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Surgical correction of complete atrioventricular septal defect associated with tetralogy of Fallot

Objective To summarize the experience of surgical correction of complete atrioventricular septal defect associated with tetralogy of Fallot(CAVSD-TOF). Methods Twelve patients aged 6-16(11.1±2.8) years underwent correction of CAVSD-TOF. The atrioventricular septal defect was closed through a right atriotomy and longitudinal right ventriculotomy in each case. The three-patch technique was used for the first 7 cases and two-patch technique for the later 5 cases. The commissure between the superior and inferior bridging leaflets of the left portion of the common atrioventricular valve was closed in each patient. Right ventricular outflow tract obstruction was relieved by a transannular patch. Results There were 4 deaths in the early postoperative period, 3 deaths in the first 7 cases compared to 1 death in the later 5 cases. The causes of death included severe low cardiac output syndrome(3 cases) and perfusion pulmonary edema(1 case). Six survivors were followed up from 3 months to 13.5 years. Heart function (NYHA) was class I or Ⅱ in all cases. Conclusion CAVSD-TOF can be corrected by using the two-patch technique and closure of atrioventricular septal defect through a combined approach through right atriotomy and right ventriculotomy. Routine closure of the commissure of the left portion of the atrioventricular valve achieves a low incidence of regurgitation.

冠狀動脈瘺27例

The Long Effect of Nonpulsatile Flow on Changes of Structure and Function in Pulmonary Microcirculation

Objective To investigate the long effect of nonpulsatile flow on changes of structure and function in pulmonary microcirculation and to identify the pulmonary reconstruction under this blood perfusion. Methods Canine models with nonpulsatile flow in the right lung was established, and sacrificed 6 months later. Compare endothelial nitric oxide synthase (eNOS) in vascular endothelium, apoptosis in smooth muscle cell with immunohistochemistry by streptavidinbioepidermmultienzyme complex methodes, and observe structural changes in pulmonary arterioles with optical microscope. Results The expression of eNOS in the right nonpulsatile flow perfusing lung was weaker as compared to the left lung （10 846.7±177.8 vs. 13 136.1±189.6;t＝2.240, P=0.040）, the fas was ber as compared to the left lung（14 254.1±217.1 vs. 11 976.7±195.7; t＝2.160, P=0.040）. The ratio of wall thichness/vessel diameter in the right lung（13.64%±12.80% vs. 14.96%±13.10%） and wall area/vessel area(46.40%±11.70% vs. 47.80%±12.20%) was lower as compared to the left lung(Plt;0.05). Conclusion Longterm nonpulsatile flow can decrease the expression of eNOS, contract the muscles in capillary net, and increase pulmonary vascular resistance. Moreover it canincrease the arteriole apoptosis, leading to vascular structure remodeling.

The Effect of Ischemic Preconditioning on Myocardial Ischemic Reperfusion of Elderly Rats

