目的 探讨保留主动脉瓣的根部替换术(David手术)对于急性A型夹层合并主动脉瓣关闭不全的患者其临床疗效研究.方法 从2016年至2017年,8例急性主动脉A型夹层患者在我院行了David手术,均行David I手术.患者的平均年龄为49±6岁,全部为男性.1名患者进行了单纯David手术,1例患者进行了半弓替换,2例患者进行了杂交全主动脉弓置换,其余4名患者进行了全弓替换.平均随访时间为24±6月.观察David手术治疗主动脉A型夹层患者的临床效果.结果 本组患者均痊愈出院,无30天内死亡及随访期间死亡;术中体外循环时间141～305(189±37)min;心肌阻断时间111～219(144±37)min,术后8例患者随访时间为24～49(21±13)月,随访期间无患者需再次手术及死亡,主动脉瓣无反流3例、少量反流4例、中量反流l例.结论 David手术为合并主动脉瓣关闭不全的年轻主动脉夹层患者提供了一个具有挑战性的治疗选择.目前我们的数据表明这一方法是安全可行的.对于有经验的心脏中心这一术式用于治疗急性主动脉夹层患者,其近中期瓣膜相关事件很少见,主动脉瓣功能在近期随诊中表现稳定.

目的:基于计算机断层摄影术(CT)数据制作部分类型先天性心脏病的虚拟现实(VR)教材,使学员能够对部分先天性心脏病的病理性解剖结构产生直观而准确的认识.方法:选取部分先天性心脏病病种的典型CT图像(包括房间隔缺损、室间隔缺损、法乐四联症、肺动脉闭锁、右心室双出口),将图像导入到影通和Unity3D软件中.经过阈值调节、三维重建、分割、渲染等操作构建心脏3D模型.将3D模型通过影通VR软件输出到头戴式显示器(HMD)中,学员佩戴HMD即可全方位观看心脏的解剖结构.在系统地学完VR课程后,学员填写一份调查问卷以评价VR教材的教学效果.结果:我们成功构建了先天性心脏病的VR教材,共有18名学员体验了VR课程.问卷结果显示教材有着良好的交互性和沉浸感.18位学员问卷的平均分为44.6分,标准差为3.7分,平均分显著高于持中立态度的分值(t=16.9, P＜0.01),学员对学习效果的评价倾向于积极.所有学员均未出现视觉和位置觉相关的不适.结论:基于VR的教学方式具有良好的教学效果.我们制作的VR教材精确地展现了心脏的解剖结构,能够满足心血管外科学的培训要求.

目的 分析心脏脂肪瘤的临床特征和外科治疗结果.方法 回顾性分析我院2002～ 2012年间582例行外科手术的心脏肿瘤病人的临床资料.其中,共10例心脏脂肪瘤病人接受外科手术切除,女5例,男5例;年龄7～62岁,中位年龄46.5岁.7例在体外循环下手术,3例在非体外循环下手术.合并房间隔缺损1例,同期外科手术修补.结果 心脏脂肪瘤占总体心脏肿瘤的1.72％.老年病人占所有脂肪瘤病人的10％(1/10).10例中完全切除8例(80％),部分切除2例(20％),无早期死亡.老年心脏脂肪瘤病人的手术体外循环时间、主动脉阻断时间长于非老年病人;术后呼吸机辅助时间、ICU时间及术后住院时间长于非老年病人.9例(9/10,90.00％)病人随访72～193个月,平均(126.10±44.46)个月,无远期死亡,心功能(NYHA分级)Ⅰ级或Ⅱ级.结论 本组心脏脂肪瘤占总体心脏肿瘤的1.72％.老年病人占脂肪瘤病人的10％.老年心脏脂肪瘤病人的手术时间及手术后恢复时间长于非老年病人,外科治疗远期结果良好.

目的 分析使用双侧乳内动脉(BIMA)行冠状动脉旁路移植术(CABG)后的桥血管通畅情况.方法 回顾性分析2015年12月～2017年8月于中国医学科学院阜外医院心外科应用BIMA行CABG的182例患者的临床资料,其中男性153例,女性29例,平均年龄(56.2±7.2)岁.分析患者术中即刻桥血管流量、手术效果,并通过出院前及术后3月计算机断层扫描血管造影(CTA)结果评价桥血管通畅情况.结果 患者均无围手术期死亡.术后3个月右乳内动脉(RIMA)桥及左乳内动脉(LIMA)桥通畅率为97.8％,静脉桥通畅率为95.4％(P<0.05).乳内动脉-前降支搭桥总体通畅率为99.5％,其中RIMA-前降支搭桥通畅率为99.4％,LIMA-前降支搭桥通畅率为100％.结论 BIMA行冠状动脉旁路移植术是安全的,早期效果及桥血管通畅率良好.LIMA-前降支及RIMA-前降支搭桥均有较高的近期通畅率.

