目的 探讨在冠状动脉移植时应用"半兜状"自体心包片吻合技术治疗左冠状动脉开口较低且合并主动脉瓣病变的升主动脉瘤的临床效果.方法 回顾性分析我院心外二科2012年11月至2016年1月应用"半兜状"自体心包片吻合技术治疗7例左冠状动脉开口较低行Bentall术患者的临床资料,其中男5例、女2例,年龄(45.2±3.1)岁,术前主动脉CT血管造影(CTA)提示升主动脉瘤样扩张,直径(6.8±0.8) cm,合并主动脉瓣重度狭窄2例,余5例主动脉瓣中-重度关闭不全.手术在常规Bentall术式的基础上对左冠状动脉移植进行改良.应用自体心包片修剪成梭形,使之呈"半兜状"兜住左冠状动脉开口下缘,将左冠状动脉开口上缘与人工血管打孔处上缘直接缝合,完成左冠状动脉移植.结果 全组无死亡病例,体外循环时间(168.0±38.2)min,其中主动脉阻断时间(98.0±28.1) min.术后24h引流量(575.0±65.0) ml.出院前复查心电图及心肌酶学指标(血清肌钙蛋白I、肌酸激酶同工酶、肌酸激酶)均正常.出院随访左室舒张期末内径与术前差异有统计学意义[(5.4±0.5) cm vs. (7.0±0.6)cm, P<0.001].结论 本技术手术操作相对简单、吻合方便、吻合口张力较小、出血风险小、止血方便.冠状动脉吻合口无扭曲及牵拉,不影响冠状动脉血流.术后患者心功能恢复良好,取得了良好的早、中期效果.

In the development of cardiac surgery ,cardioplegic arrest perfusion has been used as the foremost method of myocardial protection until today.In the subsequent studies ,it's discovered that although the technique plays an important role in protecting myocardium ,it may cause serious adverse consequences such as myocardial edema ,energy metabolism dis-order,myocardial stunning and apoptosis.With the constant exploration of science , medical scientists put forward a new myocardial protection scheme-heart beating perfusion,which not only can avoid adverse consequences brought by the cardio-plegic arrest perfusion,but also has obvious advantages in the heart operation with hypertrophic myocardium.Heart beating perfusion has a good development prospect in the application of cardiac surgery.

目的:2002-04 至 2015-12 期间我院心脏外科收治 6 例左心室近心尖部心脏肿物患者.探讨左心室肿物的临床特点、诊断和和外科治疗的手术效果. 方法:男4例,女2例,年龄34~58岁,平均年龄(42.2±6.7)岁.术前均有活动后心悸、气短临床表现,听诊发现心脏杂音 l 例,晕厥病史 1 例,脑栓塞病史 l 例,反复下肢动脉栓塞病史 1 例.心电图显示阵发性室性心动过速 1 例.所有患者术前均经超声心动图明确诊断,瘤体直径 1.5~3.8cm,显示肿物靠近左心室心尖部,2 例患者可见瘤蒂连于左心室侧壁心尖段.手术均在胸部正中切口、中低温体外循环下完成,根据超声心动图显示肿物位置及周围解剖关系选择不同的手术路径,其中 3 例患者采用右心房 - 房间隔入路,1 例患者通过主动脉切口入路,另 2 例患者采用左心尖切口.术中均完整显露并切除肿物,1 例患者肿物宽基底与室间隔紧密连接,切除肿物后行室间隔补片加固,1 例患者肿物包绕二尖瓣腱索和乳头肌导致二尖瓣关闭不全,术中切除肿物后二尖瓣成形效果不满意再行二尖瓣置换术.术后病理诊断:(左心室)黏液瘤 3 例,弹性纤维瘤 l 例,血管瘤 1 例,陈旧性血栓 1 例,均为良性肿物,术后无需放化疗治疗.

目的:总结冠状动脉瘘合并冠状动脉瘤样扩张的外科手术疗效和相关经验教训,为该类患者选择手术方式提供依据,提高治疗效果. 方法:2002-04 至 2015-12 期间我院心脏外科收治 6 例冠状动脉瘘合并冠状动脉瘤样扩张的患者,男 4 例,女 2 例,年龄 24~62 岁.所有患者均出现活动后心悸、胸闷、气促、心前区疼痛等相关临床症状,查体可闻及心脏杂音.所有患者均接受超声心动图和冠状动脉造影检查.其中 5 例患者冠状动脉病变位于右冠状动脉,另 1 例位于左冠状动脉回旋支.冠状动脉瘘漏入右心室 3 例,左心房 1 例,左心室 1 例,冠状静脉窦 1 例.1 例患者合并房间隔缺损,1 例患者冠状动脉瘤内血栓形成,3 例患者合并其他冠状动脉狭窄.全组瘤样扩张的冠状动脉直径 1.8~4.0 cm.左心室射血分数为 48%~60%.冠状动脉瘘的处理采用体外循环下阻断主动脉,心脏停搏后纵行切开瘤样扩张的冠状动脉,在血管内用 7-0 prolene 线缝闭瘘口或者应用自体心包补片闭合瘘口.根据患者冠状动脉自身条件采用不同策略处理冠状动脉瘤样扩张:4 例患者切除部分瘤壁直接行血管成形术.1 例患者冠状动脉瘤内血栓形成,仔细剥离血栓并缝闭瘘口后,缝闭冠状动脉瘤入口和出口,远端行冠状动脉旁路移植.另 1 例患者瘤样扩张的冠状动脉病变较广泛,切除瘤样冠状动脉并远端行冠状动脉旁路移植术.术前造影显示冠状动脉狭窄者远端均行冠状动脉旁路移植.术后常规行抗血小板治疗.

Objective:To study the effect of euthyrox on myocardial and cerebral ischemia reperfusion injury in valve replacement under cardiopulmonary bypass.Methods:A total of 76 patients who received valve replacement under cardiopulmonary bypass in our hospital between January 2013 and December 2016 were collected and divided into control group (n=38) and observation group (n=38) according to random number table.One week before surgery,patients in observation group took euthyrox orally(50 μg/d),while patients in control group took vitamin C tablets (1 tablet/d),and both therapies lasted for 1 week until the morning of surgery day.Before medication and after cardiopulmonary bypass (before the end of surgery),serum levels of myocardial enzyme spectrum indexes and nerve injury indexes were compared between the two groups of patients.Results:Before medication,differences in the serum levels of myocardial enzyme spectrum indexes and nerve injury indexes were not statistically significant between the two groups of patients (P>0.05).After cardiopulmonary bypass,serum myocardial enzyme spectrum indexes cTnT,CK-MB,α-HBD and LDH levels in observation group were significantly lower than those in control group;serum nerve injury indexes NSE,S100B and GFAP levels were lower than those in control group while bFGF level was significantly higher than that in control group (P<0.05).Conclusions:Euthyrox intervention in valve replacement under cardiopulmonary bypass can effectively reduce the myocardial and cerebral ischemia reperfusion injury.