患者2年前行经导管主动脉瓣瓣中瓣置换术治疗重度主动脉瓣狭窄,术后并发中度瓣周漏(PVL),后进展为重度PVL、纽约心脏病协会(NYHA)心功能分级Ⅳ级、慢性心力衰竭.进行经导管介入封堵术成功封堵多漏口,PVL改善为轻-中度.半年后复查,NYHA心功能分级Ⅱ级、PVL改善为轻度,治疗效果满意.本例提示经导管主动脉瓣置换术(TAVR)术前影像评估应对PVL进行可能性分析,预计发生概率较大时,可针对性选择瓣膜以预防或改善PVL,并做好同期PVL封堵术准备;充分利用CT 3D重建、计算机辅助3D打印技术对多隧道PVL直观、立体和精准显示,对于合理选择封堵器和导丝,指导封堵策略,提高手术成功率具有重要价值.

More and more biological valves have been used in aortic valve replacement in the world due to their unique advantages; however, due to the poor durability of biological valves and other reasons, valve deterioration is an inevitable problem of artificial biological valves. Once severe valve deterioration occurs, it can lead to valve stenosis or regurgitation, which may result in cardiac enlargement and cardiac insufficiency and often require valve re-replacement. Surgical valve replacement has long been the gold standard for the treatment of aortic valve deterioration, but since biological valves are mostly used in the elderly and there is a high risk of surgical valve re-replacement, many patients are rejected from surgery. In recent years, due to the accumulation of experience in transcatheter aortic valve replacement (TAVR) and related technical advances, it has been increasingly applied in the treatment of biological valve deterioration, especially the application of “valve-in-valve” TAVR.

62岁男性患者，发现右心室肿物1天。既往有骨肉瘤病史。超声心动图示右心室心腔内及右心室壁占位性病变。2019年2月在全麻低温体外循环下行右心室肿物切除术＋三尖瓣生物瓣膜置换术＋心外膜临时起搏导线缝置术。术后病理检查示间叶源性恶性肿瘤，考虑心脏转移性骨肉瘤。术后随访1年，患者心功能良好，心腔内未见肿瘤复发，右心室壁占位无明显变化。

目的 比较二叶式主动脉瓣(BAV)和三叶式主动脉瓣(TAV)对经导管主动脉瓣置换术(TAVR)后患者左心室逆向重构的影响.方法 回顾性分析我院TAVR术后至少有3次连续超声心动图随访(1、3个月和1年)的67例患者的临床资料,比较BAV和TAV对经TAVR治疗后患者左心室逆向重构的影响.结果 67例患者中BAV 23例,TAV 44例.两组患者术前基线资料比较差异无显著性(P>0.05);两组患者术后肺动脉收缩压(PASP)、左心室质量分数(LVMi)、相对室壁厚度(RWT)均随时间延长逐渐下降(F=3.64～25.59,P<0.05);术后1年BAV组的LVMi明显小于TAV组(F=16.98,P<0.05).两组术后病死率及并发症发生率差异均无显著性(P>0.05).结论 BAV与TAV患者在接受TAVR术后均发生明显的左心室逆向重构,两者治疗效果相近.

二叶式主动脉瓣(BAV)畸形是主动脉瓣畸形中较为常见的一种瓣膜发育异常.目前,经导管主动脉瓣置换术(TAVR)是治疗中、高风险BAV患者的重要方法,但一些围术期因素仍是影响患者预后的重要因素.我们通过对TAVR治疗BAV畸形的相关研究进行回顾分析,希望为提高患者的预后提供更多方法.

目的 探讨采用胸主动脉腔内修复术(TEVAR)治疗主动脉溃疡(PAU)患者的远期效果.方法 选取2008年1月—2017年1月本院心血管外科经主动脉CT血管造影(CTA)确诊的PAU患者86例,根据患者的病情分为TEVAR治疗组(A组)67例和药物治疗组(B组)19例.记录两组患者年龄、性别、并发症、吸烟史、饮酒史、住院时间、随访结果 等.结果 所有患者住院期间均无死亡.A组的随访结果 分级与B组比较差异具有显著意义(χ2=2413.00,P＜0.05);A组患者的中位生存时间与B组比较差异具有显著统计学意义(χ2=2.28,P＜0.05).结论 TEVAR治疗PAU患者安全有效,患者中位生存时间长,值得在临床推广应用.

