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Surgical Treatment of Cardiac Complications Caused by Permanent Pacemaker Implantation

Objective　To investigate clinical features and treatment strategy of cardiac complications caused by permanent pacemaker （PPM） implantation.?Methods?We retrospectively reviewed clinical records of 10 patients with cardiac complications caused by PPM who received surgical treatment in General Hospital of People’s Liberation Army from January 2003 to May 2010. There were seven males and three females with an average age of 62.9 years. One patient had an Atrial demand inhibited pacemaker （AAI） PPM and the other nine patients had a DDD PPM. Cardiac complications included infective endocarditis （IE） in 5 patients, tricuspid insufficiency （TI） in 4 patients and pulmonary artery thrombosis in one patient. According to their respective situation, these patients underwent different surgical treatment such as tricuspid valve plasty （TVP）， tricuspid valve replacement and/or removal of PPM lead and vegetations as part of intensive debridement of the infected area.?Results?Postoperatively， all the patients were successfully discharged. Five patients whose PPM lines and leads were preserved in the surgery had normal PPM function. Three PPM-dependent patients whose PPM leads were removed in the surgery received a PPM reimplantation later. Nine patients were followed up for an average of 5.5 months and all these patients had a significantly improved quality of life. One patient　after TVP had mild TI　during follow-up.　Conclusion　Surgical treatment should be performed as early as possible when infection is too severeto control in patients with IE caused by PPM. PPM-induced TI may be hard to be diagnosed preoperatively, and transesophageal echocardiography or surgical exploration should be considered to establish the diagnosis. Measures should be taken to protect PPM if PPM lines and leads are preserved during operation. Patients whose PPM lines and leads are removed during the surgery need to choose a suitable time for PPM reimplantation.

动脉导管未闭合并其他心脏畸形的外科治疗

摘要: 　目的　总结动脉导管未闭合并其他心脏畸形的外科治疗经验, 以提高手术效果。　方法　2004 年11 月～2006 年12 月手术治疗动脉导管未闭合并其他心脏畸形44 例, 40 例采用正中切口, 上、下腔静脉插管, 转流前游离动脉导管, 双10 号线结扎; 对导管粗大者可在并行转流下分离导管并结扎, 4 例患者实行分期手术。　结果　本组无手术死亡。术后发生低心排血量综合征3 例, 经积极治疗治愈; 2 例发生血红蛋白尿, 均在2d 内恢复。44 例术后超声心动图复查均无再通, 无灌注肺发生。术后随访36 例, 均在3 个月～ 2 年顺利恢复, 活动正常。　结论　经胸部正中切口手术是一种简单、有效的方法, 可同时修补其他心内畸形。分离、结扎动脉导管时应熟练掌握导管及其邻近解剖关系, 根据生命体征及导管直径的大小决定是否应用并行心肺转流。

Surgical Treatment of Hilar Cholangiocarcinoma

目的 探讨肝门部胆管癌2种手术方法的疗效。方法 回顾性分析我院1998～2006年期间收治的37例肝门部胆管癌患者的临床资料。结果 37例患者中13例行根治性手术切除, 其1年与3年的生存率分别为100%（13/13）和76.92%（10/13），中位生存期为22.43个月； 另24例行姑息性手术（均为肝内胆管内引流术），其1年与3年生存率分别为54.55%（12/22）和9.09%（2/22），中位生存期为15.42个月。结论 根治性手术是治疗肝门部胆管癌的主要手段； 姑息性手术，如合理的肝内胆管内引流能改善患者的生存质量。

胸壁去分化脂肪肉瘤外科治疗一例

The Hot Point and Difficult Key Point in Surgical Treatment of Thyroid Disease

甲状腺外科疾病常见，有许多进展和进步，这是热点； 但许多治疗意见不一，分歧极大，长久难以统一，故又有许多难点

小儿主动脉缩窄或主动脉离断合并心内畸形的诊断与外科治疗

目的　探讨主动脉缩窄（CoA）或主动脉离断（IAA）合并心内畸形的诊断及手术方式选择。　方法　2003年1月至2010年3月济宁医学院附属医院手术治疗14例小儿CoA（9例）或IAA（5例）合并心内畸形 ［包括室间隔缺损（VSD）、房间隔缺损（ASD）、房室隔缺损（APSD）等畸形，但不包括单纯合并动脉导管未闭（PDA）］ 患者， 其中男10例，女4例；年龄0.7～12.0 （3.2±4.5）岁；体重5.5～25.5 （10.2±5.5） kg。分期手术3例，经胸骨正中切口径路一期手术矫治11例。　结果　手术死亡2例，其中1例为分期手术，二次手术行VSD修补术后死于急性左心衰竭；1例术前诊断为VSD＋PDA合并重度肺动脉高压，术前未发现IAA，术后死于急性肾功能衰竭。随访12例，随访时间6～84 （32±22）个月，患者恢复良好。复查心脏超声心动图提示：胸主动脉轻度狭窄2例，继续随访观察。　结论　多层螺旋CT和核磁共振成像是目前诊断CoA和IAA的首选检查方法。经胸骨正中切口径路一期手术治疗CoA或IAA合并心内畸形婴幼儿，可获较好的显露及疗效。

