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双极射频消融迷宫术后同步电复律治疗心房颤动

目的 总结双极射频消融迷宫术（CoxⅣ）术后同步电复律治疗心房颤动（AF）的临床经验。 方法 2006年7月至2009年7月沈阳军区总医院对223例AF患者行CoxⅣ治疗，其中13例患者(包括男4例，女9例；年龄41～69岁；风湿性心脏病7例，退行性心瓣膜病5例，继发孔型房间隔缺损合并三尖瓣关闭不全1例)于出院后仍为AF而药物转复不佳，行同步电复律治疗。电复律后观察心率和心律情况，监测生命体征，出院后继续口服胺碘酮200 mg，1次/天，定期门诊随访。 结果 CoxⅣ手术后6个月内行同步电复律4例，即刻转复窦性心律3例；6个月以上行同步电复律9例，即刻转复窦性心律4例、AF 2例、交界性心律3例。CoxⅣ术后1年以上行电复律3例，转复窦性心律2例。13例均获随访，随访时间6个月～1年。随访期间窦性心律8例（61.54%）、AF4例（30.77%）、交界性心律1例（7.69%）。7例电复律后即刻转复为窦性心律的患者中有1例复发，窦性心律维持率为85.71%（6/7）；6例即刻未转复为窦性心律患者中有2例转为窦性心律。窦性心律患者复律后左心房内径（LAD）较复律前明显减小（39.00±5.15 mm vs. 54.50±3.63 mm, t=6.958, P=0.000），而AF患者LAD在复律前后无明显改变（51.00±5.72 mm vs. 48.00±5.89 mm,t=0.731,P=0.493）。 结论 CoxⅣ手术后电复律治疗AF安全有效，成功率高，是CoxⅣ术后控制AF的重要治疗手段。复律时机以术后6个月以内为宜，即刻转复窦性心律成功率较高，维持率也高。LAD明显缩小者电复律效果较好。

老年瓣膜病患者心瓣膜置换术的临床分析

目的 总结老年瓣膜病患者行心瓣膜置换术的经验，以提高手术效果。 方法 回顾性分析2000年1月至2009年4月沈阳军区总医院收治74例老年瓣膜病患者行心瓣膜置换术的临床资料，其中男51例，女23例；年龄60～74岁。术前经心电图、胸部X线片、彩色超声心动图、主动脉根部造影和左心室选择性造影检查诊断，均经手术证实，单纯二尖瓣病变45例；单纯主动脉瓣病变13例，其中7例为先天性二叶主动脉瓣畸形导致退行性改变；主动脉瓣和二尖瓣联合病变16例。均在全身麻醉体外循环下行心瓣膜置换术。 结果 全组无手术死亡，围术期死亡2例。74例患者体外循环时间58.0～136.5 min，主动脉阻断时间36.0～102.0 min。生存患者均无明显并发症，术后9～32 d顺利出院。 结论 心瓣膜置换术是治疗老年瓣膜病的安全方法，对左心房增大者进行减容并对三尖瓣关闭不全者进行良好处理，可获得满意的临床效果。

心肌肽在心脏手术中应用的安全性观察

摘要： 目的 探讨注射用心肌肽在体外循环心脏手术中使用的安全性。 方法 选择2008年4月至10月在我院心脏外科择期行心脏手术患者100例，并分为两组，实验组：50例，男27例，女23例；年龄46.50±17.80岁；患者在麻醉后静脉滴注心肌肽1 mg/kg，30 min完成；在第1次的灌注液中一次性加入心肌肽2 mg/kg；于术后第1 d，2 d和3 d静脉滴注心肌肽3 mg/kg。对照组： 50例，男24例，女26例；年龄50.10±20.40岁；患者给予相同剂量的5%葡萄糖溶液。 术后5～7 d检测血、尿常规及生化检查，行心电图和彩色超声心动图等安全性指标检测。 结果 术后实验组血、尿常规及生化指标包括肝功能（门冬氨酸氨基转移酶29.10±18.19 U/L vs. 37.27±21.81 U/L）、肾功能（血清肌酐65.84±22.69 μmol/L vs. 68.50±17.71 μmol/L），血糖、血清电解质、心率、ST段、左心室舒张期末内径(48.00±7.59 mm vs. 50.23±5.76 mm)、左心室射血分数(69.00%±7.00% vs. 67.00%±9.00%)与对照组比较差异均无统计学意义（Pgt;0.05）。 结论 注射用心肌肽在心脏手术围手术期对人体重要器官无明显影响，使用是安全的。