目的 通过对经导管主动脉瓣植入(TAVI)术患者术后抗血栓治疗情况的随访,比较华法林和阿司匹林联合波立维抗血栓治疗的效果.方法 选取于我院心血管外科2017年9月—2019年3月行TAVI术后的患者32例,分为华法林治疗组(华法林组)15例及阿司匹林联合波立维治疗组(双抗组)17例.术后通过住院观察、电话随访和门诊随访,了解并记录两组患者预后及抗血栓并发症的发生率,并进行统计学分析比较.结果 术后随访32例,随访率100%.两组患者均无死亡.华法林组有2例发生脑梗死,双抗组无脑梗死发生,两组比较差异无统计学意义(P=0.212);华法林组患者无消化道大出血,而双抗组发生1例,两组比较差异无统计学意义(P＞0.05).结论 TAVI术后服用阿司匹林联合波立维与华法林抗血栓治疗的患者短期生存率及并发症发生率无明显差异,TAVI术后患者可以单独采用华法林进行抗血栓治疗.

1 临床资料 患者 男,73岁.因"发作性胸痛20年,进行性加重1周",于2019年10月10日在青岛大学附属医院就诊.现病史:患者近20年反复出现无明显诱因胸痛,夜间平卧入睡无憋醒,2016年6月于本院心内科给予前降支置入支架一枚,病情仍未缓解.既往病史:高血压病史20年;冠心病史6年,4年前行冠状动脉左前降支近端支架置入术.入院查体:主动脉听诊区可闻及舒张期杂音,P2稍亢,伴分裂,股动脉枪击音(-).超声心动图示:左心室扩大,左心室舒张末期内径6.2 cm,左心室射血分数38％,左心室壁节段性运动异常;主动脉瓣四叶式畸形,主动脉瓣重度反流(图1～2).冠状动脉造影示:左前降支支架通畅(图3).胸腹部增强CT结果及相关测量数据显示:瓣环为椭圆形,周长67 mm,平均内径21.3 mm,瓣膜见点状钙化;四叶式法氏窦(图4)周长124.2 mm,直径分别为34.5 mm、31.0 mm、32.5 mm、30.7 mm,左冠状动脉高度20.4 mm,右冠状动脉高度13.2 mm,胸腹主动脉未见明显异常,双侧股动脉最小直径≥7.6 mm.该患者心功能不全(美国纽约心脏病协会心功能分级Ⅲ级),纠正后反复再发,伴夜间阵发性呼吸困难.美国心胸外科学会评分系统示手术的病死率为9.32％,外科手术风险极高危,且四叶式主动脉瓣(quadricuspid aortic valve,QAV)罕见.经青岛大学附属医院心脏瓣膜团队评估,决定选择经导管主动脉瓣置入术(transcatheter aortic vale implantation,TAVI)进行瓣膜置入.

主动脉瓣狭窄是一种常见的心脏瓣膜疾病.成人主动脉瓣口面积≥3.0 cm2. 一般认为,瓣口面积减小50％以上时会改变其血流动力学,出现跨瓣压力差. 当主动脉瓣口面积<1.50 cm2且>1.00 cm2为主动脉瓣轻度狭窄,0.75～1.00 cm2为中度狭窄,<0.75 cm2或跨瓣压差≥70 mmHg为重度狭窄. 据调查,65 岁以上人群中明显主动脉瓣钙化约 25％, 70岁以上约35％. 其中10％～20％在10～15年后可进展为有血流动力学意义的主动脉瓣狭窄[1]. 近年来,主动脉瓣狭窄发病率呈上升趋势. 主动脉瓣狭窄的原因主要有风湿热引发的瓣膜病变、先天性瓣膜发育不全、老年退行性病变或感染性心内膜炎导致的较大赘生物阻塞瓣口等[2]. 由于左心室有较强的代偿性,在发病或很长一段时间都不表现明显症状. 在长期的高强度作功条件下,左心室出现向心性肥厚,心肌耗氧量增加,最终导致心力衰竭.

临床资料 患者男,78岁.主因劳累后胸闷、憋气不适5年,加重1个月入院.既往高血压病史5年余,收缩压最高达190 mmHg(1 mmHg=0.133 kPa);糖尿病史;肝炎病史30年.入院查体:体温36.5℃,血压180/92 mmHg,心率60/min,心率齐,心音正常,主动脉瓣听诊区可闻及舒张期杂音,P2稍亢,伴分裂,股动脉枪击音(-).实验室检查:血糖14.08 mmol/L,肌酐272 μmol/L.

