不同国家、地区和组织，对老年的定义不同[1,2]，WHO定义年龄大于65岁即为老年。随着国家经济的发展，人们的寿命不断延长，心血管疾病的发病率也随之增加，而老年是心脏疾病的多发人群[3]，且手术治疗者日益增多。老年心脏疾病患者常合并高血压、高血脂、糖尿病等，手术风险和死亡率增高，术后并发症较多[4]。老年心脏疾病以冠状动脉病变居多，其次是主动脉瓣退行性病变，部分为两种病变同时存在。

目前风湿性心脏瓣膜病治疗的主要有效措施是行人工心脏瓣膜置换术，其是国际上公认的改善患者心功能最根本的治疗手段。有研究表明［1］，行瓣膜手术的患者房颤发生率高，约为40%~60%。房颤多发生于心脏手术后5d内，术后第2天是房颤发生的高峰期［2］，本文通过临床药师对1例瓣膜置换术后合并心房颤动患者的抗凝治疗实施药学监护，重点关注抗凝强度的确定、国际标准化比值（INR）监测以及华法林剂量的调整等多种影响因素，为临床提供药学技术服务，保障使用华法林抗凝治疗的患者用药安全有效。

Objective To compare the effects of Kangsite Cardioplegic Solution (histidine-triptophan-ketoglutalate solution, HTK Solution) and Lenghanxue Cardioplegic Solution in myocardial protection during surgery in patients with severe valvular heart disease. Methods The patients (n=46) undergone open-heart surgery supported by cardiopulmonary bypass (CPB) and without active rheumatism and coagulation disorders were chosen from Mar. 2012 to Mar. 2014. All patients were divided into observation group and control group (each n=23), and observation group was given HTK Solution and control group, Lenghanxue Cardioplegic Solution. CPB time, aorta cross-clamping time, auto-rebeat rate, incidence of post-surgery arrhythmia, dosage of vasoactive drug, duration of mechanical ventilation time and ICU monitoring time were recorded in 2 groups. The levels of creatine kinase MB (CK-MB) and serum cardiac troponin T (cTnT) were detected respectively at different time points (before surgery, and 4 h, 12 h and 24 h after surgery). Results The difference in CPB time, aorta cross-clamping time, incidence of post-surgery arrhythmia, duration of mechanical ventilation time and ICU monitoring time had no statistical significance between 2 groups during surgery (all P>0.05). Compared with control group, auto-rebeat rate increased (54.17%vs. 79.17%) and dosage of dopamine decreased after surgery for 24 h [(6.6±2.3)μg/(kg·min) vs. (5.2±2.1)μg/(kg·min), all P<0.05] in observation group. Compared with control group, the level of CK-MB decreased after 4 h [(49.7±11.8) IU/L vs. (24.5±2.0) IU/L], 12 h [(83.9±18.3) IU/L vs. (31.1±2.6) IU/L] and 24 h [(62.4±12.5) IU/L vs. (32.4 ±3.3) IU/L, all P<0.05] in observation group. Compared with control group, the level of cTnT decreased after surgery for 4 h [(1.20±0.13)μg/L vs. (0.21±0.04)μg/L], 12 h [(2.35 ±0.64)μg/L vs. (1.22±0.59)μg/L] and 24 h [(1.75 ±0.24)μg/L vs. (0.76±0.41)μg/L, all P<0.05] in observation group. Conclusion The protective effect of HTK Solution on heart function is better than that of Lenghanxue Cardioplegic Solution during surgery in patients with severe valvular heart disease.

抗菌药物使用的合理与否对减少耐药菌株的产生和预防手术部位感染有重要意义［1］。为进一步加强医疗机构抗菌药物临床应用管理，促进抗菌药物合理使用，有效控制细菌耐药，保证医疗质量和医疗安全，2011年、2012年卫生部在全国范围内开展抗菌药物临床应用专项整治活动，将Ⅰ类切口手术预防用药作为抗菌药物专项整顿的重点内容之一。为落实规定，本院采取一系列措施对抗菌药物的使用进行管理，其中针对Ⅰ类切口围手术期预防用药进行调查分析，并针对性的进行干预。现对调查分析及干预效果报告如下。

<正>随着人们生活方式的改变和人口的老龄化,主动脉瓣硬化、钙化与狭窄的发病率日益增高。研究显示,年龄大于65岁的人群中1/4存在主动脉瓣硬化[1],而其中约1/6主动脉瓣硬化将发展成主动脉瓣狭窄(aortic stenosis,AS)[2],而半数轻-中度AS患者将会发展为血流动力学异常的重度主动脉瓣狭窄(symptomatic severe aortic stenosis,SAS)[3]。有症状的AS患者预后比较差,易发生意外心脏事件,主动脉瓣置换术(aortic valve replacement,AVR)是公认的最有效

