目的: 总结射频消融迷宫术治疗风湿性心脏病慢性心房颤动8 a临床经验及体会. 方法: 以射频消融的方法替代"切和缝",完成迷宫手术即射频消融迷宫术,共施行236例,对其中后166例患者的经典迷宫手术路线进行了改良,包括在右心房下部行三条短线性射频消融,在左心房长径>70 mm、房颤病史>3 a的病例增加左心房消融线路. 结果: 整个射频消融过程耗时13~39(平均21) min. 无手术死亡,无射频消融相关并发症. 手术后2 wk 210例恢复窦性心律,总转复率89%,其中前70例患者有51例恢复窦性心律,转复率73%,后166例患者有159例恢复窦性心律,将手术后恢复窦性心律的比例提高到95.7%(P<0.01). 前70例中有63例曾发生手术后心房扑动,但在后166例,行射频迷宫术时在右心房下部加三条短线性消融后,仅有58例患者术后短期内发生心房扑动,占35%,明显少于经典迷宫手术路线组(P<0.01). 结论: 射频消融迷宫术简便易行,与"切和缝"的迷宫手术比较明显缩短手术时间,并发症少,手术疗效确切,经过改良路线,房性心律失常并发症减少,房颤窦性转复率高于经典的"切和缝"的迷宫手术.

法乐四联症(Teralogy of fallot,TOF)是常见的先天性紫绀型心脏病.病变畸形复杂,冠状动脉阻断时间长,侧支循环丰富,术后易发生低心排综合征和灌注肺等严重并发症.我院于1996年1月至2001年12月共行婴幼儿TOF矫治术177例,其体外循环管理体会报告如下.

0 引言主动脉瘤特别是主动脉夹层,是危害生命的灾难性疾病,如不及时救治可猝死. 此类手术操作方法复杂,体外循环采用不同脑灌注方法,对患者预后至关重要. 我院1998-01/2001-07共完成主动脉瘤手术53例,术后效果满意.

Objective:To assess the effect of radiofrequency ablation maze procedure for patients with atrial fibrillation. Method:One handres and thirty six cases of atrial fibrillation with rheumatic valvular heart disease underwent radiofrequency ablation maze procedure, following heart valve replacement; 18 patients with atrial fibrillation including 5 cases of congenital heart disease, 13 cases of rheumatic valvular heart disease, underwent radiofrequency ablation procedure of single right atrium during open heart surgery. Result:No early death occurred. In radiofrequency ablation maze procedure group, 112 cases of 136 cases restored sinus rhythm( 82.4%). In radiofrequenc ablation procedure of single right atrium group, 11 cases of 18 cases restored sinus rhythm( 61.1%).Conclusion:Radiofrequency ablation maze procedure is a simple, safe and effective method to treat atrial fibrillation.

目的:探讨不停跳心内直视术体外循环(CPB)方法.方法:120例先天性心脏病房间隔患者,采用右前外侧小切口心脏不停跳体外循环下进行房间隔缺损的修补,术中鼻温维持在33～35.5℃,HCT维持在18%～25%.结果:120例患者CPB时间19～70min,平均(45±12)min,术后呼吸机辅助呼吸3～5h,24h胸引量80～300ml,平均(150±59)ml,除1例发生脑部气体栓塞后治愈外,其他患者均恢复顺利,并痊愈出院.结论:右前外侧小切口不停跳体外循环心内直视术对心脏病房间隔缺损的手术治疗是安全可靠的.

2000年1～10月我们为5例病人实施了同种原位心脏移植手术,术后4例生存、死亡1例.现将体外循环方法总结报道如下. 临床资料 5例心脏移植受者心功能均为IV级,并伴有严重心律不齐,其中合并重度肺动脉高压1例,轻度肺动脉高压3例,其余临床资料等见表1.

