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find Author "徐志云" 44 results
  • 心血管手术风险预测研究与现状

    手术风险预测模型是术前风险评估的重要工具,在外科临床工作中起着十分重要的作用,它对手术适应证的确定、手术相关危险因素的识别、评分标准的确立以及不同中心手术疗效的比较都具有十分重要的意义。而心脏外科手术因受到多方面因素的影响,其围术期的病死率仍较高。因此,在心脏外科临床研究领域很早便开展了有关建立手术风险预测模型的工作。 从国外研究背景来看,至1986年美国胸外科医师协会(The Society of Thoracic Surgeons,STS)公布的第一个心脏术后风险预测模型Parsonnet评分系统起,近20余年间在北美、欧洲及澳洲等地区相继出现了一系列高质量的手术风险预测模型。目前,被广泛应用的预测评分系统包括Parsonnet评分系统、欧洲心脏手术风险评估系统(the European System for Cardiac Operative Risk Evaluation ,EuroSCORE)、STS评分系统及美国心脏病学院/美国心脏协会(American College of Cardiology/American Heart Association,ACC/AHA)评分系统等。  而从国内研究现状来看,由北京阜外心血管病医院牵头联合全国32家心脏中心率先建立了首个国内大型多中心冠状动脉旁路移植术数据库及中国冠状动脉旁路移植术评分系统(SinoSCORE),同时完成了EuroSCORE对我国冠心病患者手术死亡预测能力的评价研究。但目前国内有关其他重要预测评分系统的评价研究以及对我国心脏瓣膜病患者手术风险预测评价研究的报道仍相对缺乏。北京阜外心血管病医院撰写的“不同心脏手术风险预测评分系统对中国冠状动脉旁路移植术后患者早期死亡的预测”论文,收集了该院2006年11月至2007年12月年间1 559例18岁以上施行单纯冠状动脉旁路移植术(CABG)患者的临床资料,参照STS评分系统、EuroSCORE、Parsonnet评分系统和ACC/AHA评分系统的评分及分组方法,采用HosmerLemeshow(HL)卡方检验及受试者工作特征(ROC)曲线下面积的统计学方法,完成了4种预测评分系统对我国行CABG患者早期死亡的预测评价研究,提示除STS评分系统对单纯CABG患者具有潜在的临床应用可能外,其他3种评分系统对单纯CABG术后早期死亡风险预测的准确性均较差。而上海第二军医大学长海医院撰写的“EuroSCORE模型对心瓣膜手术患者死亡风险的预测”论文,收集了该院1998年1月至2008年12月年间4 155例各类心脏瓣膜手术患者的临床资料,参照additive和 logistic EuroSCORE评分及分组方法,采用HL卡方检验及ROC曲线下面积的统计学方法,完成了EuroSCORE模型对心脏瓣膜手术患者在院死亡率的预测评价研究,提示EuroSCORE模型对该中心心脏瓣膜手术患者死亡风险预测的准确性较差。 两篇论文的研究均表明,目前国际上公认的几种重要的手术风险预测评分系统对我国心脏手术患者术后早期死亡的预测效能均存在不同程度的限制,而建立适合我国患者心脏手术的风险预测模型及评分标准具有必要性及重要性。讨论中作者均提出由于地域及人种的差异,我国心脏手术患者的病因学与国外患者存在较大的差异,尤其是心脏瓣膜病的流行病学特点差异,是导致最终结论差异的重要原因。但两篇论文也同样存在一定的研究局限: (1)均为单中心研究,虽样本量较大,但我国地域广大,各心脏中心接诊患者的病种、病情轻重程度及诊疗技术仍存在一定差异,故应用单中心研究对研究结论的正确性可能会造成不同程度的影响,因此仍需扩大样本量以得到更为准确的研究结论。(2)临床资料的收集以回顾性研究为主,且各临床变量的采集标准国内尚未统一,评分系统中变量的定义也存在一定差异,故每例患者评分预测的真实结果存在一定偏倚,对研究结论的准确性也存在影响。随着对手术风险预测模型的临床研究重视程度不断地增加,目前我国各心脏诊疗中心均已开始建立各自的心脏外科临床数据库,故建议加强国内相关临床研究的学术交流,统一数据库建立方法及临床变量的采集标准,建立符合我国国情的大型多中心心脏外科临床数据库,用以进一步规范我国心脏手术术前风险评估工作,这对制定相关临床指南以及进一步降低心脏手术 在院病死率及并发症发生率,必将起到非常积极的作用。综合国内外心脏手术风险预测模型的建立方法和纳入因素,目前均没有考虑到“人”的因素,也就是说同样的手术,由技术水平不同的医师或医院实施,其结果实际上存在很大的差异,而术后处理不恰当也可造成较大的差异。因此,目前在制定手术风险预测模型时,实际上是建立在外科医师手术技术水平相当、正确实施手术和正确处理患者的基础上。就当前而言,要将医师的水平和能力考虑在内,确实非常困难,实际上也无法做到,这也是目前各种风险预测模型所存在的共同限制。  “不同心脏手术风险预测评分系统对中国冠状动脉旁路移植术后患者早期死亡的预测”和“EuroSCORE模型对心瓣膜手术患者死亡风险的预测”两篇论文均紧紧把握了目前我国心脏外科术前风险预测模型相关临床研究的重要方向,研究目标明确,样本量较大,科研设计合理,统计学方法正确,结论可信,具有较高的学术价值和社会价值,对临床工作具有一定的指导意义,希望在今后的研究工作中能不断完善。

