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肺部隐球菌病伴隐球菌性脑膜炎一例

Leaflet extension in reoperation after tricuspid valve repair in children

Objective To summarize our experience on leaflet extension in reoperation after tricuspid valve repair in children at age≤15 years and to explore the application indicators and skills of this technique. Methods We retrospectively analyzed the clinical data of 23 children who underwent reoperation after tricuspid valve repair in Xinhua Hospital between January 2006 and October 2015. There were 15 males and 8 females with a mean age of 8.7 years, ranging from 5 to 15 years. The leaflet was extended by artificial pericardium patch. After surgery, warfarin anticoagulation therapy was done, and international normalized ratio was maintained 2.0 to 3.0. Results The average cardiopulmonary bypass time was 87-132 (98.5±35.7) minutes, and average aortic cross-clamping time was 56-97 (68.40±23.78) minutes. One patient died in hospital. There were 3 patients with complications including respiratory failure in 1 patient, acute renal failure in 1 patient, and right heart insufficiency in 1 patient. All the children cured and were followed up for 5 months to 10 years, with a mean follow-up of 3.5 years. One patient died during the follow-up. Six patients suffered mild to moderate tricuspid regurgitation and tricuspid valve function of the rest patients was good. No other redo-valve surgery or complications correlated to anticoagulation occurred. Conclusion Leaflet extension in reoperation after tricuspid valve repair in children is useful with optimistic middle to long term efficacy and needs intensive care therapy during the perioperative period.

复制缺陷的重组腺病毒载体直接转染猪慢性缺血心肌的研究

目的 建立猪慢性心肌缺血模型,评价腺病毒载体的转染效率和持续时间. 方法 应用磷酸钙沉淀法制备携带大肠杆菌LacZ基因复制缺陷的重组腺病毒(Ad.LacZ),将健康家猪8条随机分为实验组和对照组,每组4条.两组猪均经左前外侧开胸,于冠状动脉左回旋支(LCX)放置Ameroid环, 28天后二次开胸,实验组:在缺血心肌部位每点直接注射Ad.LacZ 100μl,1010噬斑形成单位,共10点;对照组:在缺血心肌部位每点注射磷酸盐缓冲液(PBS)100μl,共10点.于注射后3天、7天和28天对缺血心肌进行染色和病理观察. 结果 冠状动脉造影证实LCX完全闭塞,心肌有缺血和小面积心肌梗死;实验组注射Ad.LacZ后第3天、7天和28天X-gal染色有阳性细胞,以7天时明显,对照组无阳性细胞. 结论 应用Ameroid环可成功建立猪慢性心肌缺血模型,腺病毒载体转染缺血心肌基因表达可持续4周.

Surgical Management of Left Atrioventricular Regurgitation after Repair of Atrioventriclar Septal Defects

Abstract： Objective To improve therapeutic outcomes for severe leftsided atrioventricular valve regurgitation (LAVVR) after repair of atrioventricular septal defect (AVSD) through discussing pathological changes of the valve and surgical management for these patients, and summarizing the medical experiences of perioperative managements. Methods We retrospectively analyzed the clinical data of 29 patients including 16 males and 13 females with LAVVR after repair of AVSD treated in Xinhua Hospital, Medical College of Shanghai Jiaotong University between January 1995 and December 2009. The age of these patients ranged from 4 to 62 years, averaging at 26.5. According the classification of New York Heart Association (NYHA), there were 10 patients of class Ⅱ, 17 of class Ⅲ and 2 of class Ⅳ before reoperation. Partial repair of AVSD had been carried out for 18 patients, and complete repair had been performed on 11 patients. At reoperation, valve rerepair was performed on 17 patients and mechanical valve replacement (MVR) was necessary in 12 patients. Results In the early period after operation, one patient died of multiple organ failure, one patient had a permanent pacemaker inserted because of complete atrioventricular block, and 1 patient aged 4 years got recovery after 56 hours of circulatory support for severe cardiac failure after reoperation. A mean follow-up of 8.2 years (6 months to 14 years) was done for 25 patients with 3 missing. During the follow-up for 14 patients undergone heart valve repair, there was no obvious acceleration of the forward blood flow of the leftside atrioventricular valve. Ten patients had mild or less LAVVR, 1 had moderate LAVVR and 3 underwent successful left atrioventricular valve replacement at 10 days, 3 years or 6 years after reoperation because of severe LAVVR. Clinical status, as assessed by the NYHA classification, improved after surgery for LAVVR in 25 patients who were followed up with 17 in NYHA class Ⅰ, 6 in class Ⅱ, and 2 in class Ⅲ. Podoid decreased significantly and cardiothoracic ratio was 0.53-0.67 (0.60±0.11) in chest Xray picture. There was no late death. Conclusion With timely surgical treatment, and appropriate surgical method, LAVVR after complete or partial AVSD repair can be managed with excellent shortterm and longterm outcomes.

Cardiac Valve Operation in Children

Objective To report the experiences of cardiac valve operation in children. Methods Cardiac valve operations were performed in 87 children who were 58 male and 19 female between age of 4 to 14 years (mean 10.2 years). Of the 87 patients, 36 underwent mitral valve replacement, 13 aortic valve replacement, 6 mitral and aortic valve replacement, 13 aortic valvuloplasty, and 19 mitral valvuloplasty. Associated cardiac lesions were simultaneously managed. Results Postoperative complications included low car...

