 BJVC用于复杂先天性心脏病右室流出道的重建可获良好的近期治疗效果,但远期效果仍有待进一步观察.

目的 总结80例心脏瓣膜疾病的外科治疗经验.方法 80例患者中行二尖瓣置换术43例,二尖瓣成形术5例,主动脉瓣置换术12例,双瓣置换术12例,单瓣膜置换+冠状动脉搭桥术4例,二尖瓣成形+主动脉瓣置换术1例,带瓣人工血管置换术(Bentall术)2例,三尖瓣置换术1例,同期三尖瓣成形18例,血栓取出术13例,左房缩缝+左心耳结扎3例.结果 死亡3例,死亡率为3.7%.死亡原因为左室破裂、低心排并肾衰、心律紊乱各1例,低心排3例,心律紊乱10例,心包积液1例,术中二次转机2例,二次剖胸止血1例.结论 提高手术疗效,降低死亡率,应重视围术期处理及心脏功能的支持、保护,提高手术质量,减少手术并发症.

Objective To estimate clinical outcome of aortoatrial shunts for inaccessible bleeding in aortic root replacement.Methods Review 515 cases of aortic root replaoement done in our hospital from 4, 1989 to 12,2005.Among them 112 cases were performed aortoatrial shunts for inaccessible bleeding in aor- tic root.Estimate the CPB time,postoperative bleeding volume,blood products perfusion volume,morbidity of re-open chest for bleeding.Results Among the 112 cases,male 91,female 21;average age 40±12.8; average weights69±10.6 kg;postoperative bleeding volume is 400～1340 ml,average 848±271 ml.Aver- age blood perfusion volume is 750±250 ml.Average plasma perfusion volume is370±230 ml.3 cases were performed re-open chest for bleeding of remote anastomosis site.1 died for infection of graft.Conclusion Aortoatrial shunts can effectively control inaccessible bleeding in aortic root replacement.It also can roduce CPB time,lessen postoperative bleeding volume and blood products perfusion volume.

目的探讨成人主动脉缩窄的临床特点和外科治疗方法。方法40例成人主动脉缩窄患者行手术矫治,其中心脏不停跳手术28例,常规体外循环下手术12例。行主动脉狭窄段切开、人工血管补片扩大术12例,人工血管置换术15例,锁骨下动脉-降主动脉旁路移植术1例,采用人工血管行胸-腹主动脉旁路移植术9例,经心包后径路行升主动脉-降主动脉旁路移植术3例。结果全组无手术死亡,几种术式术后均无脑部和脊髓等神经系统并发症。术后36例得到随访,平均随访12个月。36例患者上、下肢血压差均小于10 mmHg(1kPa=7.5mmHg)。超声心动图和超高速CT检查提示人工血管血流通畅,无假性动脉瘤形成。结论成人主动脉缩窄的外科术式有多种选择,掌握好手术适应证,根据患者的具体病理生理状况选择合适的手术方式可获得满意的治疗效果。

Objective To compare the effects of two kinds of cannulation sites on the myocardial oxygen metabolism during left ventricular assistance to provide experimental basis for clinical selection of proper cannulation sites.Methods Twelve mongrel dogs were randomized equally into the left atrium to aorta group(LA group) and left ventricle to aorta group(LV group),and underwent left ventricular assistance.At different times before and during left ventricular assistance,the heart rate,coronary sinus flow rate and blood gas were determined and coronary sinus oxygen saturation,arteriovenous oxygen difference and myocardial oxygen consumption were calculated.Results There was no statistical difference of heart rate in both groups(P>0.05).The coronary sinus flow rate and mean myocardial oxygen consumption reduced in both groups after left ventricular assistance,whereas the effect was more remarkable in the LV group(P<0.01).Conclusion Both cannulation methods could reduce the myocardial oxygen consumption during left ventricular assistance,and the effect is more apparent in left ventricular cannulation.