    Release date:2016-08-30 05:57 Export PDF Favorites Scan
  • Current issues should be emphasized on preoperative evaluation of heart valvular disease

    Preoperative evaluation is crucial for heart valvular surgery. This article discusses some issues that need to be emphasized: the impact of hypertension on the severity of aortic valve lesions, and how to improve the accuracy of clinical assessment; the identification of functional tricuspid regurgitation, in order to choose the appropriate surgical technique; the need for right ventricular function testing, and the use of risk scoring models, to better grasp surgical timing and indications and improve efficacy; and the importance of evaluating atrial mitral and/or tricuspid regurgitation complications in chronic atrial fibrillation, and making rational choices for interventional and surgical treatment.

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  • Progress in Evaluating Quality of Life in Postoperative Patients with Valvular Heart Disease Using SF-36 Health Survey

    Abstract: Quality of life (QOL) refers to an individual’s perception and subjective evaluation of their health and well-being, and has become an important index to evaluate the outcomes of clinical treatment in the last past decades. There are a large number of different instruments to evaluate QOL, and the 36-Item Short Form Health Survey (SF-36) is currently one of the most widely used instruments. In recent years, SF-36 has been used to evaluate QOL of valvular heart disease patients to investigate the risk factors those influence their postoperative QOL, provide more preoperative evaluation tools for clinical physicians, and improve postoperative outcomes of patients with valvular heart disease. However, it is now just the beginning to use SF-36 to examine QOL of valvular heart disease patients. Because of significant differences in sample size, follow-up period, country and culture, current research has some controversial results. This review focuses on the progress in evaluating QOL in postoperative patients with valvular heart disease using SF-36.

    Release date:2016-08-30 05:50 Export PDF Favorites Scan
  • The Advancement of Early Enteral Nutrition in Critical Patients after Cardiopulmonary Bypass

    Early enteral nutrition after cardiopulmonary bypass (CPB) has been shown to have beneficial effects on intestinal integrity, lower mortality and also on the patient’s immunocompetence. Even in critical patients after CPB, enteral nutrition should be reasonable to start early and also be supplemented by parenteral nutrition in order to meet energy requirement. We conclude that enteral nutrition is preferable in the majority of patients with severe hemodynamic failure, but gastrointestinal complication and hypocaloric feeding should be simultaneously noticed. This paper comprehensively described enteral nutrition’s protective mechanism and effects on digestive system, enteral nutrition’s implementing methods after CPB, and problems or prospects needing attention in execution.

    Release date:2016-08-30 06:09 Export PDF Favorites Scan
  • Methods and Results of Supra-annular Aortic Valve Replacement for Patients with Severely Damaged Aortic Annulus

    Abstract: Objective To summarize the methods and results of supra-annular aortic valve replacement(AVR) in patients with severely damaged aortic annulus. Methods Supra-annular AVR was performed in 5 patients between March 2008 and Dec. 2010 in Changhai Hospital, Second Military Medical University. There were 4 males and 1 female with their mean age of 46.3 years (ranging from 38 to 53 years). Non-specific infectious diseases were diagnosed in 4 patients who had severe paravalvular leakage after their first AVR operations (2 patients with Behcet’s disease and 2 patients with arteritis), and one patient had severe infectious endocarditis. All the patients had severely destroyed aortic annulus and could not undergo routine AVR. The prosthetic valves were fixed to the aortic sinus wall between the annulus and coronary arterial ostia, and the sutures passed through from the outside of aortic wall into the inside and prosthetic valve ring. Coronary artery bypass grafting was performed if the coronary ostium was involved. Results All patients recovered from the operations uneventfully, and were followed up from 6 months to 3 years. All patients were in New York Heart Association(NYHA) functional class Ⅰ or Ⅱ during the follow-up period, and paravalvalar leakage, pseudoaneurysm and aortic root aneurysm were not found by the examination of 3D computed tomographic angiography and echocardiography at 6 months(4 cases), 1 year(2 cases), and 3 years(1 case), respectively . Conclusions Supra-annular AVR is an alternative surgical method for patients with severely damaged aortic annulus. The procedure is simple and effective to prevent paravalvular leakage and pseudoaneurysm formation.

