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Coronary Artery Bypass Grafting: A Report of 253 Patients

Abstract: Objective To summarize the 17-year clinical experience of coronary artery bypass grafting (CABG). Methods From April 1987 to May 2004, total 253 patients with coronary artery disease underwent CABG. The operation were performed in 217 patients under cardiopulmonary bypass (CPB) with moderate hypothermia, because of calcified ascending aorta, partial replacement of ascending aorta wall with apiece of Gore-Tex graft for the proximal anastomosis were done in 10 patients. Off-pump coronary artery bypass grafting (OPCAB) were performed in 30 patients. The operation under CPB with heart beating were performed in 6 patients. Cardiac valvular operations were performed in 15patients. Left atrium myxoma operation was performed in 1 patient. Left ventricular aneurysm plasty operation were performed in 10 patients. Results Total mortality rate was 7.9% (20/253). There was significant difference between the mortality rate of the first 10 years (16.0%,8/50) and that of the last 7 years (5.9%,12/203; χ2=5.62，Plt;0.05). The causes of death were: 3 patients died on table because of low cardiac output after valvular replacement though emergent CABG were conducted, 2 patients died of multiple organ failure after valvular replacement and emergent CABG had undergone, 3 patients died of ventricular fibrillation during closing the sternum, 6 patients died of multiple organ failure caused of severe lung infection, 2 patients died of ventricular fibrillation after operation, and 4 patients died of acute renal failure. One hundred and fiftyseven patients (67.4%, 157/233) were followed up, follow-up time was 6 months to 15 years. Three of them died of unknown causes, most of them have improved life quality. There were 87 patients in New York Heart Association (NYHA) class Ⅰ, 49 patients in NYHA class Ⅱ, 16 patients in NYHA classⅢ, and 2 patients in NYHA classⅣ. Conclusion When the experience of surgery and postoperative care is matured, CABG is a safe method for treatment of coronary artery disease. Partial replacement of ascending aorta wall with GoreTex graft for proximal anastomosis of the graft is acandidate method for the treatment of patients with calcified ascending aorta.

改良胸骨下段小切口心瓣膜置换术

目的　探讨经改良胸骨下段小切口行心瓣膜置换术的适应证、手术方法和效果。　方法　 81例心瓣膜病患者行二尖瓣置换术 4 0例 ,主动脉瓣置换术 18例 ,双瓣膜置换术 2 3例 ,三尖瓣成形术 2 9例 ,左心房血栓清除 +左心耳内缝扎术 19例。二尖瓣置换术、主动脉瓣置换术和双瓣膜置换术皮切口分别自第 4、第 3肋间水平至剑突根部 ,自下而上呈倒“J”形 ,纵行劈开胸骨分别至第 3、第 2肋间处向右侧弧形横断胸骨。切口长度 7～ 13cm。　结果　全组无手术和术后死亡 ,发生并发症 2例。主动脉阻断时间、体外循环时间、手术时间和住院时间分别为 4 6 .0± 31.6分钟、81.0± 4 7.8分钟、3.4± 1.0小时和 8.0± 2 .3天。术后胸腔引流量 2 5 0± 2 2 2 ml,有 6 2例 (76 .5 % )患者未输血。 73例随访 3个月～ 3年 ,所有置换的瓣膜位置和功能均正常 ,无瓣周漏。　结论　采用改良胸骨下段小切口行心瓣膜置换术安全可靠、美观、创伤小、恢复快 ,并不延长手术时间 ,早期结果满意。但须选择合适的手术适应证 ,手术者具有较熟练的心内手术技术。

低温生理盐水与腺苷局部灌注对脊髓缺血损伤的保护作用

目的　研究低温生理盐水和腺苷对兔主动脉阻断致脊髓缺血损伤的保护作用。　方法　30只成年健康新西兰白兔随机分成3组，每组10只。A组：作为缺血对照；B组：用低温生理盐水局部灌注；C组：用低温生理盐水和腺苷局部灌注。通过阻断兔肾动脉水平的腹主动脉60分钟建立兔脊髓缺血损伤模型。观察3组血流动力学指标、脊髓自由基含量、术后Tarlov评分和脊髓组织病理学改变。　结果　3组心率比较均无差异，C组血压于阻断腹主动脉20分钟时下降(P＜0.05)；A组丙二醛增加，超氧化物歧化酶减少，而B组和C组变化较轻；A组大部分发生截瘫，B组后肢功能部分恢复，C组后肢功能恢复良好；病理检查示A组中央灰质聚集性坏死，巨噬细胞浸润，尼氏小体消失，核仁模糊，B组和C组脊髓结构较完整。　结论　低温生理盐水和腺苷局部灌注具有良好的脊髓保护作用，其方法简便。腺苷可减少三磷酸腺苷(ATP)的耗竭，促进其恢复，并具有神经保护作用。