目的:探讨二尖瓣置换合并射频迷宫术的体外循环(CPB)方法。方法：76例风湿性心脏二尖瓣病变合并房颤患者实施瓣膜置换时，采用心内直视射频消融迷宫术对其合并的心房纤颤予以治疗。先期的13例(A组)患者在CPB转流阻闭升主动脉后进行射频消融术和二尖瓣置换；后期63例(B组)采用阻断上下腔静脉后先射频消融右心房，再行二尖瓣置换和左房射频消融。结果：A组13例患者CPB转流(104±5)min,主动脉阻断(61±11)min。B组63例患者CPB转流(81±19)min，主动脉阻断(47±11)min；应用冷晶体心肌保护患者开放升主动脉后心脏自动复跳率55.9%，应用冷血心肌保护患者心脏自动复跳率71.4%。术后恢复窦性心律64例，占84.2%。结论：在二尖瓣置换合并射频迷宫术的体外循环中阻闭升主动脉前先射频消融左房可以明显缩短体外循环时间和主动脉阻断时间；应用冷血心肌保护液可以加强心肌保护效果且射频消融迷宫术治疗顽固性房颤效果明显。

目的观察外源性1.6-二磷酸果糖(FDP)用于心脏停搏液,对心脏直视手术心肌缺血期间的保护作用. 方法将60例患者(其中瓣膜置换或成形32例,法乐氏四联症28例),随机分成St.ThomasⅡ号停搏液组(对照组)及FDP氧合血停搏液组(实验组). 观察两组不同停搏液灌注后患者心肌酶CPK-MB (hybrid muscle-brain CPK isoenzyme)的动态变化,术中心脏停搏情况,术后心脏复苏及血液动力学状况. 结果 FDP氧合血停搏液组血清CPK、MDA水平用量低于对照组. FDP加入停搏液能显著降低MDA含量,心脏超微结构保存较好. 术中心脏诱导停搏时间短,术后心脏复苏好,血液动力学稳定. 结论外源性FDP用于心脏停搏液,有明显的心肌保护效果.

Objective:To observe the effect of Gelofusine for colloid osmosis pressure(COP) during cardiopulmonary bypass.Method:In test group (10 cases),the 3/4 volume of total prince was Gelofusine.The other 1/4 volume contain 4% NaHCO\-3,20% Mannitol.In control group (10 cases),The 3/4 volume of total volume was crystal,the other 1/4 volume contain 4% NaHCO\-3 (50～100 ml),20% Mannitol (50～100 ml),blood plasma (200～250 ml).To observe the effect of Gelofusine for COP during CPB.Result:In the same condition,the average COP in test group was much higher than control group ( P 0 001).Conclusion:Large\|dose Gelofusine could rise COP during CPB.

0 引言我院2000-01/2000-09为4例晚期扩张型心肌病和1例冠状动脉搭桥术后心肌广泛缺血全心衰竭患者施行了同种原位心脏移植术,其中1例死于多脏器衰竭,1例死于全身脏器衰竭,另3例均存活至今,心功能及生活质量良好. 我们将5例心脏移植供心保护方法总结并讨论如下:1 临床资料1.1 一般情况 5例心脏移植(男4,女1)例,年龄分别为29, 17, 41, 21和53岁,体质量71, 49, 64, 60和65 kg,4例患者术前经检查,确诊为扩张型心肌病,全心衰竭,频发室性早搏伴阵发性室速,其中1例伴重度肺动脉高压. 其他3例轻度肺动脉高压. 心功能IV级. 另1例冠状动脉搭桥术后全心衰,心功能IV级.

0 引言 我院对近期心脏直视手术的体外循环灌注使用国产肝素涂层与非肝素涂层动脉过滤器,通过血小板计数及过滤器内网电镜扫描进行对比观察.

Objective The effect of XIJING-87 bubble oxygenator on warm cardiopulmonary bypass in open heart surgery was studied.Methods The arterial and mixed venous blood gas in warm cardiopulmonary bypass in 50 patients was analyzed. In order to understand the effect of XIJING-87 bubble oxygenater on warm cardiopulmonary bypass, 3M membrane oxygenator was compared in ten patients.Results During the warm cardiopulmonary bypass, when hematocrit was more than 20%, and using middle or higher flow perfusion, the arterial and mixed venous blood gas could keep in normal range and all patients were survival. Thus XIJING-87 bubble oxygenator could provide enough oxygen for body need during warm cardiopulmonary bypass. There was no difference between the effect of 3M membrane oxygenator and XIJING-87 bubble oxygenator.Conclusion It is safe and reliable for performing XIJING-87 bubble oxygenator with warm cardiopulmonary bypass in open heart operation.