Objective To investigate the effect of ischemic preconditioning(IPC) on myocardial ischemic reperfusion injury(I/R) of elderly rats. Methods Fiftysix Wistar rats, of which there were 28 aged from 21-23months(elderly rat) and 28 aged from 4-5months(young rat), were used to build isolated heart perfusion Langendorff model. The rats were divided into 7 groups with random number table（8 in each group）: adult control group, adult I/R group, adult IPC group, elderly control group, elderly I/R group, elderly IPC group and elderly enhanced IPC group. The control group underwent a 90-min perfusion without any intervention; the I/R group underwent a 30-min equilibration period, then a 30-min ischemia and a 30-min reperfusion; the IPC group underwent a 10-min equilibration period, then a 5-min ischemia for twice and a 5-min reperfusion, after that a 30-min ischemia and [CM(158-3mm]a 30-min reperfusion; the enhanced IPC group underwent a 10-min equilibration period, then a 5-min ischemia for 4-times and a 5-min reperfusion, after that a 30-min ischemia and a 30-min reperfusion. The recovery rates of cardiac output(CO), left ventricular developed pressure (LVDP), the maximum rising and descending rate of left ventricular pressure (±dp/dtmax) after a 30-min reperfusion were compared among groups. The activity of creatine kinase (CK) in coronary outflow, the level of malonyldialdehyde (MDA) and superoxide dismutase (SOD) before ischemia and after a 30min reperfusion were detected. The myocardial infarction areas were compared among groups. Results After a 30min reperfusion, compared with adult I/R group, in adult IPC group CK reduced significantly(89.48±18.72 U/L vs. 115.76±16.72 U/L，q=6.061，Plt;0.01)，the level of MDA decreased significantly（9.53±3.44 nmol/ml vs. 16.84±2.29 nmol/ml，q=7.732，Plt;0.01)，the level of SOD increased significantly（584.7±122.62 U/ml vs. 429.46±85.24 U/ml，q=4.754，Plt;0.01)，the recovery rates of CO,LVDP,+dp/dtmax and -dp/dtmax increased ignificantly(78.69%±9.68% vs. 65.10%±8.63%，83.61%±8.46% vs. 67.23±8.68%，81.68±8.68% vs. 67.89%±6.89%，89.79%±7.78% vs. 66.79%±8.46%，Plt;0.01), the myocardial infarction areas reduced significantly (5.25%±4.33% vs. 14.75%±8.02%,q=7.458，Plt;0.01)。There was no statistical significance between elderly IPC group and elderly I/R group in the above indexes（Pgt;0.05）.However, There was statistical significances between elderly enhanced IPC group and I/R group. CK reduced significantly (88.60±28.32 U/L vs. 105.76±9.64 U/L，q=5.620，Plt;0.01)，the level of MDA decreased significantly（8.38±3.36 nmol/ml vs. 16.80±3.06 nmol/ml，q=7.500，Plt;0.01)，the level of SOD increased significantly（558.87±78.66 U/ml vs. 433.75±86.65 U/ml，q=7.335，Plt;0.01)，the recovery rates of CO,LVDP,+dp/dtmax and -dp/dtmax increased significantly (77.99%±10.02% vs. 66.26%±9.78%，85.59%±6.67% vs. 73.90%±6.66%，83.87%±9.98% vs. 68.90%±8.68%，86.01%±766% vs. 70.39%±7.98%，Plt;0.01)， the myocardial infarction areas reduced significantly (795%±6.32% vs. 1568%±10.36%,q=8.680， Plt;0.01). 〖WTHZ〗Conclusion The protective effect of IPC on I/R elderly rat hearts has weakened. The enhanced IPC is able to regain the protective effect of IPC on elderly rat hearts.

慢性縮窄性心包炎的外科治療

目的 總結慢性縮窄性心包炎的外科治療經驗。方法 78例患者術前均被明確診斷為慢性縮窄性心包炎，均在全身麻醉下經胸部正中切口行心包剝脫術。結果 術后中心靜脈壓6.5～14.0mmHg（1kPa=7.5mmHg），平均8mmHg。死亡1例，再次開胸止血2例，發生低心排血量綜合征3例。術后病理檢查：心包纖維結締組織增生、玻璃樣變性60例，呈于酪樣結核病變18例（伴結核肉芽腫形成7例）。隨訪65例，隨訪時間3個月～10年，心功能（NYHA）均為I級，無心包縮窄復發和死亡。結論 手術是治療慢性縮窄性心包炎惟一有效的方法，胸部正中切口是較佳的手術徑路，心包切除范圍應根據具體病情而定，力爭將心包徹底松解切除。

嚴重左心室功能不全冠心病患者的外科治療

目的總結有嚴重左心室功能不全[左心射血分數(LVEF)≤0.35]冠狀動脈粥樣硬化性心臟病(冠心病)患者行冠狀動脈旁路移植術(CABG)的臨床經驗。方法18例有嚴重左心室功能不全的冠心病患者冠狀動脈造影均顯示為3支血管病變,在體外循環下行CABG,采用左乳內動脈18支與前降支吻合,采用橈動脈11支及大隱靜脈26支與其它血管吻合。所有患者術前、術后均行正電子發射斷層18F-脫氧葡萄糖顯像(18F-FDGPET)檢查,以判定心肌的存活狀況。結果手術死亡1例,死于心室顫動。12例使用主動脈內球囊反搏(IABP),術后二次氣管內插管3例。隨訪17例,隨訪時間14～26個月,所有患者心功能較術前均有不同程度的改善,LVEF(0.51±0.13)較術前(≤0.35)增大。2例出院后出現心絞痛復發。結論CABG是治療嚴重左心室功能不全冠心病患者的有效治療方法,其效果取決于存活心肌的多少及可再血管化的目標血管的數量。術中良好的心肌保護,積極應用IABP及護心通是手術成功的關鍵。