先天性主动脉瓣二叶化畸形的外科治疗

目的 探讨先天性主动脉瓣二叶化畸形的诊断、适宜手术时机、围术期处理以及手术疗效. 方法 60例患者被施行心瓣膜置换术,行主动脉瓣机械瓣置换术56例,行自体心包瓣置换术4例;同时行主动脉窦瘤破裂修补术2例,胸主动脉瘤修补术2例,动脉导管未闭缝扎术3例,室间隔缺损修补术5例,冠状动脉旁路移植术3例.其中伴感染性心内膜炎25例. 结果 术后早期死亡5例,死亡率为8.3%.随访49例,平均随访时间5.4年,5年生存率为84.3%. 结论 先天性主动脉瓣二叶化畸形以男性居多,左、右二叶型较前、后型常见,可致主动脉瓣关闭不全和/或狭窄,以关闭不全多见(75%).出现充血性心力衰竭、心绞痛、晕厥、感染性心内膜炎时应尽早行手术治疗,症状不明显的患者应定期复查超声心动图,主动脉瓣置换术是常用的手术方法.

双向上腔静脉肺动脉吻合术治疗左心室发育不良的右心室双出口

目的 总结双向上腔静脉肺动脉吻合术治疗合并左心室发育不良的右心室双出口（DORV）的临床经验。方法 2000年1月至2004年12月手术治疗7例患者，均伴有肺动脉狭窄和左心室发育不良，左心室舒张期末容积指数均〈30ml／m2。5例在体外循环下完成手术，2例在非体外循环下完成手术。结果 全组无手术死亡。术后机械通气时间为9.0±7.9h，无严重术后并发症发生，活动能力改善。随访6个月～4年，效果满意。结论 对左心室发育不良的DORV患者，双向上腔静脉肺动脉吻合术可以获得满意的治疗效果。

微创Nuss手术治疗漏斗胸复发患者12例

摘要： 目的 总结微创Nuss手术对漏斗胸修复失败的治疗效果，以提高治疗水平。 方法 运用微创Nuss手术对12例初次接受Ravitch手术复发性漏斗胸患者进行再次修复，患者均为男性，年龄8~17岁，平均年龄15.6岁；Haller指数均大于3.25；主要症状包括呼吸急促、胸痛、哮喘或哮喘样症状和反复上呼吸道感染。体格检查和CT扫描提示：心脏受压、心脏移位及其他心脏异常，术前肺功能检查多数患者低于正常值的80%。常规使用矫形板及固定片进行矫形；并对术前症状、术中资料、术后结果进行分析。 结果 平均手术时间100 min，较初次手术时间稍长。发生并发症为血胸2例、大量胸腔积液3例、切口疼痛超过1周1例，均经保守治疗治愈，无死亡和心脏穿孔患者。术后随访12例，随访时间6～20个月；随访结果12例患者术前症状均消失，7例患者运动耐力增加；体格检查示：心脏受压和心脏移位缓解，患者均对手术结果表示满意或非常满意。有8例术后用力呼气量(FEF)25%~75%较术前得到改善（Plt;0.05）。 结论 对初次漏斗胸修复失败或复发患者应用Nuss手术矫正后可取得理想的效果。

风湿性心脏瓣膜病合并右心室功能不全的外科治疗

目的 为了提高风湿性心脏瓣膜病合并右心室功能不全患者的治愈率，总结诊断治疗效果。 方法 回顾性分析上海交通大学医学院附属新华医院2006年1月至2010年6月期间收治24例左心瓣膜病合并右心室功能不全患者的临床资料，其中男17例，女7例；年龄41～66岁。均行心瓣膜置换术及三尖瓣成形术。 结果 24例患者术后均出现不同程度的中心静脉压(CVP)升高(CVPgt;25 cm H2O)、右心室体积增大等右心衰竭表现。术后早期死亡4例，死于感染1例，持续低氧血症1例，低心排血量2例。随访15例，随访6～50个月，随访期间死亡1例，死因不明。其余患者均生存，生活质量良好，无右心室功能不全的临床表现，9例患者无三尖瓣反流，4例轻度反流，1例中度反流。 结论 术中加用三尖瓣成形环保证三尖瓣功能是治疗右心室功能不全的解剖基础，充分的术前准备、术后强心治疗及对右心室前后负荷的调整是治疗该类患者右心室功能不全的重要因素。

埃布斯坦综合征合并预激综合征的外科治疗

目的 为了提高手术疗效,总结埃布斯坦综合征(Ebstein syndrome)合并预激综合征的手术治疗经验. 方法 11例患者均有埃布斯坦综合征及严重三尖瓣关闭不全,合并A型预激综合征4例,B型 7例.术中电生理标测显示11例中有12条附加旁道,右心室游离壁6例,左心室游离壁3例,后间隔1例,后间隔和右心室游离壁双旁道1例.所有患者的房室附加旁道均在体外循环下被成功地手术切割;埃布斯坦综合征按Danielson方法行成形术9例,三尖瓣置换术2例. 结果 全组11例无手术后早、晚期死亡;术后随访4个月～6年,平均随访3.4±1.3年,无预激综合征复发,2例有轻度三尖瓣关闭不全.心功能Ⅰ级9例,Ⅱ级2例. 结论 手术治疗埃布斯坦综合征合并预激综合征,可同时纠正埃布斯坦综合征伴三尖瓣关闭不全和预激综合征,治疗效果良好.