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分段改良De Vega三尖瓣成形术治疗功能性三尖瓣关闭不全

目的 评价分段改良De Vega三尖瓣成形术治疗功能性三尖瓣关闭不全（FTR）的临床疗效，总结治疗经验。 方法 选择2006年10月至2007年12月在我院手术治疗的风湿性二尖瓣病变合并FTR患者共58例，根据三尖瓣成形手术方式的不同分为两组，改良组：26例，男8例，女18例；年龄49.6±11.8岁；接受分段改良De Vega三尖瓣成形术。传统组：32例，男6例，女26例；年龄47.9±12.8岁；接受传统改良De Vega三尖瓣成形术。于围手术期用超声心动图测量两组患者三尖瓣瞬时反流量、三尖瓣瓣环周径，并随访术后三尖瓣反流情况。 结果 两组术后三尖瓣瞬时反流量均较术前减少（Plt;0.05），组间比较差异无统计学意义（F=1.969，Pgt;0.05）；三尖瓣瓣环周径均较术前明显缩小（Plt;0.01），组间比较差异无统计学意义（F=2.336，Pgt;0.05）；两组均无因三尖瓣反流再次手术者。随访6~12个月时，两组患者三尖瓣反流情况较出院前明显改善，组间比较差异无统计学意义（Pgt;0.05）。 结论 分段改良De Vega三尖瓣成形术，能较为有效地纠正FTR，并可取得满意的近期疗效。

白塞氏病合并主动脉瓣置换术后瓣周漏的临床分析

摘要： 目的 总结白塞氏病所致主动脉瓣置换术后发生瓣周漏的外科治疗经验，探讨相关手术方式和解决方法。 方法 回顾性分析第二军医大学附属长海医院收治的4例白塞氏病所致主动脉瓣置换术后瓣周漏患者的临床资料，均为男性，年龄24～50岁(36±7岁)。其中3例为主动脉瓣重度关闭不全行主动脉瓣置换术后出现瓣周漏行改良Bentall手术，另1例为升主动脉瘤、主动脉瓣重度关闭不全行Wheat术后出现瓣周漏行改良Bentall手术。 结果 4例患者术后恢复顺利，无并发症发生。均痊愈出院。术后随访1～24个月，心功能恢复至Ⅰ～Ⅱ级。3～6个月定期行超声心动图和全主动脉血管造影检查，未发现主动脉瓣周漏复发，人工机械瓣膜功能良好，人工主动脉血管通畅。 结论 白塞氏病合并主动脉瓣或升主动脉病变如单纯行心瓣膜置换术，术后人工瓣膜脱落的发生率较高，改良Bentall手术方式是解决问题的良好方法。

原发性左心房低度恶性纤维粘液瘤样肉瘤一例

心瓣膜置换术后早期心肌顿抑致低心排血量综合征的诊治经验

目的 探讨心瓣膜置换术后早期心肌顿抑的识别、诊断，以及由此导致严重低心排血量综合征（LCOS）的治疗方法，以提高诊断、治疗水平。 方法 回顾分析我科2004年9月至2006年9月期间4例心瓣膜置换术后早期出现心肌顿抑导致LCOS患者的临床资料，4例均为女性，年龄35～54岁，平均年龄46-75岁。术前左心室大小、收缩功能均基本正常，左心室舒张期末内径（LVEDD)3.5～6.3 cm，射血分数(EF)49%～61%；2例行二尖瓣、主动脉瓣置换术，1例行二尖瓣置换术，1例行主动脉瓣置换术。 结果 4例患者均在术后早期（14～40 h、平均26 h）出现无明确原因的LCOS，给予大剂量肾上腺素［0.10～0.15 μg/(min·kg）］治疗无效而改行主动脉内球囊反搏（IABP）治疗，4例患者IABP支持时间为7～12 d（平均8.5 d），3例痊愈，1例因肺部感染于术后28 d死于多器官功能衰竭。2例出现急性肾功能不全，1例7 d后肾功能恢复正常，1例经腹膜透析治疗2周后痊愈。 结论 心肌顿抑可出现在术前心功能良好，手术经过顺利的心瓣膜置换术患者，由心肌顿抑导致的术后早期LCOS，及时应用IABP可以减轻心脏负荷，增加冠状动脉灌注，改善重要脏器循环，有助于左心室渡过心肌顿抑期，恢复收缩功能，是成功救治的重要手段。

