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连续动脉血乳酸水平与先天性心脏病-手术预后的关系

摘要： 目的 探讨连续动脉血乳酸值与先天性心脏病患者体外循环(CPB)手术预后的关系。 方法 连续选择2006年3~9月接受CPB心内直视手术先天性心脏病患者551例，根据术后恢复情况将其分为死亡组(n＝14）和 生存组(n=537）,再根据术后乳酸变化情况将生存组分为正常恢复组(n=513）和治疗恢复组(n=24，术后乳酸升高经治疗后恢复正常)。于CPB结束后0~1 h、1~2 h、2~3 h、3~6 h、6~9 h、9~12 h、12~18 h、18～24 h等时间段测定动脉血乳酸值；采用SpearmTH〗 结果 死亡组动脉血乳酸值在CPB结束后0~1 h为4.46±2.78 mmol/L，在其后各时间段内逐渐上升，至18～24 h时达9.65±5.47 mmol/L。而术后正常恢复组在CPB结束后0~1 h内为2.80±0.90 mmol/L,在1~2 h内开始下降，至2~3 h恢复到2.00 mmol/L左右，并维持稳定。治疗恢复组在CPB结束后0~1 h内为2.93±0.59 mmol/L,并在2~3 h持续上升，到9~12 h达峰值(6.34±1.85 mmol/L)后迅速下降，于18~24 h恢复到2.14 mmol/L左右。CPB结束后0~1 h时间段的血乳酸值与死亡相关性最差(r=0.103，P=0.103)，而其后各时间段与死亡事件呈高度的相关性(P=0.000)。结论 连续动脉血乳酸测定可以对先天性心脏病患者CPB手术预后作出有效评估，持续血乳酸值上升是预测术后死亡的有效指标。

胸部创伤的临床分析

心脏恶液质瓣膜病患者的外科治疗

急诊冠状动脉旁路移植术的临床分析

目的 为提高手术成功率，探讨急诊冠状动脉旁路移植术（ECABG）的手术方法、围手术期处理措施。 方法  回顾性分析中国医科大学附属第四医院自2006年11月至2009年3月行ECABG18例患者的临床资料，其中男13例，女5例；年龄51～76岁。本组患者术前临床诊断均为急性冠状动脉综合征，其中急性心肌梗死11例，不稳定型心绞痛7例。术前经皮冠状动脉介入治疗（PCI）失败16例，冠状动脉造影及PCI检查示：右冠状动脉撕裂并发急性心脏压塞2例。 结果 本组18例患者中抢救成功15例，成功率83.3%；死亡3例，病死率16.7%；其中2例死于术后低心排血量综合征，1例死于术后急性心肌梗死。生存患者分别于术后3个月、6个月来院复诊1次，以后每年复诊1次，随访9～36个月，均无心绞痛及心肌缺血表现。 结论 掌握ECABG围手术期处理措施的特点，可提高手术成功率，挽救急性冠状动脉综合征患者的生命。

心脏病合并甲状腺功能减退症患者的外科治疗

目的 总结心脏病合并甲状腺功能减退症患者行外科手术治疗的临床经验。 方法 回顾性分析2001年9月至2009年5月解放军总医院19例心脏病合并甲状腺功能减退症患者行外科手术治疗的临床资料，男7例，女12例；年龄50～76岁，平均年龄63.20岁。冠心病15例，主动脉瓣狭窄1例，房间隔缺损1例，慢性心包炎2例；均合并甲状腺功能减退症。所有患者术前给予左旋甲状腺素钠（40~120 mg/d）口服治疗，根据其耐受程度、促甲状腺激素和甲状腺激素水平调整用量，将甲状腺激素水平调整至基本正常。行体外循环冠状动脉旁路移植术6例，非体外循环冠状动脉旁路移植术9例，房间隔缺损修补术1例，主动脉瓣置换术1例，心包剥脱术2例。术后按原剂量或加量口服左旋甲状腺素钠片，检测手术前、后甲状腺激素指标的改变。 结果 无手术死亡，术后所有患者均未发生低三碘甲状腺原氨酸（T3）综合征，甲状腺功能指标与术前比较均有不同程度的降低，以血清总三碘甲状腺原氨酸和血清游离三碘甲状腺原氨酸降低最为明显，体外循环手术患者下降幅度更大。术后继续给予甲状腺素钠口服，并持续服用维持量的甲状腺素钠。随访19例，随访时间4～7个月，随访期间均持续服用维持量的甲状腺素钠，心功能分级（NYHA）Ⅰ级14例，Ⅱ级5例；患者恢复正常生活。 结论 合并甲状腺功能减退症的心脏病患者行心脏手术是安全、可行的，体外循环和非体外循环心脏手术后甲状腺激素均有所降低，体外循环手术患者下降更明显，术后应警惕发生低T3综合征和低T3、T4综合征。