风湿性心脏病心瓣膜置换患者术前免疫功能的变化

目的 了解风湿性心脏病心瓣膜置换术患者术前免疫功能的变化.方法 将52例心瓣膜置换术患者作为心瓣膜置换术组,50例健康人作对照组.术前分别抽取空腹静脉血测定植物血凝素淋巴细胞转化率、淋巴细胞分化群分子3阳性T细胞(CD3+)、淋巴细胞分化群分子4阳性T细胞(CD4+)、淋巴细胞分化群分子8阳性T细胞(CD8+)、中性粒细胞吞噬率和杀伤率、免疫球蛋白G(IgG)、免疫球蛋白A(IgA)、免疫球蛋白M(IgM)、免疫球蛋白E(IgE)、补体3(C3)、补体4(C4)和循环免疫复合物(CIC).结果 心瓣膜置换术组术前的细胞免疫指标及IgE,C4均明显低于对照组(P＜0.05或P＜0.01),心瓣膜置换术组IgG,IgA,C3和CIC明显高于对照组(P＜0.05或P＜0.01).IgE与CD4+呈相关关系(r=-0.314,P＜0.05),C3与植物血凝素淋巴细胞转化率和中性粒细胞杀伤率呈相关关系(r=0.311和r=0.300,P＜0.05);CIC与CD3+,CD4+和CD8+呈相关关系(r=0.422,r=0.311和r=0.391;P＜0.01,P＜0.05和P＜0.01).结论 风湿性心脏病心瓣膜置换患者术前的免疫功能与正常人有明显差异,患者处于易感染状态,心外科医师应采取有效措施预防和治疗患者术前可能发生的感染.

马方综合征的外科治疗

目的 总结10年来36例马方综合征(Marfan syndrome)的外科治疗经验,以提高手术疗效. 方法 全组均在全身麻醉、中度低温、体外循环下完成手术,其中Bentall手术35例,Cabrol手术1例;同期行二尖瓣成形术5例, 动脉导管未闭直视缝闭术1例,漏斗胸行胸骨翻转术1例,急诊手术1例. 结果 36例中存活33例,死亡3例,术后6小时因大量渗血致心律失常死亡1例,术后3天因多器官功能衰竭死亡1例,术后7天因肾功能衰竭死亡1例.早期主要并发症为术后出血,后期未出现严重并发症. 结论 Bentall和Cabrol手术对Marfan综合征手术治疗效果满意.

漏斗胸合并先心病的外科治疗

感染性心内膜炎的围术期治疗和危险因素分析

目的总结感染性心内膜炎的外科治疗经验，对其围术期危险因素进行分析。 方法回顾性分析2006年1月至2012年12月福建省立医院224例感染性心内膜炎患者行外科手术治疗的临床资料，男127例，女97例；年龄1～72（47.7±7.2）岁。均有心脏基础性病变，包括心脏瓣膜病171例（二尖瓣病变99例，主动脉瓣病变30例，双瓣膜病变42例）；先天性心脏病40例（先天性二尖瓣关闭不全14例，主动脉瓣关闭不全5例，动脉导管未闭2例，室间隔缺损10例，法洛氏三联症1例，室间隔缺损合并瓦氏窦瘤脱垂3例，室间隔缺损术后主动脉窦脱垂伴主动脉瓣关闭不全4例，先天性主动脉瓣畸形合并动脉导管未闭1例）；3例梅毒性二尖瓣主动脉瓣病变；8例亚急性细菌性心内膜炎（SBE）行主动脉瓣置换术后瓣周漏再发SBE；2例主动脉瓣病变合并动脉导管未闭。分析术后并发症及死亡率，探讨SBE患者的高危因素及治疗方法。 结果术中探查赘生物192例，全部送培养，阳性100例，检出率52.08%，其中以金黄色葡萄球菌、表皮葡萄球菌、草绿色链球菌为多见。手术近期死亡10例，死亡率4.46%，主要并发症有低心排血量综合征、肾功能衰竭、术后严重感染、出血、肝功能损害等。 结论感染性心内膜炎内科难以控制者应尽早手术治疗。术前心功能低下、严重的耐药性金黄色葡萄球菌感染、心瓣膜置换术后再发感染及术前营养状况不良是感染性心内膜炎治疗的高危因素。