先天性心脏病合并肺动脉瓣感染性心内膜炎的外科治疗

目的　探讨先天性心脏病合并肺动脉瓣感染性心内膜炎的外科治疗方法和效果。　方法　2009年1月至2012年1月第二军医大学长海医院收治先天性心脏病合并肺动脉瓣感染性心内膜炎患者6例，男1例，女5例；年龄8～41 （24.8±11.8）岁。动脉导管未闭（PDA）4例，PDA合并先天性主动脉瓣狭窄1例，室间隔缺损（VSD）合并三尖瓣反流1例。3例行PDA结扎＋肺动脉内赘生物清除术，1例行PDA结扎＋肺动脉瓣赘生物切除术，1例行PDA结扎＋肺动脉瓣赘生物切除术＋主动脉瓣置换术（AVR，置换19 mm CarboMetics环上机械主动脉瓣），1例肺动脉瓣膜破坏严重，行VSD修补＋右心室流出道赘生物清除＋右心室流出道拓宽＋三尖瓣成形术＋肺动脉生物瓣置换术（置换27 mm HancockⅡ型生物瓣）。　结果　6例患者术后均恢复良好，无围术期死亡和心内膜炎复发。所有患者复查超声心动图提示，未见赘生物、残余漏、瓣周漏等并发症。术后随访6个月～3年中，患者临床症状完全消失，均无明显不适。术后心功能恢复至Ⅰ级5例，Ⅱ级1例。　结论　对于先天性心脏病合并肺动脉瓣感染性心内膜炎患者，正确把握手术时机，积极行外科手术治疗是最有效的治疗方法。

Clinical Analysis of Repeated Heart Valve Surgery in 325 Patients

Abstract： Objective To summarize surgical experiences and explore risk factors of patients undergoing repeated heart valve surgery. Methods Clinical records of 325 consecutive patients who underwent repeated heart valve surgery from January 1998 to December 2008 in Changhai Hospital of Second Military Medical University were retrospectively　 analyzed. There were 149 male patients and 176 female patients with their average age of （47.1±11.8） years. Following　 variables were collected: preoperative morbidity， heart function， indications and surgical strategies of repeated heart valve surgery， postoperative mortality and morbidity， which were compared with those clinical data of patients who underwent their first heart valve surgery during the same period. Multivariate logistic regression was used to determine risk factors of perioperative death of patients undergoing repeated heart valve surgery. Results The main reasons for repeated heart valve surgery were mitral valve restenosis after closed mitral commissurotomy and new other valvular diseases. Postoperatively， 28 patients died in the early-stage with the overall mortality of 8.6% （28/325）. The main reasons of in-hospital death included low cardiac output syndrome （LCOS）and acute renal failure. Compared with patients undergoing their first heart valve surgery， patients who underwent repeated heart valve surgery were more likely to have chronic obstructive　 pulmonary disease （COPD)， New York Heart Association (NYHA） classⅢ-Ⅳ， and atrial fibrillation， preoperatively. Their cardiopulmonary bypass time and aortic cross clamp time were comparatively longer. They also had more postoperative　 morbidities such as LCOS， acute renal failure and acute respiratory distress syndrome （ARDS）. Multivariate logistic regression showed that preoperative critical state （OR=2.82， P=0.002）， cardiopulmonary bypass time longer than 120 minutes （OR=1.13， P=0.008）， concomitant coronary artery bypass grafting （OR=1.64， P=0.005）， postoperative LCOS（OR=4.52， P＜0.001）， ARDS （OR=3.11， P＜0.001） and acute renal failure （OR=4.13， P＜0.001）were independent risk factors of perioperative death of patients undergoing repeated heart valve surgery. Conclusion Repeated heart valve surgery is a difficult surgical procedure with comparatively higher risks. Full preoperative assessment of the valvular lesions，　 proper timing for surgery and perioperative management are helpful to reduce postoperative mortality and morbidity.

Clinical Outcomes of Aortic valve Replacement for Surgical Treatment of Patients with Severe Aortic Stenosis and Left Ventricular Dysfunction

ObjectiveTo investigate clinical outcomes of aortic valve replacement (AVR)for surgical treatment of patients with severe aortic stenosis (AS)and left ventricular dysfunction (LVD). MethodsClinical data of 29 patients with severe AS and LVD (left ventricular ejection fraction (LVEF) < 0.50)who underwent AVR in Changhai Hospital between January 2000 and December 2011 were retrospectively analyzed. Patients with mitral stenosis were excluded from this study. There were 22 male and 7 female patients with their age of 14-76 (56.3±12.9)years. Preoperative and postoperative clinical and echocardiographic findings were compared to assess AVR effects. Possible risk factors affecting postoperative recovery of left ventricular function were analyzed according to postoperative LVEF changes. ResultsOne patient died within 30 days after AVR. In the other 28 patients, postoperative aortic pressure gradient (APG)decreased from 97.6±25.1 mm Hg to 25.0±9.7 mm Hg, while LVEF increased from 41%±6% to 56%±11%. Postoperative left ventricular end-diastolic/systolic diameter/volume all significantly improved (all P < 0.001). ConclusionsAVR is an effective treatment for patients with severe AS and LVD. Left ventricular function improves significantly in most patients after AVR. Patients with a less dilated left ventricle may have a better LVEF recovery.