    Release date:2016-08-30 05:48 Export PDF Favorites Scan
  • 二尖瓣置换术后左心室破裂的防治方法

    摘要: 目的 探讨二尖瓣置换术后发生左心室破裂的预防及处理方法,总结治疗经验。 方法 1998年1月至2007年12月第二军医大学长海医院救治7例二尖瓣置换术后发生左心室破裂患者,男2例,女5例;年龄49~72岁(60.0±8.4岁)。术中发生左心室破裂3例,其中1例予以心外修补,2例予以心内、心外联合修补;术后发生左心室破裂4例,立即床旁开胸,在ICU内行心外修补2例;重返手术室1例;放弃救治1例。 结果 围术期死亡5例(71.43%),其中1例术后发生低心排血量综合征和肾功能衰竭,术后3 d死亡;术后发生左心室破裂的3例均未抢救成功而死亡,另1例放弃救治死亡。生存的2例患者采用主动脉内球囊反搏分别支持6 d和8 d,出院前超声心动图提示:左室后壁运动幅度减小。随访2例,随访时间分别为2年和6年,均生存,心功能Ⅰ~Ⅱ级,无假性室壁瘤形成。 结论  左心室破裂的预防至关重要,应在体外循环心脏停搏下修复裂口,术后主动脉内球囊反搏支持有助于提高救治的成功率。

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  • 经右胸前外侧切口径路行再次三尖瓣手术的技术改良

    目的 [HTSS]探讨经右胸前外侧切口径路行再次三尖瓣手术的手术技术改良方法,以提高手术疗效。 方法 1997年1月至2009年6月,第二军医大学长海医院对32例左心瓣膜置换术后重度三尖瓣关闭不全患者经右胸前外侧切口径路行再次三尖瓣手术,其中男23例,女9例;年龄43~62岁 (49.5±8.7岁)。行三尖瓣置换术29例,三尖瓣成形术3例。手术中均不做心包粘连分解或上、下腔静脉套带;上腔静脉采用带气囊直插管;下腔静脉仅做引流而不阻断;三尖瓣置换的人工瓣膜置于冠状静脉窦口下方。 结果 手术时间152±38 min,体外循环时间45±13 min;术中出血量272±59 ml;术后24 h胸腔引流量420±93 ml 。术后早期死亡4例(12.5%),其中死于肾功能不全1例,呼吸功能不全2例,多器官功能衰竭1例。随访28例,随访时间3~152个月,随访期间死亡3例,生存患者心功能分级(NYHA)Ⅰ级11例,Ⅱ级13例,Ⅲ级1例。 结论 再次三尖瓣手术的改良技术简化了操作、减少出血、缩短了手术时间。

    Release date:2016-08-30 05:57 Export PDF Favorites Scan
  • Discussion on Clinical Classification of Cardiac Myxoma [CX4]——[CX] With Report of Recurrent Cases and Review of Domestic Literature

    Objective To analyze the causes of cardiac myxoma recurrence and discuss its clinical classification. Methods We reviewed the data of two female patients, aged thirty three and forty two, with recurrent cardiac myxoma, who were admitted into our hospital separately in December 2004 and October 2005. We searched articles with “cardiac myxoma” as the key words at www.cqvip.com, and reviewed literature of big case groups having undergone surgical operations, case reports of recurrence and literature with a followup time longer than 4 years between January 1994 and December 2008. Results We reviewed a total of 1 969 cases of cardiac myxoma, in which there were 60 recurrent cases with a recurrence rate of 3.0%, and there were 15 recurrence case reports. Data analysis showed that single pedicle recurrence rate was 3.0% (3/99) and multiple pedicle recurrence rate was 35.7% (5/14); In two reports on cardiac myxoma distributed in multiple chambers, the recurrence rate was 41.7% (5/12) and 33.3% (3/9) respectively;Average interval of recurrence was 4.1 years; Repeated recurrence happened to 9 cases (12.0%) with the most repetition times of 4 in one case; Malignancy on recurrence was found in one case; Reoperation rate was 64.0% (32/50); Six cases (8.0%) were familial myxoma. Accordingly, we advocate a clinical classification of “typical” and “atypical” cardiac myxoma. The typical myxoma refers to the tumors located at left atrium with single pedicle, rooted at or around fossa ovalis, and without abnormal DNA, while the atypical myxoma are familial tumors and tumors stemming from multiple points or multiple chambers, rooted in abnormal position of the left atrium, arising from clear gene mutation, or with malignant tendency. Conclusion Myxomas with multiple pedicles, distributed in more than one chamber, and rooted in abnormal position of the left atrium have a much higher recurrence rate. Close follow-up is needed for abovementioned patients to achieve an optimal treatment results.