先天性心脏病合并感染性心内膜炎的外科治疗

目的 总结先天性心脏病（congenital heart disease，CHD）合并感染性心内膜炎（infective endocarditis，IE）的外科治疗经验，以提高诊断、治疗效果。 .方法 .回顾性分析我院73例CHD合并IE患者行瓣膜手术的临床资料，对30例主动脉瓣感染性心内膜炎者行主动脉瓣置换术，另3例行Ross手术。在IE累及二尖瓣21例患者中，行二尖瓣成形术5例，二尖瓣置换术16例；10例主动脉瓣、二尖瓣IE行双瓣膜置换术；对6例肺动脉瓣IE患者行单瓣法做肺动脉瓣成形术2例，肺动脉瓣置换术4例，其中1例同期行主动脉弓置换；3例三尖瓣IE均行三尖瓣置换术。结果 主动脉瓣感染33例(45.2％)，二尖瓣感染21例(28.8％)，肺动脉瓣感染6例(8.2％)，双瓣膜感染10例(13.7％)，三尖瓣感染3例(4.1％)。血培养及赘生物培养总阳性率为23.3％，其中链球菌8例（47.1％），葡萄球菌3例（17.6％）。本组无手术死亡，除1例二尖瓣置换术后1年再次发生IE，拒绝手术治疗外，其余72例患者随访1年均治愈。 结论 CHD应尽早行根治性手术，以避免远期并发IE，损坏心脏瓣膜。对CHD合并IE出现瓣膜关闭不全者应尽快手术，如IE累及二尖瓣、三尖瓣且无瓣膜结构的严重损毁者，施行瓣膜成形术是较好的方法。

右腋下直切口手术治疗先天性心脏病

目的 通过右腋下直切口治疗先天性心脏病可以达到创伤小、疼痛轻、美观的目的.方法 本组40例患者中,进行单纯型继发孔房间隔缺损修复18例,房间隔缺损并二尖瓣关闭不全修复3例,室间隔缺损修复15例,法洛四联症心内根治术2例,心内型完全性肺静脉异位引流和部分房室管畸形修复各1例.结果 全组无手术死亡.体外循环时间18～66分30秒,主动脉阻断时间为3～52分;术后6～12天出院.结论 微创伤切口先天性心脏病手术能达到完全修复的效果.

Surgical Treatment of Aortic Regurgitation with Lower Ejection Fraction

ObjectiveTo summarize the surgical experience of aortic regurgitation with lower ejection fraction (EF). MethodsWe retrospectively analyzed the clinical data of 34 patients with aortic regurgitation and lower ejection fraction received aortic valve replacement in the General Hospital of Shenyang Military Region between January 2012 and December 2013. There were 27 males and 7 females with age of 21-74 (51.03±12.06) years. All surgical procedures were performed under general anesthesia during cardiopulmonary bypass. ResultsThere was no operative mortality. Cardiopulmonary bypass time was 40-155 (60.92±22.89) minutes, aortic clamping time varied from 24 to 79 (37.12±12.61) minutes. Postoperative ventilator-assisted time was 4 to 67 (16.12±12.74) hours. The patients were discharged 8-15 (11.03±2.04) days after surgery. When discharged, EF value was 30% to 48% (41%±4%) and significantly improved compared with that before operation (P<0.01). Pulmonary artery systolic pressure varied from 33 to 50 (38.35±4.35) mm Hg and decreased significantly than that before operation (P<0.01). Left ventricular end-diastolic volume reduced to 168-380 (269.12±52.01) ml and obviously decreased than that before operation (P<0.01). ConclusionSurgical treatment can be carried out on patients with aortic insufficiency and lower EF. Treatment results are satisfactory.

Comparison of Milrinone, Phenoxybenzamine, and Mixture of Nitroglycerin and Verapamil for the Prevention and Treatment of Human Radial Artery Spasm

Objective To compare milrinone （MIN）, Phenoxybenzamine （PHE），and mixture of nitroglycerin and verapamil(NVC) for the prevention and treatment of human radial artery spasm. Methods Residuary radial arteries from 30 patients undergoing coronary artery bypass grafting （CABG） using autologous radial artery from March to September of 2012 in General Hospital of Shenyang Military District were collected. All the artery specimens were cut into 60 vessel rings of 3 mm in width and hanged in the Organ-Bath. Using a random number table，all the vessel rings were divided into 4 groups：PHE group，NVC group，MIN group and blank group （control group）. Firstly，20 vessel rings were used for spasm relaxation experiment with 5 rings in each group. Phenylephrine was added into the Organ-Bath to reach final concentration of 10-3 mol/L　in order to cause vessel rings spasm. PHE of 1 mmol/L，NVC of both 30 μmol/L，MIN of 30 μmol/L and Krebs-Ringer’s　solution were added respectively into above groups to compare the relaxant effect of these vasodilators on radial artery spasm. Secondly，the other 40 vessel rings were used for spasm prevention experiment with 10 rings in each group. All the 40 vessel rings were dipped in above 4 groups. After 30 minutes，phenylephrine was added to the Organ-Bath to reach final concentration　of 10-3 mol/L. Time-dependent constriction of the vessel rings were compared to examine the prevention effect of these vasodilators on radial artery spasm. Results In the spasm relaxation experiment, vessel ring spasm relaxed most quickly in NVC group （P＜ 0.01）. Vessel rings in MIN group relaxed more slowly but steadily （P＜ 0.05）. Vessel rings in PHE group relaxed most slowly （P＜0.01）. And there was no relaxation in the control group. In the spasm prevention experiment，vessel rings in the control group contracted （spasm） 100% immediately after phenylephrine administration. Vessel rings in MIN group contracted immediately after phenylephrine administration too，but slower than the control group（P＜0.01）. Vessel rings in NVC group did not contract right after phenylephrine administration，but the sedentary tension of these vessel　rings gradually increased 120 minutes after phenylephrine administration，and vessel ring contraction reached 46.89% 240 minutes after phenylephrine administration. There was no vessel ring contraction in PHE group. Conclusions All the vasodilators in our experiment are effective for the prevention and treatment of radial artery spasm to different degree，but each medication has its own characteristics，vasodilatation result and time-dependent effect. NVC is most effective to dilate radial artery which has been in spasm state, while radial artery pretreated by PHE is least to become spasm after being stimulated.