目的 分析合并糖尿病对双侧乳内动脉(BIMA)冠状动脉旁路移植术(CABG)手术效果的影响.方法 2015年12月至2017年8月,我科应用BIMA行CABG的患者共182例,其中男153例、女29例,年龄(56.5±6.8)岁.按是否合并糖尿病进行分组,并应用倾向评分匹配进行配对,分为糖尿病组(n=66)和无糖尿病组(n=66).其中糖尿病组男53例、女13例,年龄(57.8+7.2)岁;无糖尿病组男56例、女10例,年龄(56.3±6.0)岁.回顾性分析两组术中情况、术后并发症及术后3个月复查冠状动脉计算机断层扫描血管造影(CTA)的情况,并分析糖化血红蛋白(HbA1c)对上述指标的影响.结果 倾向评分匹配后糖尿病组和非糖尿病组的各项术前指标差异无统计学意义.术后两组胸骨切口并发症发生率差异无统计学意义(P=0.466).术后3个月冠状动脉CTA提示两组乳内动脉(IMA)和大隐静脉(SVG)通畅率差异无统计学意义(P=0.730、0.684).术前HbAlc异常者54例,其术后胸骨切口并发症发生率显著高于HbAlc正常组(P=0.006).出现胸骨切口并发症者HbAlc水平显著高于无胸骨切口并发症者(P=0.016).结论 合并糖尿病并不增加胸骨切口并发症等围手术期并发症,不应成为应用BIMA CABG的顾虑.对合并糖尿病患者,应注意将糖化血红蛋白控制在正常水平.

目的 分析外科和介入复合技术(hybrid surgical and interventional ablation,HA)治疗持续性心房颤动(房颤)疗效是否优于单纯胸腔镜下外科射频消融(video-assisted thoracoscopic surgical radiofrequency ablation,VATS-RA).方法 2010年9月至2017年12月,连续79例持续性房颤患者在阜外医院接受VATS-RA或HA治疗,其中,VATS-RA治疗60例,为单纯外科组,男48例、女12例,平均年龄(56.0±7.6)岁;HA治疗19例,为复合组,男14例,女5例,平均年龄(58.0±7.3)岁.术后3个月、6个月、1年和每年进行定期随访.术后恢复窦性心律定义为,随访期间24h或7d动态心电图提示窦性心律并未出现持续时间≥30s的快速性房性心律失常(房颤、心房扑动或房性心动过速).结果 78例(98.7％)持续性房颤患者完成随访.尽管复合组术前左房前后径[(49.1±5.3)mm]明显大于单纯外科组[(41.7±6.2)mm,P＜0.001],但复合组总体窦性心律维持率(94.7％)优于单纯外科组(64.4％,P=0.011),复合组免除抗心律失常药物(AADs)治疗和导管消融窦性心律维持率(84.2％)也优于单纯外科组(50.8％,P=0.010).结论 HA治疗持续性房颤疗效优于单纯VATS-RA,但需要更大样本量的前瞻性研究进一步验证.