Surgical treatment for double outlet of ventricle with atrioventricular discordance

Objective To report the surgical treatment for double outlet of ventricle with atrioventricular discordance. Methods 11 patients aged from 3 to 25 years underwent surgical treatment for double outlet of ventricle with atrioventricular discordance. 10 of them were double outlet right ventricle and the other one was double outlet left ventricle. The surgical treatment included biventricular repair (n=9) and single ventricular repair (n=2). The biventricular repair was performed by intraventricular patch repair and extracardiac valved conduit or homograft valved conduit. The single ventricular repair included bidirected Glenn operation and total cavopulmonary connect. Results There were two early deaths in biventricular repair and no death in single ventricular repair. The cause of death was severe low cardiac output syndrome. Four survivors in biventricular repair were followed up from 1 to 11.5 years, three of them were in NYHA class Ⅰ or Ⅱ and one in NYHA class Ⅲ. Conclusions Double outlet of ventricle with atrioventricular discordance can be treated by biventricular repair or single ventricular repair according to the development of ventricle and pulmonary arteries. Closure of ventricular septal defect , no obstruction from ventricle to great artery and no harm of conduction system are the keys of conventional management to achieve good results.

Outcome of Short and Middle Term of Right Ventricular Outlet Tract Reconstruction with Gore-Tex Monocusp Valve

Abstract: Objective To evaluate the outcome of reconstruction of right ventricular outlet tract (RVOT) with 0.1 mm Gore-Tex monocusp valve for short and middle term. Methods Between June 2002 to July 2006, 48 patients underwent reconstruction of RVOT with Gore-Tex monocusp valve to correct cardiac anomalies, including 33 patients with tetralogy of Fallot (TOF) and pulmonary stenosis, 8 patients with TOF and pulmonary atresia, 3 patients with TOF and absent pulmonary valve, 2 patients with double outlet of right ventricle and pulmonary stenosis, 1 patient with truncus arterious and 1 patient with complete transposition of great artery, ventricular septal defect and pulmonary stenosis. Results There was no operative death. The postoperative blood oxygen saturation was up to 1.00. The ratioes of right ventricular systolic pressure and left ventricular systolic pressure were between 0.22 to 0.65.The gradient between right ventricle and left or right pulmonary artery was less than 10 mmHg. All patients were followed up including echocardiography ranged from 3 to 48 months. There were no late death and complication. Trivial and mild pulmonary insufficiency was detected in 18 patients and valvular motion remained competent in 40 patients. Conclusion The results suggest that the reconstruction of RVOT with Gore-Tex monocusp valve can achieve excellent outcome for short and middle term.

右腋下直切口手術治療先天性心臟病

目的 通過右腋下直切口治療先天性心臟病可以達到創傷小、疼痛輕、美觀的目的.方法 本組40例患者中,進行單純型繼發孔房間隔缺損修復18例,房間隔缺損并二尖瓣關閉不全修復3例,室間隔缺損修復15例,法洛四聯癥心內根治術2例,心內型完全性肺靜脈異位引流和部分房室管畸形修復各1例.結果 全組無手術死亡.體外循環時間18～66分30秒,主動脈阻斷時間為3～52分;術后6～12天出院.結論 微創傷切口先天性心臟病手術能達到完全修復的效果.

主動脈竇瘤破裂的外科治療

摘要 目的　總結1973～1999年85例主動脈竇瘤破裂的外科治療經驗。　方法　主動脈竇瘤破裂85例，合并室間隔缺損40例(47.1%)，主動脈瓣關閉不全15例(17.6%)，均以補片行主動脈竇瘤修補，其中40例以同一補片修補主動脈竇瘤和室間隔缺損，5例同期行主動脈瓣置換術，3例行主動脈瓣成形術。　結果　全組死亡3例，死亡率3.5%，無殘余分流等并發癥，71例隨訪2個月～24年，心功能恢復良好。　結論　主動脈竇瘤破裂一經確診，應盡早手術，采用補片修補主動脈竇瘤及用同一乒乓球拍形補片修補竇瘤和室間隔缺損，效果較好。對于嚴重的主動脈瓣關閉不全，應同期行主動脈瓣置換術，而輕度主動脈瓣關閉不全可不用特殊處理。