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华法林抗凝过量致自发性后腹膜出血一例

右侧乳缘下切口在再次瓣膜手术中的应用

目的 探索经右侧乳缘下切口行再次瓣膜手术的临床应用效果。 方法 2012 年 12 月至 2017 年 3 月南京大学医学院附属鼓楼医院共 20 例患者经右侧乳缘下切口行再次瓣膜手术（右侧乳缘下切口组），其中男 11 例、女 9 例，平均年龄（51±8）岁。选取同时期 20 例经胸骨正中切口再次行二、三尖瓣手术患者（正中开胸组），其中男 13 例、女 7例，平均年龄（46±5）岁。右侧乳缘下切口组采用股动静脉插管，上腔静脉常规直角插管，第 4 肋间进胸，不断肋骨，常规升主动脉阻断或心室颤动下完成二、三尖瓣成形或置换、心房颤动消融和左房折叠等术式。 结果 正中开胸组有 3 例开胸时出现心脏破裂，而右侧乳缘下切口组只有 1 例游离下腔静脉时右房破裂。右侧乳缘下切口组开胸体外循环时间和术后住院时间均显著短于正中切口组［（55.0±22.0）min vs.（94.0±38.0）min，P<0.001；（12.3±3.7）dvs.（15.7±6.7）d，P=0.032］。右侧乳缘下切口组开胸时出血量和术后 24 h 引流量均显著少于正中开胸组［（92.0±37.0）ml vs.（342.0±157.0）ml，（202.0±117.0）ml vs.（567.0±254.0）ml，P均<0.001］。 结论 右侧乳缘下切口行再次心脏手术可完成除升主动脉和主动脉瓣操作之外的任何瓣膜和左房操作，具有手术创伤小、出血少、患者术后恢复快、美容效果好等优点。此外，对于外科医生而言，该技术手术难度较低，如果具备正中切口的解剖基础，完全可胜任此手术，但术中需注意肺和心肌保护。

Treatment of Gartland type Ⅱ and Ⅲ supracondylar fracture of humerus in children

ObjectiveTo analyze the treatment of Gartland type Ⅱ and Ⅲ supracondylar fracture of the humerus in children.MethodsBetween January 2015 and January 2017, 45 cases of Gartland type Ⅱ and Ⅲ supracondylar fracture of the humerus were treated. There were 28 boys and 17 girls with an age of 1-13 years (mean, 5.7 years). The causes of injury included sports injury in 43 cases and falling from height in 2 cases. Fractures were classified as type Ⅱ in 12 cases and type Ⅲ in 33 cases according to Gartland classification. The time from injury to operation was 2-12 hours (mean, 4.6 hours). All fractures were treated with closed reduction first, and 12 cases of Gartland type Ⅱ fracture were successful in closed reduction; 20 cases of Gartland type Ⅲ fracture were successful in closed reduction, 11 cases with reduction failure and 2 cases with radial nerve injury underwent assisted anterior transverse approach reduction. Then percutaneous crossed Kirschner wires fixation was performed.ResultsThe operation time was 16-52 minutes (mean, 32 minutes). The perspective frequency was 4-17 times (mean, 6.7 times). The hospitalization time was 3-7 days (mean, 4 days). All the 45 cases were followed up 8-20 months (mean, 12 months). The ulnar nerve paralysis occurred in 3 cases of Gartland type Ⅲ fracture that were treated with closed reduction, and recovered after 1-3 months. All fractures healed after operation, and the healing time was 2-3 months. No incision infection, Volkmann muscle contracture, and other complications occurred. The elbow joint function score at 6 months after operation showed that the results of closed reduction was excellent in 16 cases, good in 12 cases, and fair in 4 cases, with the excellent and good rate of 87.5%; in which Gartland type Ⅱ fracture was excellent in 9 cases and good in 3 cases, with an excellent and good rate of 100%, and Gartland Ⅲ was excellent in 7 cases, good in 9 cases, and fair in 4 cases with an excellent and good rate of 80%. The results of assisted anterior transverse approach reduction was excellent in 7 cases, good in 5 cases, and fair in 1 case, and the excellent and good rate was 92.3%.ConclusionGartland type Ⅱ and Ⅲ supracondylar fractures of the humerus can be treated with closed reduction or combined with the assisted anterior transverse approach reduction, then fixed by percutaneous crossed Kirschner wire, which is operational, smaller invasive, and less radiation exposure during operation, while postoperative function is good.