In order to study the influence of atrial remodeling on the effect of radiofrequency ablation maze procedure in treating chronic atrial fibrillation(AF) in patients of rheumatic heart disease,the relationship between the result of the procedure and the duration of AF and the largest dimention of left atrium was analysed.The difference of the AF duration and the largest left atrium dimention betweem patients who restored to sinus rhythm and those who didn′t was significant(3.84±3.24 vs 11.13±8.74 year and 66.17±9.88 vs 81.83±12.85 mm, P0.01 respectively).The longer was the AF duration and the larger was the left atrium,the worse was the effect of the procedure.The difference between the percentage of patients who restored to sinus rhythm between patients whose AF duration3 year and those whose AF duration3 year was significant(72.5% vs 96.2%, P 0.01 ).The difference between the percentage of patients who restored to sinus rhythm between patients whose largest left atrium70 mm and those70 mm was significant(61.5% vs 95%, P0.01 ).Atrial remodeling has a notable negative influence on the effect of radiofrequency ablation maze procedure.

目的:分析婴幼儿体外循环心内直视术后并发症的发生情况,为婴幼儿术后的监护提供指导.方法:分析1998年9月～1999年12月共256例婴幼儿患者体外循环心内直视术后并发症的发生率及死亡率.结果:256例患儿术后肺部并发症占6.6%,低心排出量综合征5.1%,消化道出血占4.7%,心脏猝死综合征占3.1%,急性肾功能衰竭占2.3%;术后死亡12例,占总人数的4.7%.结论:由于婴幼儿机体发育及体循环的特殊性,术后以肺部并发症发生率最高,依次为低心排出量综合征、消化道出血、心脏猝死综合征、急性肾功能衰竭.并发症发生率的不同应引起医护人员在术后监护时的高度重视.

自2000年1月至10月我科为5例患者实施了原位心脏移植术,取得良好效果,现报道如下. 临床资料 5例患者,男性4例,女性1例.3例诊断为扩张性心肌病;1例诊断为克山病;1例诊断冠状动脉搭桥术后全心衰.5例患者的年龄分别为27、18、41、21和53岁;体重分别为71、49、64、60和65 kg;与之相对应的5例供体均为男性,脑死亡患者,年龄分别为27、24、21、25和23岁,体重分别为72、65、76、55和75 kg.供体与受体血清抗巨细胞病毒、肝炎病毒、EB病毒及爱滋病病毒均为阴性,无感染征象,淋巴细胞交叉毒性试验阴性.1.供心取材时的保护: 经供体外周静脉推注2.5 mg/kg肝素抗凝并静脉推注甲基强的松龙500 mg.纵劈胸骨,倒"T”型剪开心包,分离上下腔静脉和主动脉并放置阻断带;先阻断上、下腔静脉,数个心动周期心脏排定后随即阻闭升主动脉,由主动脉根部灌注4 ℃的冷晶体停搏液(K+浓度28 mmol/L,护心通2.5 g/L)1200～1500 ml,冷灌压力维持在150～200 mmHg(1mmHg=0.133kPa);主动脉远端保留阻断带以供继续灌注.供心取出后以冰盐水纱布包裹后置入密封冰水容器中转运,间隔15 min重复冷灌1次,冷灌量为500 ml.供心在手术室修剪时置入4 ℃的冰水中操作.2.供心植入时的心肌保护:供心植入时仍采用顺灌,灌注液改用1∶4的冷血停搏液(K+浓度20 mmol/L),冷血停搏液中加入护心通2.5 g/L;冷灌灌注的间隔时间为20 min,每次灌注量为500 ml～800 ml.

AIM:To study the influence of left atrium size and AF duration on the result of radiofrequency ablation maze procedure(RAMP) in treating chronic atrial fibrillation(AF) for patients with rheumatic heart disease(RHD). METHODS: Echocardiography examination was made for all patients before operation and long dimension of left atrium and AF duration were recorded. The patients were divided and analyzed according to the result of radiofrequency ablation maze procedure. RESULTS: The difference of the AF duration and the left atrium long dimension between patients who restored and didn't restore was significant(3.8±3. 2 year vs 11.1±8.7 year,66±10 mm vs 82±13 mm, P 0.01 respectively). The percentage of patients who restored to sinus rhythm with AF duration 3 year was significantly higher than those with AF duration ≥3 year(72% vs 96%, P 0.01). The percentage of patients who restored to sinus rhythm with long dimension of left atrium 70 mm was significantly higher than those with left atrium dimension ≥70 mm (62% vs 95%, P 0.01). CONCLUTION:The longer the AF duration and the larger the left atrium are, the worse the effect of the RAMP is.

