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。

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 evaluate the curative effect of artificial chordae loop technique or loop in loop technique and annuloplasty ring on the treatment of mitral valve prolapse. Methods From September 2015 to January 2016,totally 8 patients with mitral valve prolapse underwent artificial chordae loop technique or loop in loop technique and annuloplasty ringimplantation. There were 7 males and 1 female,with the average age of (58. 15 ± 4. 2) years. Among them,regurgitation caused by chordal rupture after SBE in 1 pa-tient,chordal rupture after heart tumor in 1 patient,simple chordal rupture in 4 patients,and chordal extension 2 patients. Preoperative echoeardiography demonstrated:prolapse of anterior leaflet in 5 patients,posterior leaflet in 1 patient,and both leaflets in 2 patients ac-cording to carpentier standard. Severe mitral regurgitation existed in 5 patients,moderate-severe mitral regurgitation existed in 2 pa-tients,and moderate mitral regurgitation existed in 1 patient. Preoperative ejection fraction (EF)value was (58. 83% ± 2. 9%),left ventfieular diastolic diameter (LVDD)was (46. 7 ±1. 5)mm,diameter of left atrium dimension (LAD)was (50. 6 ±1. 7)mm. Mitral prolapse was corrected with artificialchordae loops or loop in loop and annuloplasty ring implantation. Mean CBP time was ( 123 ± 11. 7)minutes,mean aortic clamped time was (106 ± 9. 5) minutes. Duran rings were implanted in 4 cases and Edwards Physio Ⅱrings in 4 cases for annuloplasty. Concomitant procedure included tricuspid valve annuloplasty in 7 cases,tricuspid valve repalcement in 1 case,CABG in 1 case,and aortic valve replacement in 1 case. Results No petioperative death and serious complications occulted in any cases. Postoperative echocardiography demonstrated trace MR in 6 patients and no MR in 2 patients. Postoperative EF value was (58. 13% ± 2. 9%),LVDD (46. 7 ± 1. 5)mm and LAD (42. 9 ± 1. 1)mm,all decreased significantly. The follow-up ranged from 1 to 3 months,trace MR in all 8 eases. Conclusion Artificial chordae loop technique or loop in loop technique and annuloplasty ring were easy and effecrive to correct mitral valve prolapse. The early and mid-term outcome was satisfactory,and long-term result required fur-ther investigation. Although it is easy to anchor the loop to the tip of the prolapsed leaflet,take-down of the anchored loop is not easy. The devised loop-in-loop technique makes intraoperative adjustment of the neochordae quick and easy. As for the technique of chordae reconstruction,loop in loop technique seems much better than loop technique.

