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心肌肽在心臟手術中應用的安全性觀察

摘要： 目的 探討注射用心肌肽在體外循環心臟手術中使用的安全性。 方法 選擇2008年4月至10月在我院心臟外科擇期行心臟手術患者100例，并分為兩組，實驗組：50例，男27例，女23例；年齡46.50±17.80歲；患者在麻醉后靜脈滴注心肌肽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；于術后第1 d，2 d和3 d靜脈滴注心肌肽3 mg/kg。對照組： 50例，男24例，女26例；年齡50.10±20.40歲；患者給予相同劑量的5%葡萄糖溶液。 術后5～7 d檢測血、尿常規及生化檢查，行心電圖和彩色超聲心動圖等安全性指標檢測。 結果 術后實驗組血、尿常規及生化指標包括肝功能（門冬氨酸氨基轉移酶29.10±18.19 U/L vs. 37.27±21.81 U/L）、腎功能（血清肌酐65.84±22.69 μmol/L vs. 68.50±17.71 μmol/L），血糖、血清電解質、心率、ST段、左心室舒張期末內徑(48.00±7.59 mm vs. 50.23±5.76 mm)、左心室射血分數(69.00%±7.00% vs. 67.00%±9.00%)與對照組比較差異均無統計學意義（Pgt;0.05）。 結論 注射用心肌肽在心臟手術圍手術期對人體重要器官無明顯影響，使用是安全的。

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.

先天性心臟病合并感染性心內膜炎的外科治療

目的 總結先天性心臟病（congenital heart disease，CHD）合并感染性心內膜炎（infective endocarditis，IE）的外科治療經驗，以提高診斷、治療效果。 .方法 .回顧性分析我院73例CHD合并IE患者行瓣膜手術的臨床資料，對30例主動脈瓣感染性心內膜炎者行主動脈瓣置換術，另3例行Ross手術。在IE累及二尖瓣21例患者中，行二尖瓣成形術5例，二尖瓣置換術16例；10例主動脈瓣、二尖瓣IE行雙瓣膜置換術；對6例肺動脈瓣IE患者行單瓣法做肺動脈瓣成形術2例，肺動脈瓣置換術4例，其中1例同期行主動脈弓置換；3例三尖瓣IE均行三尖瓣置換術。結果 主動脈瓣感染33例(45.2％)，二尖瓣感染21例(28.8％)，肺動脈瓣感染6例(8.2％)，雙瓣膜感染10例(13.7％)，三尖瓣感染3例(4.1％)。血培養及贅生物培養總陽性率為23.3％，其中鏈球菌8例（47.1％），葡萄球菌3例（17.6％）。本組無手術死亡，除1例二尖瓣置換術后1年再次發生IE，拒絕手術治療外，其余72例患者隨訪1年均治愈。 結論 CHD應盡早行根治性手術，以避免遠期并發IE，損壞心臟瓣膜。對CHD合并IE出現瓣膜關閉不全者應盡快手術，如IE累及二尖瓣、三尖瓣且無瓣膜結構的嚴重損毀者，施行瓣膜成形術是較好的方法。

老年瓣膜病患者心瓣膜置換術的臨床分析

目的 總結老年瓣膜病患者行心瓣膜置換術的經驗，以提高手術效果。 方法 回顧性分析2000年1月至2009年4月沈陽軍區總醫院收治74例老年瓣膜病患者行心瓣膜置換術的臨床資料，其中男51例，女23例；年齡60～74歲。術前經心電圖、胸部X線片、彩色超聲心動圖、主動脈根部造影和左心室選擇性造影檢查診斷，均經手術證實，單純二尖瓣病變45例；單純主動脈瓣病變13例，其中7例為先天性二葉主動脈瓣畸形導致退行性改變；主動脈瓣和二尖瓣聯合病變16例。均在全身麻醉體外循環下行心瓣膜置換術。 結果 全組無手術死亡，圍術期死亡2例。74例患者體外循環時間58.0～136.5 min，主動脈阻斷時間36.0～102.0 min。生存患者均無明顯并發癥，術后9～32 d順利出院。 結論 心瓣膜置換術是治療老年瓣膜病的安全方法，對左心房增大者進行減容并對三尖瓣關閉不全者進行良好處理，可獲得滿意的臨床效果。

雙極射頻消融迷宮術后同步電復律治療心房顫動

目的 總結雙極射頻消融迷宮術（CoxⅣ）術后同步電復律治療心房顫動（AF）的臨床經驗。 方法 2006年7月至2009年7月沈陽軍區總醫院對223例AF患者行CoxⅣ治療，其中13例患者(包括男4例，女9例；年齡41～69歲；風濕性心臟病7例，退行性心瓣膜病5例，繼發孔型房間隔缺損合并三尖瓣關閉不全1例)于出院后仍為AF而藥物轉復不佳，行同步電復律治療。電復律后觀察心率和心律情況，監測生命體征，出院后繼續口服胺碘酮200 mg，1次/天，定期門診隨訪。 結果 CoxⅣ手術后6個月內行同步電復律4例，即刻轉復竇性心律3例；6個月以上行同步電復律9例，即刻轉復竇性心律4例、AF 2例、交界性心律3例。CoxⅣ術后1年以上行電復律3例，轉復竇性心律2例。13例均獲隨訪，隨訪時間6個月～1年。隨訪期間竇性心律8例（61.54%）、AF4例（30.77%）、交界性心律1例（7.69%）。7例電復律后即刻轉復為竇性心律的患者中有1例復發，竇性心律維持率為85.71%（6/7）；6例即刻未轉復為竇性心律患者中有2例轉為竇性心律。竇性心律患者復律后左心房內徑（LAD）較復律前明顯減小（39.00±5.15 mm vs. 54.50±3.63 mm, t=6.958, P=0.000），而AF患者LAD在復律前后無明顯改變（51.00±5.72 mm vs. 48.00±5.89 mm,t=0.731,P=0.493）。 結論 CoxⅣ手術后電復律治療AF安全有效，成功率高，是CoxⅣ術后控制AF的重要治療手段。復律時機以術后6個月以內為宜，即刻轉復竇性心律成功率較高，維持率也高。LAD明顯縮小者電復律效果較好。

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.

非心外管道方法矯治合并異常冠狀動脈的法洛四聯癥

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.

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.

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.