Left ventricular rupture after mitral valve replacement is a rare but lethal complication. Between 1995 and 2003, left ventricular rupture occurred in 13 of 5,449 patients who underwent mitral valve replacement, with an incidence of 0.24%. There were 4 immediate ruptures and 9 delayed ruptures. Urgent repair of the rupture was performed under cardiopulmonary bypass in 11 cases. All mitral prostheses were explanted. External repair alone was performed in one patient. External repair combined with internal repair was performed in 10 patients. Two patients died of cardiac tamponade and failure of cardiac resuscitation. Of the 11 patients who had a re-operation, 6 died in hospital and 5 survived. The mortality was 61.5% (8/13). At a mean follow-up of 4 years, 2 patients were in New York Heart Association functional class II and 3 were in class III. Proper diseased valve removal, decalcification, and prosthesis selection could minimize the incidence of left ventricular rupture. Immediate diagnosis and urgent surgical intervention are crucial for successful repair.

Objective To summarize the experience of emergency coronary artery bypass grafting (CABG) after failed percutaneous coronary intervention. Methods From January 1998 to December 2002, 9 patients underwent emergency CABG after failed percutaneous coronary intervention. The indications of emergency CABG were coronary artery dissection (5 cases)or perforation (2 cases) and acute arterial occlusion (2 cases). The time averaged 2 hours from onset of ischemia to revascularization. The CABG was performed under off-pump bypass in 3 cases and under CPB in 6 cases. The mean graft number was 3. Results There were no hospital death. The mean follow-up was 17 months. No death and angina occurred. The function of New York Heart Association class Ⅰ-Ⅱ were in 8 patients, class Ⅲ in 1 patient. Conclusion Emergency CABG is an effective management for failed percutaneous coronary intervention if the indication is right.

目的讨论法洛四联症(TOF)术后肺动脉瓣关闭不全的外科治疗时机和方法. 方法 5例TOF患者行根治术后发生严重肺动脉瓣关闭不全,选用液氮保存的同种带瓣肺动脉行肺动脉瓣置换术(PVR),并同期分别行三尖瓣成形术(TVP)、右心室流出道(RVOT)成形术、VSD残余漏修补术或RVOT疏通. 结果 1例术后早期因进行性右心功能衰竭死亡;余4例均恢复良好,无严重心律失常;分别随访3个月～4年,心功能为Ⅰ～Ⅱ级. 结论早期PVR能明显改善右心功能;采用同种带瓣肺动脉手术简便,早期效果满意.

OBJECTIVE:To study the efficiency of surgical treatment on coarctation of the aorta and associated with heart defect.METHODS:From 1994 to 2001, 45 patients with aortic coarctation and associated with heart defect underwent surgical repair. They were divided into two groups: single-stage repair group (26 cases) and two-stage repair group (19 cases). There was mild or severe pulmonary hypertension in 23 cases (with mean pulmonary artery pressure being 56 mm Hg). There were two incisions used in first-stage group (single midline incision in 21 cases and left-side combined midline incision in 5 cases). The mean course for the second operation was 105 days in second-stage group.RESULTS:Two patients died in each group. Twenty-four patients had not blood pressure difference between arm and leg after operation. The mean systolic blood pressure difference was less than 10 mmHg in 10 patients. Mean period of follow-up was 28.6 months. No patients died and had re-coarctation.CONCLUSION:The operative results showed no difference between single-stage and two-stage repair in surgical correction of aortic coarctation associated intracardiac defect. The left-side combined midline incision in single-stage operation was an effective and safe technique.

目的 总结冠状动脉旁路移植术(CABG)后早期严重心肌缺血的急诊外科治疗经验. 方法 1998～2002年间,13例CABG患者术后早期因严重心肌缺血而急诊二次CABG.病因包括静脉移植物血栓形成4例,未完全再血管化3例,移植物痉挛1例和移植物吻合口狭窄或闭合5例.二次CABG移植血管1～3支(1.8±0.9支). 结果手术死亡6例,手术死亡率46%.平均随访31个月,无心绞痛复发.NYHA心功能Ⅰ～Ⅱ级. 结论急诊外科是挽救CABG术后早期严重心肌缺血患者生命的重要方法,强调围术期预防以及早期处理.