1999年1月至2000年11月我们为72例病人实施了冠状动脉搭桥术,其中17例同时行心脏瓣膜置换或其它心内畸形的矫治,术后恢复良好.现将17例手术体外循环的管理报道如下.

资料和方法病例1：男，35岁，体重57 kg，体表面积1.65 m2，HCT 30.9%。患者因先天性心脏病室间隔缺损伴主动脉瓣赘生物，在全麻低温体外循环下行Ross手术。常规建立体外循环，人工心肺机为Sarns 8000型，氧合器为Jostra，体外循环预充醋酸钠平衡盐1000 ml，全血400 ml，血浆240 ml，4%NaHCO3250 ml，速尿10 mg，地塞米松100 mg，心肌保护液用K+20 mmol/L的冷血。首次采用逆灌，冷灌量为1000 ml，间隔20 min冷灌1次，复灌量为300～400 ml，冷灌液温度6～8℃。心包腔内放置冰袋，转流中最低鼻温24℃，流量1.8～2.5 L/m2/min，平均灌注压60～78 mmHg(1 mmHg=0.133 kPa)，转流中HCT 19%～20%，转流中尿量1350 ml。病例2：男，9岁，体重24 kg，体表面积0.95 m2，HCT 40%。患者因先天性主动脉瓣发育不良，在体外循环下行Ross手术。心肺机为Sarns8000型，氧合器为dideco705型。体外循环预充醋酸钠平衡盐500 ml，血定安500 ml，4%NaHCO3 100 ml，速尿10 mg，地塞米松100 mg。心肌保护方法同病例1。此例患儿在体外循环中最低鼻温17.2℃，转流中灌注流量2.0～2.4 L/m2/min，HCT 20%～22％，平均灌注压50～65 mmHg，转流中尿量500 ml。

1 临床资料 患者男，47岁，体重72 kg。患者自幼发现心脏杂音，术前持续发烧3个月，B型超声心动图检查诊断为：室间隔缺损，主动脉瓣关闭不全，右心室流出道狭窄。拟在体外循环下行室间隔缺损修补，主动脉瓣置换。在术中探查发现主动脉瓣、二尖瓣、三尖瓣、肺动脉瓣广泛增厚，瓣叶脱垂，三尖瓣、肺动脉瓣被侵蚀破坏严重并附有多处赘生物。术中共置换4枚进口机械瓣(主动脉瓣23#，二尖瓣29#，三尖瓣27#，肺动脉瓣25#)。 应用的心肺机为Sarns8000型，人工肺西京-87型鼓泡式氧合器。采用中度低温体外循环；冷血停搏液含K+20 mmol/L，间隔20 min重复灌注1次，心脏停搏期间在心包腔内放置冰袋，以确保心肌低温。主动脉阻断期间共冷灌9次，其中8次为逆行灌注。体外循环转流中灌注流量4 000～4 200 ml/min，转流中平均灌注压(MAP)维持在8～11 kPa(1 kPa=7.5 mmHg )，中心静脉压0～1.0 kPa。在心脏复跳后置换三尖瓣。 体外循环转流时间210 min，主动脉阻断时间149 min，开放升主动脉，心脏自动复跳。术中尿量500 ml,术后2 h苏醒，重症监护病房辅助呼吸15 h。术后第31天痊愈出院。 2 讨论 重症心脏瓣膜病患者体外循环心内直视术瓣膜置换术后早期死亡率为19.6%，明显高于一般瓣膜病术后的死亡率4.0%。目前心脏四瓣膜同期置换，国内有1例报道。此例患者的体外循环预充与一般体外循环的预充无明显差异。我们主要加强体外循环过程中的心肌保护，心脏停搏液灌注的温度要低(6℃～8℃)，灌注量要大，保护心肌充分均匀地维持低温状态；间隔20 min重灌注1次，同时在心包内放置冰袋，并定时更换冰袋；采用中度低温，防止心肌过早复温，并利于降低机体组织器官的能量代谢。心肌保护是重症心脏手术成功及术后心功能恢复的重要环节。我们在此例患者的心肌保护中除注意维持心肌低温和冷血灌注外，还采用了心脏复跳后进行三尖瓣置换，可以明显缩短主动脉的阻断时间，减轻心肌的缺血性损伤。