非心外管道方法矫治合并异常冠状动脉的法洛四联症

Surgical Treatment for Early Left Ventricular Rupture after Mitral Valve Replacement

Abstract：　Objective　To investigate the cause, treatment， and prevention strategy of early left ventricular rupture after mitral valve replacement （MVR）.　Methods　We retrospectively analyzed clinical data of 7 patients who had early left ventricular rupture after MVR， among a total of 2 638 MVR patients， between May 1981 and November 2010 in General　Hospital of Shenyang Military District. There were 2 male patients and 5 female patients with their age ranging from 28 to 71 years old. One patient was New York Heart Association （NYHA） functional classⅡand 6 patients were NYHA functional classⅢ. Preoperative echocardiography showed that their left ventricular ejection fraction （LVEF） was 49%-60%　and their left ventricular end diastolic volume （LVEDV） was 29-42 ml. All the patients underwent prothetic valve　replacement under moderate hypothermia， general anesthesia and extracorporeal circulation.　Results　All the 7patients underwent surgical repair for their early left ventricular rupture. There were 2 patients with TypeⅠ， 4 patients with TypeⅡ， and 1 patient with TypeⅢleft ventricular rupture. Four patients died of hemorrhagic shock or low cardiac output　syndrome. Three patients were successfully healed and discharged from hospital 7-15 days after the operation. The 3　surviving patients were followed up for 4.5-18.0 years, and they all had good general condition and satisfactory quality of life. No late pseudo-aneurysm was found during follow-up.　Conclusions　Early left ventricular rupture is difficult to repair with a high mortality. Effective prevention strategy should be applied to avoid it as much as possible. Once left ventricular　rupture occurs during the surgery， extracorporeal circulation should be quickly established， and it’s possible to save　patients’ life by reliable intracardiac and epicardial repair according to patients’ individual condition.

Relationship between Postoperative Atrial Function and Fibrosis of Patients after Mitral Valve Replacement and Concomitant Radiofrequency Ablation for Atrial Fibrillation

ObjectiveTo investigate the restoration of left atrial function and its relationship with atrial fibrosis of patients after mitral valve replacement (MVR)and concomitant radiofrequency ablation (RFA)for atrial fibrillation (AF). MethodsClinical data of 32 patients with mitral valve disease and chronic AF who underwent surgical treatment in General Hospital of Shenyang Military Area Command from January to August 2010 were retrospectively analyzed in this cohort study. There were 11 male and 21 female patients with their age of 49.8±8.7 years. There were 14 patients with rheumatic mitral stenosis (MS), 8 patients with rheumatic MS and mitral regurgitation, and 10 patients with mitral valve prolapse. Preoperative AF duration was 3.6±4.6 years. All the patients received MVR and concomitant RFA for AF. According to the cutting off extent of left atrial fibrosis (10.9%), all the 32 patients were divided into 2 groups. There were 19 patients with more severe left atrial fibrosis ( > 10.9%)in group A and 13 patients with milder left atrial fibrosis ( < 10.9%)in group B. Immunohistochemistry was performed to examined left atrial fibrosis, and echocardiography was performed to examined the structure and function of left atrium. ResultsThere was no perioperative death. Cardiopulmonary bypass time was 84.6±22.6 minutes, aortic cross-clamping time was 47.6±15.6 minutes, and ICU stay was 3.2±1.5 days. All the 32 patients were followed up for longer than 6 months (1.3±0.6 years). The extent of left atrial fibrosis of the 32 patients was 4.8%-18.3% (10.7%±4.2%). There was no statistical difference in left atrial diameter (LAD), left atrial fractional area change (LAFAC)or mitral annular motion between group A and group B preoperatively and 3 months after surgery respectively (P > 0.05). At 6 month after surgery, LAD of group B was significantly smaller than that of group A (P < 0.05), late diastolic mitral annular velocity (Am)of group B was significantly higher than that of group A (P < 0.05), and there was also some improvement in LAFAC of group B compared with group A (P=0.067). Among the 32 patients, 28 patients (87.5%)restored sinus rhythm (SR)3 months after surgery, and 21 patients (65.6%)maintained SR longer than 6 months after surgery. Patients in group B were more likely to maintain SR than patients in group A (P=0.010). ConclusionImprovement of left atrial function can be observed 6 month after MVR and concomitant RFA for AF, which is related to the extent of left atrial fibrosis.