Objective To compare the short-term and mid-term curative effects between endoscopic saphenous vein harvesting(EVH) and direct-vision open saphenous vein harvesting(OVH) during coronary artery bypass grafting(CABG).Methods The CHD patients(n=268) with CABG and whole follow-up materials were chosen from Apr.2005 to Jan.2010,and then divided into EVH group(n=129) and OVH group(n=139).The patency rate of saphenous vein was compared and analyzed by using 64-MSCT respectively after the operation for three months,one year and three years.Results There was no statistical difference in patency rate of saphenous vein between two groups respectively after the operation for three months,one year and three years(88.0%vs.85.6%,78.9%vs.79.9% and 72.2%vs.71.8%,P<0.05),while the harvesting time was longer [(50.23±5.87) min vs.(38.65±7.96) min] and damaged veins were more [(1.51±0.19)vs.(0.84±0.04)] in EVH group(P<0.05).Conclusion EVH and OVH have similar short-term in mid-term patency rates of saphenous vein,but EVH has longer harvesting time and more damaged veins.

随着社会的老龄化和人们对生活质量的重视,老年冠心病患者日益增多,如何使具有多重高危因素老年冠心病患者完全再血管化、减少并发症和提高远期疗效是冠心病治疗的难点之一.

Objective This study was focus to observe the influence of extracorporeal circulation(ECC) on circulating endothelial progenitor cells(EPCs) in infants with congenital heart disease by measuring the EPCs amount.Methods Between July 2010 and December 2010,40 infants with congenital heart disease and pulmonary arterial hypertension were divided into ECC group and off-pump group.In off-pump group,20 cases received ligation of patent ductus arteriosus and closure of artrial sepectal defect without cardiopulmonary bypass.In ECC group,20 cases had open heart operations with cardiopulmonary bypass.The amount of circulating EPCs counted by flow cytometer at anesthesia completion(T1),the end of surgery(T2),4 h(T3),24 h(T4) and 72 h(T5) after operations.The relation of ECC and EPCs amount was analyzed.Results The amount of circulating EPCs in the two groups had no statistically significant differences at T1(P>0.05).The amount of circulating EPCs in ECC group was significantly higher than that in off-pump group at T3(P<0.01).The amount of circulating EPCs at T2,T4,T5 in ECC group was significantly lower than that at T1 and those time points in off-pump group(P<0.01).Conclusion The levels of circulating EPCs reduce after ECC.

Objective To summarize the experiences in greater saphenous vein harvesting during video-assisted endoscopic technique in elderly patients undergoing coronary artery bypass grafting.Methods Between April 2005 and March 2010,303 elderly patients with coronary heart disease,aged 60 to 84(68.6±7.3) years,underwent selective coronary artery bypass grafting.Of the 303 patients.197 cases received video-assisted endoscopic technique for greater saphenous vein harvesting(ESVH).106 cases had open procedure for greater saphenous vein harvesting(OSVH).There was no difference in sex.body mass,left ventricular ejection fraction(LVEF),the number of bypass grafting and concomitant diseases.The operative efficacy was compared between the two groups.Results The mean operation time duration was(38.3±8.8) min and(35.5±7.2) min in ESVH and OSVH groups respectively(P0.01).The subcutaneous hematoma occurred in 8(4.1%) cases and 2(1.9%) cases in ESVH group and OSVH group respectively(P0.05).There was no abnormal feeling,incision infection and fat necrosis of lower extremity in ESVH group.The incidence of chronic leg edema in ESVH group was 2.0%.which was remarkably lower than that in OSVH group(19.8%,P0.05). Leg pain in ESVH group was much less intensive than that in OSVH group.The patients receiving ESVH had shorter hospital stay than those receiving OSVH[(8.4±1.8) vs(13.3±2.8) d.P0.001].Conclusion ESVH,as a minimally invasive technique,can significantly reduce postoperative leg incision complications in elderly patients undergoing coronary artery bypass grafting.