三尖瓣关闭不全外科治疗282例

目的　探讨三尖瓣关闭不全（TI）外科治疗时机、手术方式与疗效的关系。　方法　回顾性分析中山大学附属第一医院2003年1月至2010年10月手术治疗的282例TI患者的临床资料，其中男115例，女167例；年龄（42.00±15.90） 岁。按手术方式分为三尖瓣置换术（TVR）34例，三尖瓣成形术（TVP）248例（包括改良De Vega成形术、Kay’s成形术、瓣裂修补术、人工瓣环成形术），评价患者疗效。　结果　术后早期死亡13例，死于低心排血量综合征7例，室性心律失常3例，感染性休克2例，心脏破裂1例。早期死亡率为4.61% （13/282）。手术时间（167.47±37.34） min，体外循环时间（109.67±27.98） min，主动脉阻断时间（66.20±18.42） min，住院时间（16.46±5.29） d。术后1年随访249例，三尖瓣反流改善总有效率为90.76% （226/249）），其中改良De Vega成形术有效率为91.41% （117/128），Kay’s成形术为80.49% （33/41），瓣裂修补术为92.31% （24/26），人工瓣环成形术为96.00% （24/25），TVP为96.55%（28/29）。术后肺动脉压较术前明显降低（P＜0.01），右心室内径缩小。　结论　对中-重度TI或瓣环明显扩大者，应积极手术干预；Kay’s成形术后三尖瓣反流复发率较高，人工瓣环成形术效果良好；对于瓣膜发育不良或毁损者应首选TVR。

心脏原发恶性间皮瘤一例

老年危重心瓣膜病的外科治疗与围术期处理

目的　总结老年危重心瓣膜病患者的手术治疗和围术期处理经验。　方法　回顾性分析 2008年6月至2010年6月中国医科大学附属第一医院37例60岁以上老年危重心瓣膜病患者手术治疗的临床资料，其中男21例，女16例；年龄60～79 （67.3±6.9）岁。二尖瓣病变15例，主动脉瓣病变8例，主动脉瓣＋二尖瓣病变14例；合并左心房血栓9例，三尖瓣反流11例。　结果　围术期死亡3例，其中死于术后肺部感染1例，多器官功能衰竭1例，脑梗死1例。术后发生并发症18例，包括呼吸道并发症、室性心律失常、低心排血量综合征和急性肾功能衰竭等，经相应的治疗治愈。随访26例，随访时间6～23个月，心功能分级（NYHA）Ⅰ级13例，Ⅱ级12例，Ⅲ级1例。　结论　完善的术中操作、加强围术期处理，可有效降低老年危重心瓣膜病患者术后并发症的发生和病死率。

Surgical Treatment of Tetralogy of Fallot with Anomalous Coronary Artery

Abstract： Objective To summarize our surgical experience of tetralogy of Fallot（TOF） with anomalous coronary artery（ACA）， explore diagnostic method of ACA， and evaluate surgical strategy choices and clinical outcomes of right ventricular outflow tract（RVOT） reconstruction. Methods From January 2004 to January 2010， 29 patients with TOF and ACA underwent total correction in Wuhan Asia Heart Hospital. There were 18 male patients and 11 female patients with their median age of 7 years （5 months to 33 years）and median body weight of 18 （5 to 51） kg at operation. Their preoperative arterial oxygen saturation was 65%-91%. One patient underwent RVOT enlargement and repair of ventricular septal defect via right atrial approach. Three patients underwent RVOT enlargement， repair of ventricular septal defect and main pulmonary artery enlargement using autologous pericardium patch via right atrial approach. Three patients received pulmonary artery translocation （REV） technique. Five patients received double outlet technique. Eleven patients underwent RVOT enlargement via incisions above， below or beside coronary arteries （single patch or two patch technique）. Six patients underwent RVOT reconstruction using trans-annular patch after coronary artery bypass grafting. Results　 The median cardiopulmonary bypass time was 78 （65-102） min， median aortic crossclamp time was 50（40-82） min， and median operation time was 150 （126-178） min. There was no early death or severe coronary artery injury. Two　 patients underwent reexploration because of postoperative bleeding. Two patients had low cardiac output and were both cured with inotropic support. The median follow-up period was 51 （21-83）months and there was no late death during　 follow-up. All the patients were in New York Heart Association （NYHA） classⅠduring follow-up， their left ventricular ejection fraction was normal， there was no sign of myocardial ischemia in electrocardiogram， and their arterial oxygen saturation was 96%-99%.Mean early RVOT gradient （△P） was 19 （8-38） mm Hg， and the RVOT gradient （△P） did not increase during follow-up. Conclusion Preoperative diagnosis of ACA in TOF patients can be made by 64-slice multislice compute tomography （64-MSCT）. Proper surgical strategy for RVOT reconstruction should be chosen according to the distribution of coronary arteries to achieve satisfactory surgical outcomes.