Objective To compare the mid-long-term efficacy in the treatment of permanent atrial fibrillation (AF) in rheumatic heart disease using monopolar vs.biopolar radiofrequency ablation during the cardiac valve replacement surgery.Methods 151 patients with rheumatic heart disease and permanent atrial fibrillation underwent modified maze procedure using monopolar or biopolar radiofrequency ablation concomitant the cardiac valve replacement in the affiliated hospital of Qingdao university form January 2007 to December 2010.Seventy-nine of them were given the monopolar radiofrequency ablation (monopolar group),and remaining 72 the biopolar radiofrequency ablation (biopolar group).We collected the perioperative data of the patients,and collected the 12-lead electrocardiogram (ECG) or the dynamic electrocardiogram (24 h Holter),the echocardiography data immediately after the operation,at the time of discharge from hospital,3rd month,6th month,and 1 st year postoperatively,and every year after the operation.We also collected the related complications,the recovery of their cardiac function and life quality and some other useful information.We compared the related indexes including the eliminating rate of the atrial fibrillation (including sinus rhythm and nodal rhythm),operation time,postoperative drainage volume,hospital stay after operation,severe postoperative complications,and the mortality in the two groups.Results The radiofrequency ablation time in the biopolar group was longer than in the monopolar group [(31.5 ±3.9) min vs.(17.1 ±2.5) min,P ＜0.01].There was no significant difference in the ascending aorta clamping time [(61.4 ± 20.1) min vs.(57.0 ± 21.6) min,P ＞ 0.05] and the cardiopulmonary bypass time [(104.1 ±27.1) min vs.(93.9 ±37.9) min,P ＞0.05] between the two groups.In terms of the severe perioperative complications such as the renal insufficiency undergoing hemodialysis (2/77 vs.1/71,P ＞ 0.05),the refractory ventricular arrhythmias (1/78 vs.0/72,P ＞ 0.05),the exploratory thoracotomy for bleeding (5/74 vs.4/68,P ＞ 0.05),and the mortality (1/71 vs.1/78,P ＞ 0.05),the difference between the two groups had no statistical significance,suggesting the safety of the two groups was similar.The postoperative hospital stay [(13.6 ± 4.7) days vs.(15.7 ± 10.9) days,P ＞ 0.05] showed no statistically significant difference.The elimination rate of the atrial fibrillation in the bipolar group was significantly higher than in the monopolar group (27/45 vs.36/43,x2 =4.342,P ＜ 0.05).Conclusion The mid-long-term efficacy in the treatment of the permanent atrial fibrillation in rheumatic heart disease using the biopolar radiofrequency ablation during the cardiac valve replacement surgery is better than the using of the monopolar radiofrequency ablation.

目的 分析风湿性心脏病瓣膜置换术中行单极射频消融改良迷宫术治疗永久性心房纤颤(房颤)术后远期疗效及其影响因素.方法 回顾性分析2004年10月至2010年12月青岛大学附属医院116例同期行瓣膜置换及单极射频消融术的风湿性心瓣膜病合并永久性房颤患者的临床资料,其中男43例、女73例,年龄(50.5±7.5)岁;收集患者术后即刻、出院时、术后3个月、6个月、1年及随后每年的12导联心电图及超声心动图结果,并且记录术后并发症、心功能及生活质量改善情况等.根据末次随访时心电图结果,将患者分为房颤消除组(窦性心律+结性心律)与房颤组,其中房颤消除组52例(男16例、女36例),年龄(48.4±7.3)岁;房颤组50例(男22例、女28例),年龄(51.9±7.1)岁.分析影响术后远期效果的因素.结果 住院期间死亡3例(1例因溶血、急性肾功能不全、高钾血症死亡,1例因急性肾功能不全引发多脏器功能不全死亡,1例因反复室性心动过速、心室颤动致多脏器功能不全死亡).全组随访3～9年,随访期间死亡3例(1例因瓣周漏于外院行二次手术后死亡,余2例原因不详),失访8例,共有效随访102例(90.3％).随访中,房颤组有1例患者出现脑栓塞,1例出现脑出血.单因素分析显示房颤消除组与房颤组在患者年龄、术前房颤病程、左心房内径、体外循环时间及升主动脉阻断时间方面差异均有统计学意义,是影响手术效果的因素;多因素分析显示年龄及术前左心房内径是影响手术效果的危险因素.结论 瓣膜置换术中单极射频消融改良迷宫术治疗风湿性心瓣膜病合并永久性房颤远期疗效好,年龄及术前左心房内径是影响手术远期疗效的因素.