Objective This study aimed to evaluate the safety and efficacy of video-assisted thoracoscopic bipolar radio-frequency ablation in the treatment of isolated paroxysmal atrial fibrillation.Methods From September 2010 to December 2016,Seventy-two consecutive patients with paroxysmal atrial fibrillation underwent video-assisted thoracoscopic bipolar radio-frequency ablation at Fuwai Hospital.There were 50 males and 22 females with an average age of(56.5 ± 10.5) years and duration of atrial fibrillation with (6.5 ± 4.8) years.45 patients had previous catheter ablation.The patients were followed up at postoperative 3 months,6 months,1 year and annually.Success of ablation was defined as sinus rhythm and no duration of ≥30 s for rapid atrial arrhythmias,including atrial fibrillation,atrial flutter or atrial tachycardia in 24 h Holter examination.Univariate and multivariate logistic regression models were used to analyze the risk factors for atrial fibrillation recurrence.Results One patient converted to sternotomy due to bleeding on operation.All patients were successfully discharged.69 patients completed follow-up,with an average follow-up of(28 ± 18)months(3-60 months).The overall success rate was 73.9％,and the success rate without antiarrhythmic drug was 62.3％.Subgroup analysis showed that the success rate was 80％ when left atrial anterior and posterior diameter(LAD) ≤40 mm,and 57.9％ when LAD ＞ 40 mm (P =0.035).Multivariate logistic regression analysis showed that LAD ＞40 mm was an independent risk factor for postoperative recurrence of atrial fibrillation.Conclusion Video-assisted thoracoscopic bipolar radiofrequency ablation is a safe and effective method for the treatment of paroxysmal atrial fibrillation,especially in patients with LAD≤40 mm.

Objective To summarize the experience and strategy of surgical treatment of Kommerell diverticulum and related aortic dissection aneurysm.Methods From November 2012 to January 2018,4 patients(all males),with median age of 44 (from 40 to 49) years old,underwent surgical treatment in our institution.All the patients had fight-sided aortic arch and aberrant left subclavian artery.One patient had type A aortic dissection and other 3 had type B aortic dissection(one had chronic type B dissection).The patient with type A aortic dissection had Bentall procedure plus total arch replacement and frozen elephant trunk implantation.One patient with chronic type B aortic dissection received type 2 hybrid aortic arch repair.One patient with acute type B aortic dissection had ascending aorta and total arch replacement plus frozen elephant trunk implantation followed by TEVAR.The last patient underwent graft replacement of aorta,total arch and descending thoracic aorta.Results There was no operative mortality.The median mechanical ventilation time was 229 (from 13 to 485) hours,the median ICU stay was 12 (from 2 to 27) days.One patient died from respiratory and circulatory failure due to compression of left main bronchus on the 17th day after operation.One patient had irritating cough due to mild compression of bifucation of trachea and the symptom resolved spontaneously before discharge.One patient had critical illness polyneuropathy after operation and received mechanical ventilation therapy for 485 hours.He recovered through neurotrophic drug treatment.The median follow-up time is 15 (from 4 to 36) months.The patients with type A dissection had delayed dilation of descending thoracic aorta beyond the frozen elephant trunk and received TEVAR 6 months later.The CT scans of the other two patients during follow-up time showed good morphology and patency of graft and branches.There was no anastomotic leakage and pseudoaneurysm.Conclusion The decision making of treatment of Kommerell diverticulum and related aortic dissection should be on the basis of classification of aortic dissection.Operation combined with TEVAR is safe and effective.

目的 评估胸腔镜辅助下心外膜射频消融治疗持续性房颤的远期结果.方法 2010年9月至2016年12月,连续32例持续性房颤患者在阜外医院接受胸腔镜辅助下射频消融治疗.术后3、6、12个月和随后每年进行定期随访,随访时完成动态心电图检查和问卷调查,分析随访结果.结果 全组患者男性24例,女性8例,平均年龄56.6±7.6岁,房颤病史时间7.9±7.2年,16例患者有介入导管消融史.全组无死亡,均顺利出院.31例(96.9％)患者完成随访,平均随访39±18个月.无患者出现心力衰竭、栓塞或出血并发症.3例(9.7％)患者因房颤复发再次行导管射频消融.总体窦性心律维持率为77.4％,免除抗心律失常药物治疗和再次消融窦性心律维持率为64.5％.结论 胸腔镜辅助下心外膜射频消融技术治疗持续性房颤远期疗效确切,可让大部分患者恢复窦性心律,无心血管不良事件.