    Release date:2016-08-30 05:59 Export PDF Favorites Scan
  • Mild Functional Tricuspid Regurgitation Approach to Mitral Valve Repair

    Abstract: Objective To explore whether clinically mild functional tricuspid regurgitation should be addressed at the time of mitral valve repair (MVP) for moderate or severe mitral regurgitation due to myxomatous degeneration. Methods We retrospectively analyzed the outcomes of 135 patients with moderate or severemitral regurgitation due to myxomatous degeneration with mild functional tricuspid regurgitation. All patients were treated between January 1993 and March 2008 in the Department of Cardiothoracic Surgery of Changhai Hospital, the Second Military Medical University. We divided the patients into a MVP group (n=76) and a MVP+tricuspid valvuloplasty (TVP) group(n=59) according to whether they underwent combined TVP, and observed the perioperative mortality rate, degree of tricuspid regurgitation, and compared survival rate, and freedom from longterm moderate or severe tricuspid regurgitation after operation. Cox regression was used to analyzethe risk factors for longterm moderate or severe tricuspid regurgitation after operations. Results (1) There were no deaths during the perioperative period, and postoperative transthoracic echocardiography of all patients indicated that tricuspid regurgitation was mild or less. (2) Survival rate at 5 years, 10 years after operations in MVP group was 98.4%, 95.0%, respectively, and survival rate at 5 years, 10 years after operations in MVP+TVP group was 100.0%, 93.7%, respectively, and there was no significant difference in the survival rate after operations between the two groups(P=0.311), butthere was a significant difference in the freedom from longterm moderate or severe tricuspid regurgitation after operations between the two groups (P=0.040). Multivariate Cox regression showed that preoperative pulmonary artery pressure gt;30 mm Hg (95%CI 1.127 to 137.487, P=0.040 )and atrial fibrillation (95%CI 1.177 to 23.378, P=0.030) wereindependent risk factors for longterm moderate or severe tricuspid regurgitation afteroperations.Conclusion TVP is necessary for most patients undergoing MVP for moderate or severe mitral regurgitation due to myxomatous degeneration who have coexistent mild functional tricuspid regurgitation, especially those patients with preoperative pulmonary artery pressure gt;30 mm Hg or atrial fibrillation.

    Release date:2016-08-30 05:57 Export PDF Favorites Scan
  • Evaluation of Cardiopulmonary Bypass Technique in Treating Descending Aortic Aneurysms

    Objective To investigate the clinical effects and the brain protection effect of different cardiopulmonary bypass in treating descending aortic aneurysms. Methods From January 2001 to December 2008, 65 patients were diagnosed to have descending aortic aneurysm with magnetic resonance imaging (MRI) in our hospital. Among them, there were 56 males and 9 females whose age was between 15 and 71 years old with an average of 48.1 years. The disease process ranged from 6 days to 4 months (19.0±6.5 d ). Preoperative diagnosis showed that there were 41 cases of DeBakey type Ⅲinterlayer, 9 cases of Marfan syndrome with postoperative complications of type Ⅲ interlayer, 7 cases of pseudoaneurysm and 8 cases of true aneurysm. We adopted artificial blood vessel repair patch to repair the damaged point of the descending aorta in 2 cases, performed vascular aneurysm resection and artificial vessel replacement on 63 patients, and carried out descending aorta replacement and intercostal artery grafting in 18 cases. Results Among the 65 cases of cardiopulmonary bypass patients, there were 13 cases of left heart bypass, 12 cases of heart bypass, 30 cases of deep hypothermic circulatory arrest (DHCA) with total body retrograde perfusion (TBRP) and 10 cases of modified separate perfusion of upper and low body. Cardiopulmonary bypass time, DHCA time, retrograde perfusion time, upper body circulatory arrest time and low body circulatory arrest time were respectively 51-212 min, 18-75min, 18-73 min, 21-31 min, and 39-67 min. No death occurred during the operation, and there were no brain complications or complications of paralysis among all the patients. Two patients died after operation because of renal failure. Conclusion Good results can be achieved by selecting different method of cardiopulmonary bypass based on the anatomical location and range of the thoracic descending aortic aneurysms. The selection criteria should be favorable to the surgical operation and organ protection.

    Release date:2016-08-30 06:02 Export PDF Favorites Scan
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