Objective To discuss the management of extracorporeal circulation for totally robotic assisted mitral valve repairor replacement. Methods MethodsFrom December2014to June 2015,10 patients underwent mitral valve repairor replacement, including 5 cases of MVR and 5 patients MV repair.The setting up of ECC was achieved with femoral artery cannulation and femoral venous can?nulation under the guidance of transesophageal echocardiography. All the patients were perfused bycentrifugal pump. Myocardial protec?tion was managed with St. Thomas solution plusHTK solution. For all cases, VAVD, SvO2 mornitoring and conventional ultrafiltration were routinely performed. Results The ECC time was 171~249 (192.7±18.7) min and aortic clamp time was 95~165 (115.9±21.5) min. All cases were resuscitated automatically and no hemoglobinuriaoccurred. Eight patients hadpostoperative intubation time less than 24h in,and 2 cases had prolonged intubation up to 48hdue to excessive chest drainage. No death orother complication occurred in 10 ca?ses. Conclusion The establishment of ECC system through femoral artery and femoral venous cannulation is reliable for totally robotic assisted mitral valve repairor replacement. Myocardial protection was managed with St. Thomas and HTK solution. VAVD,SvO2 and conventional ultrafiltration are extremely necessary and the result is reliable.

目的:分析心脏瓣膜置换同期行双极射频消融改良迷宫术治疗房颤的术后中远期疗效及其影响因素.方法:选取2007年7月至2010年12月于我院行心脏瓣膜置换同期行双极射频消融改良迷宫术治疗房颤的72例患者,术后随访3至6年,获得患者术后十二导联心电图、24h动态心电图和心脏彩超结果,并且记录术后药物应用、相关并发症、心功能恢复情况及生活质量是否改善等情况.根据心电图结果,将患者分为窦性心律组与非窦性心律组,应用统计学方法比较两组患者术前相关因素是否有差异.结果:截止至随访终点,有效随访的68例患者中窦性心律维持率为63.2％.单因素分析显示术前房颤病程、术前左室射血分数、是否合并三尖瓣成形或置换是影响手术效果的影响因素,多因素分析显示术前房颤病程、合并三尖瓣成形或置换是影响手术效果的危险因素.结论:心脏瓣膜置换同期行双极射频消融改良迷宫术治疗房颤的中晚期疗效好,术后并发症少,能够有效防止血栓栓塞,术前房颤病程长、合并三尖瓣成形或置换的患者术后中远期效果相对较差.

BACKGROUND: Allogeneic blood transfusion in humans of the same blood type has been implemented, but studies regarding swine blood type and how to perform allogeneic blood transfusion have been rarely reported. OBJECTIVE: To investigate the feasibility of preoperative autologous blood donation using the leap-frog technique for cardiopulmonary bypass surgery in a swine model.METHODS: Sixteen domestic swine were randomly divided into two groups: autologous blood donation and allogeneic blood transfusion. Another four swine were used as blood donors. Two groups of swine underwent cardiopulmonary bypass surgery. The autologous blood donation group received self-transfusion reserved before surgery while the allogeneic blood transfusion group received the same amount of allogeneic blood. Hemoglobin (Hb) concentration and hematocrit (Hct) level prior to and after donation in the autologous blood donation group was recorded. Hb concentration in the two groups was recorded prior to, during, immediately after, and 1 day after the surgery. RESULTS AND CONCLUSION: The total blood volume of each experimental swine was (2500±428) mL. For the autologous blood donation group, the predicted blood volume of the first donation was (501±86) mL and the actual blood volume was (493±93) mL; in the second donation, the predicted blood volume was (750±128) mL and the actual blood volume was (719±98) mL. There was a significant difference in Hb concentration and Hct level between prior to and after donation in the autologous blood donation group (P < 0.01). Hb concentration at 1 day after the surgery was significantly higher in the autologous blood donation group than in the allogeneic blood transfusion group (P < 0.01), while no significant difference in Hb concentration existed between these two groups prior to, during, and immediately after the surgery (P > 0.05). Compared with prior to surgery, Hb concentration in each group was significantly lower at 1 day after the surgery (P < 0.01). The autologous blood donation group exhibited significantly higher survival rate of swine than the allogeneic blood transfusion group (P < 0.01). These findings indicate that compared with allogeneic blood transfusion, preoperative autologous blood donation using the leap-frog technique appears to be a safe, effective method with a high survival rate for cardiopulmonary bypass surgery.