内窥镜采集大隐静脉联合直视采集桡动脉在冠状动脉旁路移植术中的应用

目的 总结在冠状动脉旁路移植术（CABG）中应用内窥镜采集大隐静脉(EVH)联合直视采集桡动脉技术的临床经验。 方法 回顾性分析2006年6月至2009年10月北京军区总医院收治的97例冠心病患者应用EVH联合直视下采集桡动脉技术行CABG的临床资料，其中男68例，女29例；年龄45~84岁(69.3±11.8岁)。行非体外循环冠状动脉旁路移植术(OPCAB) 91例，体外循环CABG 6例。观察大隐静脉的采集长度和采集时间。 结果 每例患者移植血管3~5支（3.7±0.6支），大隐静脉全部于单侧大腿采集，长度15~29 cm(22.0±6.0 cm)，采集时间29~52 min(32.0±11.0 min)；采集的桡动脉长度16~22 cm(22.0±6.0 cm)，采集时间25~42 min(30.0±9.0 min)。术后死亡3例，死于心肌梗死、恶性心律失常和消化道出血各1例。术后采集大隐静脉的皮肤切口均无感染，出现下肢水肿5例，淋巴漏1例，皮下血肿3例，均自行愈合。随访84例，随访时间6个月至1年，失访10例。 随访期间死于脑血管意外1例，生存的患者心绞痛症状均缓解或消失。 结论 在CABG术中采用EVH联合直视采集桡动脉，减少了大隐静脉的采集长度，缩短了手术时间，有较好的临床应用价值。

部分型房室间隔缺损二尖瓣处理策略

目的 总结部分型房室间隔缺损（PAVSD）患者外科手术的近远期疗效，探讨二尖瓣处理方法。 方法 回顾性分析1990年1月至2008年12月于第二军医大学长海医院行外科治疗PAVSD患者118例的临床和随访资料，男 51例，女67例；年龄7个月～62岁（28.5±12.6岁）。均有原发孔型房间隔缺损和不同程度的二尖瓣前瓣裂隙，其中二尖瓣中重度反流78例，三尖瓣中重度反流56例。手术均在中度低温体外循环下进行。术后通过门诊和电话随访。 结果 术后早期死亡2例，病死率1.69％。发生其他严重并发症为再次气管内插管5例，左心辅助1例，Ⅲ°房室传导阻滞1例。术后随访103例，随访时间3个月～18年（91.2±25.6个月）。再次手术8例，距第一次手术时间为5 d～18年（10.5±5.6年）。再次手术死亡1例。随访生存的102例患者生活质量均有明显改善。二尖瓣无反流70例，微量和轻度反流17例，中度4例。行二尖瓣置换术患者瓣膜功能良好，无抗凝相关并发症。心房颤动19例，Ⅰ°房室传导阻滞21例，频发性房性早搏4例。 结论 二尖瓣修复是PAVSD矫治手术成功的关键，应综合应用二尖瓣成形修复的方法，尽量消除二尖瓣反流；术后二尖瓣再反流是再次手术的主要原因，对中重度二尖瓣反流患者应定期随访和及时手术。

一种新型排线盘在心脏手术中的应用

目的 介绍一种新型排线盘在心瓣膜置换术中的应用。 方法 2009年5月至2010年6月，江苏大学附属武进人民医院收治60例二尖瓣病变患者，男26例，女34例；年龄38～69岁(54.0±8.7岁)。所有患者均行二尖瓣置换术。将60例患者随机分为两组，每组30例。新型排线盘组：使用自行设计的新型排线盘（专利号:200920301200.5）；钢丝排线盘组：使用传统钢丝弹簧排线盘；比较其各自性能，记录并分析缝瓣时间、缝线脱落次数、缝线复位时间的差异。 结果 新型排线盘组患者缝瓣时间（13.20±0.72 min vs. 16.10±1.07 min, Plt;0.05）、缝线复位时间（2.50±0.61 s vs. 6.30±0.49 s, Plt;0.05）、缝线脱落次数（26次 vs. 93次,χ2=45.770，Plt;0.05) 短于或少于钢丝排线盘组，两组缝针数差异无统计学意义（365针 vs.362针, Pgt;0.05）。 结论 新型排线盘在心瓣膜置换术中的使用效果明显优于传统钢丝弹簧排线盘。