Objective To investigate the results of the surgical treatment in the patients with Stanford type A aortic dissection.Methods Aretrospective study was performed on 88 cases of patients who were admitted and underwent surgery of the Stanford type A aortic dissection from January 2011 to March 2016.The preoperative data,in vitro circulation data,perioperative blood transfusion volume,mechanical ventilation time,ICU hospitalization time,total hospitalization time and postoperative complications were analyzed.Results In the total 88 cases,16 cases were operated by the means of the none-total arch replacement without the deep hypothermic circulatory arrest (7 cases with the ascending aorta replacement and Bentall surgery in 9 cases),and the rest of the 72 cases were operated by the total arch replacement (ascending aorta replacement + Sun's surgery in 40 cases,Bentall + Sun's surgery in 31 cases,David + Sun's surgery in 1 case).Compared with the patients of non-total arch replacement group,patients of total arch replacement group were with low intraoperative nasopharyngeal temperature and anal temperature,long time of extracorporeal circulation and the ascending aorta blocking,large amount of intraoperative red blood cells,plasma and platelet transfusion,long time of the breathing machine ventilation and ICU length of hospital stay,large amount of postoperative red blood cells,plasma and platelet transfusion,high incidence rate of postoperative neurological complications,and the differences were statistically significant(P ＜ 0.05).The autologous blood transfusion volume,the total length of hospital stay,postoperative acute kidney injury,hypoxemia,the application of continuous renal replacement therapy and secondary tracheal intubation and tracheostomy and mortality rate in the total arch replacement group were higher than those in the non-total arch replacement group,there was no statistically significant difference between the two groups(P ＞ 0.05).During the follow-up,2 patients(12.5％) were re-operated by the means of total arch replacement and descending aorta stent implantation because of the aortic dissection in the aortic arch in the none-total arch replacement group,there was no secondary surgery in the total arch replacement group,and the difference was statistically significant (P ＜ 0.05).Conclusion The surgical treatment effect of the Stanford A type aortic dissection is satisfactory although the disease is complicated,the condition is severe,the operation risk is large and the in-hospital mortality is high.Intraoperative brain protection is of particular importance,and selection of surgical methods should be considered.

体外膜肺氧合( extracorporeal membrane oxygenation,EC-MO)是指通过胸腔外血管插管进行的长时间体外心肺支持。ECMO可以对呼吸功能衰竭或心功能衰竭的危重患者进行有效的呼吸或循环支持。1972年,Hill等[1]首先报道了此技术的临床应用。 ECMO技术不仅应用于心胸外科的心肺支持、心肺移植过渡、呼吸窘迫综合征的救治,还用于新生儿胎粪吸入,气管内异物吸入、婴幼儿的室上性心动过速、重症心脏介入手术、先天性膈疝、严重心肺外伤、烧伤科患者的吸入性肺损伤、不同原因的严重肺炎及多器官功能衰竭等多种病症,并逐渐成为一个跨学科的新技术。在我国,ECMO仍处在起步阶段,对有关装置的认识及使用、临床适应证的选择、各种参数的控制及撤离ECMO的指征等,均是目前体外循环及心外科值得探讨的问题[2]。现结合青岛大学医学院附属医院心血管外科收治的l例缺血性心肌病患者,行冠脉搭桥加室壁瘤切除术后顽固性心力衰竭,应用ECMO 技术心肺辅助成功救治,对有关应用ECMO的情况进行回顾性分析。现报道如下。

Objective To review our experience in the diagnosis and treatment for 98 cases with penetrating aortic ulcer(PAU) after thoracic aortic lumen repair(TEVAR) postoperative use of immunosuppressant adjuvant therapy. Methods A retrospective analysis was performed on 98 cases of PAU with histopathological from July 2002 to May 2012. After TEVAR,patients were treated with(treatment group) or without(control group) tripterygium glycosides and prednisone for about 7 to 12 days. The average of follow-up is 32.4±6.3 months and the recurrence rate was recorded. Serum levels of vascular cellular adhesion molecule-1(VCAM-1) and heat shock protein 60(HSP60) were determined by ELISA. Results The serum levels of VCAM-1 and HSP60 were significantly reduced one month after TEVAR in treatment group,but were only modestly reduced in control group. After about three years follow-up,the recurrence rate of patients in the treatment group(11.11%) was significantly lower than that in the control group(31.91%). Conclusion Adjuvant therapy with immunosuppressants can effectively attenuate the recurrence rate of PAU after TEVAR.