分期杂交手术治疗胸腹主动脉夹层

目的总结腹主动脉去分支化手术联合主动脉腔内隔绝术治疗胸腹主动脉夹层的经验。方法自 2018 年 1 月至 2019 年 6 月，南京鼓楼医院采用腹主动脉去分支化手术联合主动脉腔内隔绝术治疗胸腹主动脉夹层 12 例，男 10 例、女 2 例，年龄 36～63（50±9）岁。结果随访 6～24 个月，全组无死亡，1 例术后左下肢单瘫，1 例出现肾功能不全。随访期间 1 例患者术后 1 个月出现主动脉支架近端逆撕，行全主动脉弓置换术后痊愈。2 例患者出现腹腔干动脉近端内漏，予以弹簧圈栓塞后痊愈，其余患者 CT 血管造影（CTA）检查未见吻合口造影剂渗漏及人工血管扭曲、闭塞。结论腹主动脉去分支化手术联合主动脉腔内隔绝术治疗胸腹主动脉夹层可取得良好近期疗效，中远期疗效仍有待进一步观察随访。

Castor stent implantation combined with subclavian artery bypass grafting for the treatment of aortic arch lesions

ObjectiveTo explore the short- and mid-term efficacy of Castor single branch aortic stent combined with subclavian artery bypass grafting for the aortic arch lesions. MethodsA retrospective analysis of the clinical data of patients with proximal anchor zone insufficiency aortic arch lesions treated with Castor stent combined with carotid-subclavian bypass at the Department of Cardiac Surgery, Drum Tower Hospital, the Affiliated Hospital of Nanjing University Medical School from August 2020 to November 2023 was performed. ResultsA total of 22 patients were included, including 19 males and 3 females, with an average age of 56±16 years. There were 18 patients of aortic dissection and 4 patients of aortic arch tumors. The success rate of surgical technique was 100.0%, and the average postoperative hospital stay for patients was 10±4 days. The median follow-up time was 20 months. During the follow-up period, there were no major complications such as endoleak, paraplegia, cerebral infarction, renal insufficiency, etc., and all patients had no readmissions. ConclusionFor proximal anchor zone insufficiency aortic arch lesions, the treatment method of using a Castor stent branch placed in the left common carotid artery can effectively extend the anchor zone, avoid the huge trauma of open chest surgery, and achieve good short- and mid-term efficacy.

老年先天性矫正型大动脉转位行心瓣膜置换术一例

Stanford B 型主动脉夹层腔内修复术后并发 A 型夹层的外科治疗

目的总结 Stanford B 型主动脉夹层胸主动脉腔内修复术（TEVAR）后并发 A 型夹层的临床特点及外科治疗经验。方法自 2013 年 11 月至 2018 年 3 月，南京鼓楼医院外科治疗 Stanford B 型主动脉夹层 TEVAR 术后并发的 A 型夹层患者 14 例，其中男 13 例 、女 1 例，年龄 24～66（52±3）岁，合并高血压 13 例，糖尿病 2 例，马方综合征 1 例。所有患者在深低温停循环选择性脑灌注下施行手术，近心端 13 例行升主动脉置换术，1 例行 Bentall 术。共实施全弓置换加象鼻手术 13 例，弓部开窗支架植入术 1 例。结果全组无死亡，1 例术后右上肢单瘫，1 例术后血行感染，1 例出现右侧偏瘫及肾功能不全行肾脏替代治疗。随访 6～45 个月，随访期间 1 例患者术后 1 个月因原介入支架远端胸降主动脉发生新的夹层再次行 TEVAR，其余患者 CT 血管造影检查未见吻合口造影剂渗漏及人工血管扭曲。结论B 型主动脉夹层 TEVAR 术后并发 A 型夹层及时给予外科手术治疗可取得良好疗效。