Biological Characteristics of Decellularized Bovine Jugular Vein Valved Conduit Treated with Dyemediated Photo Oxidation

Abstract: Objective To evaluate the biological characteristics of decellularized bovine jugular vein valved conduit treated with dyemediated photo oxidation. Methods From July 2009 to July 2010, this study was carried out in Xijing Hospital affiliated to the Fourth Military Medical University. Forty bovine jugular vein valved conduits were obtained from Qinchuan scalpers aged between 2 to 6 years with the weight ranged from 200 to 400 kg. Then, the 40 conduits were divided into four groups by random digital table with 10 in each group. The conduits were treated with glutaraldehyde in the glutaraldehyde group (GA group), were decellularized in the decellularized group (DC group), were decellularized and treated with dyemediated photo oxidation in the decellularized and dyemediated photo oxidation treated group (DP group) , and were not dealt with in the control group (CO group). Thickness, appearance, histology, water content, shrinkage temperature, breaking strength, and soluble protein level of the conduit wall and valve were detected and compared among the four groups. Results Thickness and water content of the conduit wall and valve in the DP group were similar to those in the CO group (Pgt;0.05), while thickness of both wall and valve in the DP group was less than those in the GA group (wall: 0.8±0.1 mm vs. 1.1±0.1 mm; valve: 02±0.1 mm vs. 0.3±0.1 mm, Plt;0.05), and water content of the conduit wall and valve in the DP group was more than those in the GA group (wall: 86.1%±2.2% vs. 70.4%±2.8%; valve: 87.1%±2.5% vs. 72.1%±3.1%, Plt;0.05). The breaking strength and shrinkage temperature of the DP group were similar to those of the GA group (Pgt;0.05), while the shrinkage temperature (wall: 84.7±1.4 ℃ vs. 70.4±0.3 ℃; valve: 85.7±1.5 ℃ vs. 70.7±0.6 ℃, Plt;0.05) and the breaking strength (wall: 10.4±1.1 N vs. 6.8±1.0 N; valve: 8.0±0.9 N vs. 3.2±0.6 N, Plt;0.05) of the DP group were higher than those in the CO group. Conclusion Decellularized bovine jugular vein valved conduits treated with dyemediated photo oxidation have nice biological characteristics.Key words: Dyemediated photo oxidation; Decellularized; Bovine jugular vein valved conduit; Biological characteristics

Induction of Bone Marrow Mesenchymal Stem Cells into Vascular Smooth Musclelike Cells in Vitro

Abstract: Objective To investigate the feasibility of the bone marrow mesenchymal stem cells (BMSCs) as the seed cells for construction of small diameter blood vessels and its induced mechanisms. Methods The bone marrow cells were obtained from hind femur and tibia of male Sprague-Dawley（SD） rats with a body weight of 100 g. The cells were purified by whole bone marrow primary culture before repeated passage in vitro amplification. Cell morphology was observed, and expressions of CD34, CD90, and CD105 cell factors were examined by flow cytometry to identify whether they were the BMSCs. Then, the BMSCs obtained were divided into the experiment group and the control group. The cells in the experiment group were induced to differentiate into the vascular smooth musclelike cells by the Dulbecco’s modified Eagle’s mediumlow glucose(DMEM-LG) plus alltrans retinoic acid and dbcAMP, while the cells in the control group were cultured by the normal DMEM-LG. We observed the morphological characteristics of the BMSCs and detected the expressions of smooth muscle-α actin (SM-α-actin), calponin, and vascular smooth muscle myosin heavy chain(SMMHC) by immunofluorescence and flow cytometry with the fifth generations cells after induction. Results The cells obtained through primary culture appeared spindleshaped and showed characteristic swirling growth. The surface marker CD34 was negative, while CD90 and CD105 were positive. After induction, the cells in the experiment group grew slowly and were slightly ovalshaped. The expression of SM-α-actin, calponin, and SMMHC was significant in the experiment group. In the control group, cell morphology and cell growth were similar to the those of BMSCs in the experiment group, but the expression of SM-α-actin, calponin, and SMMHC was negative. Conclusion The BMSCs can be induced to differentiate into the phenotype of vascular smooth musclelike cells by alltrans retinoic acid，the induced cells which can act as seed cells for tissue engineering construction of small diameter blood vessels.