目的对比不同微创技术在继发孔房间隔缺损治疗中的应用结果,分析其优缺点,探讨最佳手术适应证。方法 2005年1月到2010年11月我院采用微创技术治疗继发孔房间隔缺损患者140例,年龄0.3～50岁,其中经皮导管封堵术60例,非体外循环下经胸封堵术30例,常温体外循环心脏不停跳腋下小切口修补术50例。观察和比较三种微创技术治疗房间隔缺损的手术成功率、切口长度、费用等。结果经皮导管封堵术、非体外循环下经胸封堵术、腋下小切口修补术的成功率分别为95、96.7及100,三组间无显著差别（P＞0.05）,无住院死亡。三组手术切口长度分别为（0.25±0.06）cm、（4.53±1.32）cm和（10.43±2.57）cm,差异有统计学意义（P＜0.01）;手术费用分别为（24146±3073）元,（24811±3255）元,（23300±4799）元,差异无统计学意义（P＞0.05）。结论三种手术方式均是继发孔型房间隔缺损安全有效和小创伤的治疗方法。

目的探讨微创技术在老年患者冠状动脉搭桥手术中的应用。方法回顾分析2005年7月～2009年12月在我院择期行单纯冠状动脉旁路移植手术248例的临床资料。结果 248例共搭桥790条,221例经正中切口进胸,27例采用胸骨中下段小切口;off-pump209例,on-pump39例,使用左乳内动脉244例,3例二次搭桥,1例动脉血流细小,血流不畅。术后5例死亡。发生并发症:纵隔感染4例,肾衰竭6例,呼吸衰竭11例,胸腔积液39例,心房颤动56例,所有患者均经合理处置后顺利出院,随访均无心绞痛或心力衰竭发生。结论微创技术具有不用体外循环、心肌保护效果好、并发症发生率低、恢复快、痛苦小、切口美观等特点,值得在冠状动脉搭桥手术中推广应用。

2008年11月我院成功为1例复杂先天性心脏病患者再次行全腔静脉-肺动脉吻合术,其经验总结报告如下:

目的介绍直视双极射频消融术治疗心瓣膜病合并慢性心房颤动(AF)的初步体会,探讨控制慢性AF的有效方法。方法2005年5月至2007年11月,对23例心瓣膜病合并慢性AF患者采用直视双极射频消融术治疗,在常温体外循环心脏跳动下进行右心房的消融,然后在中度低温心脏停搏下做左、右肺静脉口和左心耳的消融隔离,最后行心瓣膜置换术。结果射频消融时间18～26min。术后因特发性血小板减少致消化道大出血住院死亡1例,生存的22例患者随访3～30个月,出院时、3个月、1年和2年窦性心律转复率分别是81.8%、86.4%、82.4%和77.8%,无Ⅲ度房室传导阻滞、病窦综合征和栓塞等并发症发生。结论直视双极射频消融术治疗心瓣膜病合并慢性AF操作简单、效果满意、并发症较少。

Objective To summarize the experience of stented elephant trunk procedure and aortic valvuloplasty for De Bakey Ⅰaortic dissection with aortic valve insufficiency.Methods From December 2006 to December 2007,7 patients with De Bakey I aortic dissection and aortic valve insufficiency underwent ascending aorta and total aortic arch replacement combined with stented elephant trunk procedure and aortic valvuloplasty.Operations were performed by median sternotomy with deep hypothermic circulatory arrest and right axillary artery cannulation for selective antegrade cerebral perfusion.A self-expandable stent grafting was implanted into the left half arch and proximal descending aorta through the aortic arch to make the elephant trunk.The aortic sinotubular junction was remodelled and the aortic valve was repaired through aortic commissure-suspending and/or partial David procedure.Results Deep hypothermic circulatory arrest and selective cerebral perfusion time was 20~30 min.The postoperative course was uneventful.There was no mortality and massive haemorrhage perioperatively.During a follow-up of 2~14 months,there was no aortic valve insufficiency,false lumen of the descending aorta disappeared or reduced significantly with NYHA classⅠ of cardiac function.Conclusion The stented elephant trunk procedure and aortic valvuloplasty seem to be effective and safe for De Bakey Ⅰ aortic dissection with aortic valve insufficiency.

Objective: To study on the use of patient-controlled analgesia (PCA) and discussion the safety of sequentially drug using. Method: The patients with operation drugs use on the operative day were collected and analysed in 203 cases, drugs use in dilferent department were compared, and the safety of sequentially drug using was particularly investigated. Result: 88 kinds of drugs were used 1746 times, 8.6 kinds or times of drug were administrated to a patient averagely. 49. 26% patients after operation used PCA . There was difference between departments in the use of anesthetics, analgesics and sedatives( P <0. 01). Conclusion: There are several changes in the methods and drug use in operation, and there are marked differences between departments. Administration of PCA de-creas the safety of sequentially drug using after operation, therapeutic responses must be monitored carefully.