<正>随着心血管外科临床技术的进步、人类对生活质量的追求、人均寿命的延长等诸多因素的影响,越来越多的高龄瓣膜病患者得以治疗。我院自1998年1月至2012年4月共对80例70岁以上瓣膜病患者进行了手术治疗,现回顾和总结该80例临床治疗经验,并结合国内外相关资料,进一步探讨其病因、手术适应证、手术方法、瓣膜选择以及近远期效果。

目的 对16例三瓣膜置换病例进行临床分析,以利提高对本病的手术疗效.方法 行三瓣膜置换术16例患者中男性6例,女性10例.其中风湿性心脏病14例,感染性心内膜炎2例.术前心功能Ⅱ级3例,Ⅲ级8例,Ⅳ级5例.结果 本组死亡1病,随访10 ～71个月,心功能Ⅰ～Ⅱ级12例,Ⅲ级3例.结论 对三瓣膜置换术要严格掌握手术适应症,并注意瓣膜选择.

AIM To isolate and culture human aortic valve interstitial cells and to identify their morphology,subtype and membrane molecules distribution.METHODS The endothelial cell layers on the dissected valves were removed and the remaining interstitial layers were minced and digested with collagenase I.Cells were then seeded and maintained on culture dishes.Cells were observed under light microscopy and cellular α-smooth muscle actin was detected with confocal staining microscopy.The expressed interferon(IFN)-γ and tumor necrosis factior(TNF)-α receptors were analyzed by flow cytometry with their corresponding monoclonal antibodies.RESULTS The isolated valves interstitial cells were proved to be myofibroblast.More IFN-γ receptors and TNF-α receptors were expressed on rheumatic aortic valves interstitial cells than on non-rheumatic cells and their expression was patients' sera dependent.CONCLUSION The valves interstitial cells culture system has been established successfully and the membrane molecules differ according to their origins.

Objective To explore pathogenesis of rheumatic heart vascular diseases(RHVD) from direction of valve repair after mechanical stress injury through tenascin-C(TN-C) expression by culturing valve interstitial cells in vitro with designed strain-producing instrument under mechanical stress.Methods Aortic valves were obtained under aseptic condition,and the endothelial layer deprived.The valve interstitial cells were isolated by collagenase Ⅰ and then cultured in vitro.The equi-biaxial cyclic strain production device was developed.TN-C mRNA was measured by quantitative real-time RT-PCR after mechanical application.Signal transduction pathways induced by mechanical stress were assessed after using different protein kinase inhibitors.Results The equi-biaxial cyclic strain production device was developed successfully.Cyclic strain induced TN-C transcription through RhoA/ROCK signaling pathway other than p38 mitogen-activated protein kinase,PKC and ERK activation were found.Conclusion In the process of rheumatic valvulitis,the mechanical power plays a certain role in TN-C transcription and expression and thus inducing pathologic changes of the valve.

AIM:To identify the distribution of tenascin-C(TN-C)in sera and heart valves of patients with rheumatic heart diseases and its significance.METHODS:The sera of normal subjects,patients with congenital valves malformation and patients with rheumatic heart diseases were collected and the TN-C concentrations were measured with ELISA.The heart valves were obtained surgically from patients with congenital malformation or rheumatic heart diseases.The valves were embedded in paraffin and then TN-C distribution pattern was identified by immunohistochemistry.RESULTS:Compared with normal subjects or patients with congenital valves malformation,the sera concentration of larger variants TN-C was significantly higher than that in patients with rheumatic heart diseases.TN-C was mainly distributed on the basement membrane beneath the endothelial cells in the malformed valves,and universally distributed in the rheumatic valves.CONCLUSION:To some extents,TN-C could be taken as biomarker of rheumatic heart diseases and TN-C may be involved in pathogenesis of rheumatic heart valves diseases.

20世纪50年代人工心肺机问世以来,心内操作安全的大部分问题得到了解决,但心肌保护的问题仍是人们关注的焦点.心脏停跳液的研究,使其逐步接近生理状态,并符合心肌细胞代谢的要求,明显降低了心脏术中、术后的并发症,为心脏外科的进一步发展打下了良好的基础.温血灌注常温停跳技术[1]以及国内兴起的不停跳体外循环技术[2],对传统的低温晶体停跳液提出了挑战.

目的寻找临床中实用、安全有效、制作简便的食管修复材料或食管替代物. 方法在无菌条件下手术切取犬降主动脉,制作成2 cm×3 cm的主动脉片低温保存;将3只成年健康杂种犬经手术制造颈段食管壁缺损,用预先低温保存的同种异体犬主动脉片修补缺损. 结果动物全部存活,新生食管壁具有正常食管的各层结构和功能,局部管腔无狭窄,进食正常,术后无严重急性排斥反应. 结论同种异体主动脉片可以诱导自体食管壁新生,用于食管壁缺损的修补.