Objective To summarize the experience of surgical treatment of Kommerell diverticulum and related aortic arch and descending thoracic aneurysm. Methods From November 2012 to January 2018,6 patients(5 males,and 1 fe-male),with median age of 46(from 14 to 63)years old,underwent graft replacement of involved aortic segment in our institu-tion . All the patients had symptom including persistent backache(3 patients),hoarseness( 1 patient),recurrent pneumonia( 1 patient)and hemoptysis( 1 patient). All the patients had right-sided aortic arch and aberrant left subclavian artery. True aneu-rysm occurred in 5 patients and pseudoaneurysm occurred in 1 patients. The median diameter of the aneurysms was 65mm(53- 80 mm). Two kinds of approaches were used:left posterior thoracotomy(2 patients)and median sternotomy plus right poste-rior thoracotomy(4 patients). The left posterior thoracotomy was achieved through the fourth and seventh intercostal space with excellent exposure of the whole descending thoracic aneurysm. For each patient,the aneurysm was resected with the proximal and distal aortic segment were clamped and the ligamentum arteriosum were divided. A branched woven polyester graft was used to reconstruct the descending thoracic aneurysm. 1 or 2 subclavian arteries were replaced with 10mm collagen-impregnated pol-yester grafts. One patient received total arch and partial descending thoracic aorta replacement with reconstruction of 3 supra-arch vessels. Results There was no operative mortality. The median clamping time of descending aorta was 28(22 - 61)mi-nutes,the median mechanical ventilation time was 33. 5(6 - 485)hours,the median ICU stay was 4( 1 - 31)days. One pa-tient died from central respiratory and circulatory failure due to acute brain stem infarction on the 31st day after operation. One patient suffered from reentry to ICU due to hyoxemia and recovered through expectant treatment. One patient had critical illness polyneuropathy after operation and received mechanical ventilation therapy for 485 hours,he recovered through neurotrophic drug treatment. The median follow-up time is 5( 1 - 46)months. 5 patients lived with no discomfort and the CT scans during follow-up time showed good morphology and patency of graft and branches. There was no anastomotic leakage and pseudoaneu-rysm. Conclusion Surgical treatment of Kommerell diverticulum is safe and effective. Subclavian artery should be reconstruc-ted.

主动脉根部瘤是主动脉外科常见的疾病.目前,Bentall手术已成为治疗升主动脉瘤伴主动脉瓣关闭不全和A型主动脉夹层合并主动脉瓣关闭不全的经典术式,该手术方式操作相对简单,模式相对固定.本文主要从4个方面对这个术式进行介绍,包括手术指征的选择、手术操作的具体方法、并发症的处理和手术的结果.

Objective To analyze the effect of postoperative residual interventional treatment of cardiovascu‐lar disease after complex congenital heart surgery ,and to explore the feasibility of congenital heart lesions with interventional therapy .Methods Totally 75 cases of patients with residual cardiovascular disease after complex congenital heart surgery were selected as the subjects who were treated by intervention theropy in author's hospital from January 2000 to January 2014 ,in which a total of 29 cases of patients were treated by a large pulmonary collateral vessels embolization (MAPCAS) ,26 patients with occlusion therapy and 20 patients with balloon angioplasty or stent implantation treatment ,outcomes of the patients were retrospec‐tively analyzed .Results In this study ,40 collateral vessels were thrombosis in 29 patients with MAPCAS embolization ,and no residual shunt were found after treatment by echocardiography ,including two cases of patients dead of multiple organ failure and the remaining 27 patients were recovery and discharge .26 pa‐tients treated by occlusion were one -time successful closure ,no severe postoperative atrioventricular block and other serious complications except two cases with a small amount of residual ventricular shunt .The pressure gradient in 20 patients taken balloon angioplasty or stenting was significantly lower in stenosis . The pressure gradient before intervention was (60 .2 ± 14 .9)mmHg ,significantly reduced after the inter‐vention stenosis pressure gradient ,as (17 .3 ± 11 .4)mmHg ,the difference before and after interventional treatment was statistical significance (P<0 .01);stenting in the treatment of patients with blood flow ,no <br> thrombus formation ,and no sandwich in dilatation of the aortic coarctation hintted by spiral CT examina‐tions .Conclusion The intervention may be effective in the treatment of complex congenital heart surgery residual cardiovascular disease ,but the indications should be strictly controlled and appropriate intervention programs are developed according to the disease .

主动脉缩窄是一种常见的先天性心血管缺陷.目前其治疗的主要手段包括:外科手术、球囊血管成形术、支架植入术.本综述总结了有关外科手术和介入方法治疗主动脉缩窄安全及有效性的最新观点.

1 临床资料 患者50岁,男性,主诉活动时胸闷、气短1年余,加重半个月.患者1年多前开始胸骨后憋闷、气短,偶有胸痛伴出汗,无恶心、呕吐、咳嗽、咯血、双下肢浮肿等,无乏力、盗汗.否认外伤史,否认长期卧床史.