Analysis of Risk Factors of Preoperative Sudden Death of Patients with Type A Aortic Dissection

Objective　To analysis correlation factors for preoperative sudden death of patients with type A aortic dissection in order to determine clinical management strategy.?Methods?We retrospectively analyzed clinical data of 52 patients with type A aortic dissection who were admitted in Department of Cardiothoracic Surgery of the Affiliated Drum Tower Hospital of Nanjing University Medical School from January 2003 to January 2010. According to the presence of preoperative death, all the patients were divided into two groups, 9 patients in the preoperative sudden death （PSD）group including 7 males and 2 females with their mean age of 52.0±12.1 years；43 patients in the control group including 31 males and 12 females with their mean age of 51.5±10.9 years. Univariate and multivariate logistic regression analysis were used for analysis of preoperative factors related to sudden death.?Results?Univariate analysis result showed 7 candidate variables：body mass index （BMI, Wald χ2=2.150, P=0.143）, time of onset （Wald χ2=2.711, P= 0.100）, total cholesterol （TC, Wald χ2=1.444, P=0.230）, low density lipoprotein cholesterol （L-C, Wald χ2=1.341, P=0.247）, aortic insufficiency （AI, Wald χ2=2.093, P=0.148）, aortic sinus involvement （Wald χ2=3.386, P=0.066）and false lumen thrombosis （Wald χ2=7.743, P=0.005）. Multivariate logistic regression analysis showed that BMI （Wald χ2=4.215, P=0.040, OR=1.558）and aortic sinus involvement （Wald χ2=4.592, P=0.032, OR=171.166 ）were preoperative risk factors for sudden death, and thrombosed false lumen （Wald χ2=5.097, P=0.024, OR=0.011）was preoperative protective factor for sudden death.?Conclusion?Type A aortic dissection patients with large BMI and/or aortic sinus involvement should receive operation more urgently than others and patients with thrombosed false lumen may have relatively low risk of preoperative sudden death.

右冠状动脉-右心室瘘致巨大冠状动脉瘤一例

Clinical Effect of Tricuspid Valve Re-operation after Left Cardiac Valve Surgery

ObjectiveTo evaluate the clinical efficacy of tricuspid valve re-operation after left cardiac valve surgery. MethodsWe retrospectively analyzed the clinical data of 23 patients underwent tricuspid valve re-operation in the Affiliated Drum Tower Hospital of Medical School, Nanjing University from January 2009 to November 2014. There were 3 males and 20 females with a mean age 53.48±10.79 years ranging from 34 to 71 years. The average body mass index of the 23 patients was 21.77±2.42 kg/m2. We followed up all the patients in outpatient department or through telephone for 3 months to 5 years. ResultsAll surgeries were operated under cardiopulmonary bypass. There were 15 patients underwent operation through medisternal incision and 8 patients underwent operation through the fourth intercostal incision of right anterolateral side. The mean operation time was 284.35±56.16 minutes and the mean time of cardiopulmonary bypass was 138.61±46.91 minutes. One patient died postoperatively and 2 patients chose to discharge automatically after operation. The other 20 patients recovered and discharged uneventfully. We followed up the patients for 3 months to 5 years. One patient underwent permanent pacemaker therapy for atrioventricular block, 3 patients accepted pharmaceutical therapy for atrial arrhyttmia, 1 patient underwent re-operation for infectious endocarditis of left cardiac artificial valve. and the follow-up conditions of the rest patients were well. Besides, the follow-up data showed that there was a mild regurgitation in 3 patients underwent tricuspid valve plasty. ConclusionTricuspid valve re-operation after left cardiac valve surgery can take multiple surgical pathways and strategies. The clinical effect has been proved and the midterm follow-up condition is well, but we still need the long-term follow-up for the further effect.