谈《心脏手术》课件中心脏动画设计与制作

本文通过心脏博动泵血过程动画的制作过程，介绍了3D Studio和Animator Pro两种软件的使用技巧。

Anomalous origin of left pulmonary artery branch from the aorta with Fallot's tetralogy:one case report

We report the case of a ten-year-old boy who had often presented with respiratory distress since born. Chest X-ray showed an enlarged right ventricle. Echocardiography demonstrated characteristic features of Fallot＇s tetralogy and the left pulmonary artery could not be visualized. However, cardiac catheterization disclosed that the left pulmonary artery had an anomalous origin in the ascending aorta. The patient underwent total surgical correction of the defects. Nine days later, he was discharged. We present the results of a literature review of the incidence, physiopathological, clinical, diagnostic, and surgical characteristics of this rare disease.

Risk factors for prolonged intensive care unit stays in patients after cardiac surgery with cardiopulmonary bypass:A retrospective observational study

Objectives:Patients after cardiac surgery with cardiopulmonary bypass(CPB)require a stay in the ICU postoperatively.This study aimed to investigate the incidence of prolonged length of stay(LOS)in the ICU after cardiac surgery with CPB and identify associated risk factors.Methods:The current investigation was an observational,retrospective study that included 395 ICU patients who underwent cardiac surgery with CPB at a tertiary hospital in Guangzhou from June 2015 to June 2017.Data were obtained from the hospital database.Binary logistic regression modeling was used to analyze risk factors for prolonged ICU LOS.Results:Of 395 patients,137(34.7%)had a prolonged ICU LOS(>72.0 h),and the median ICU LOS was 50.9 h.Several variables were found associated with prolonged ICU LOS:duration of CPB,prolonged mechanical ventilation and non-invasive assisted ventilation use,PaO2/FiO2 ratios within 6 h after surgery,type of surgery,red blood cell infusion during surgery,postoperative atrial arrhythmia,postoperative ventricular arrhythmia(all P<0.05).Conclusions:These findings are clinically relevant for identifying patients with an estimated prolonged ICU LOS,enabling clinicians to facilitate earlier intervention to reduce the risk and prevent resulting delayed recovery.

Transcatheter aortic valve replacement in elderly patients

Aortic stenosis is the most common native valve disease, affecting up to 5% of the elderly population. Surgical aortic valve replacement reduces symptoms and improves survival, and is the definitive therapy in patients with symptomatic severe aortic stenosis. However, despite the good results of classic surgery, risk is markedly increased in elderly patients with co-morbidities. Transcatheter aortic valve replacement （TAVR） allows implantation of a prosthetic heart valve within the diseased native aortic valve without the need for open heart surgery and cardiopulmonary bypass, offering a new therapeutic option to elderly patients considered at high surgical risk or with contraindications to surgery. To date, several multicenter registries and a randomized trial have confirmed the safety and efficacy of TAVR in those patients. In this chapter, we review the background and clinical applications of TAVR in elderly patients.

Anesthesia Management at Fuwai Hospital:Practice,Evidence and Outcomes

Fuwai Hospital was established in 1956 and the Anesthesia Department of Fuwai Hospital was one of the earliest anesthesia departments then in China.Under the leadership of several department directors and with the concerted efforts of all generations of colleagues,the Anesthesia Department of Fuwai Hospital has dramatically transformed,upgraded and modernized.For more than six decades,the Anesthesia Department has been providing high-quality peri-operative anesthesia care for cardiovascular surgeries,conducting innovative experimental and clinical researches,and offering comprehensive training on cardiovascular anesthesiology for professionals across China.Currently,Fuwai Hospital is the National Center for Cardiovascular Diseases of China and one of the largest cardiovascular centers in the world.The present review introduces the Anesthesia Department of Fuwai Hospital,summarizes its current practice of anesthesia management,the outcomes of cardiovascular surgeries at Fuwai Hospital,accumulates relevant evidence,and provides prospects for future development of cardiovascular anesthesiology.

RISK OF PATIENTS WITH HYPERTROPHIC CARDIOMYOPATHY UNDERGOING NONCARDIAC SURGERY

Objective To determine the risk of noncardiac surgery in patients with hypertrophic cardiomyopathy.Methods We reviewed the medical records of all patients who were diagnosed as hypertrophic cardiomyopathy at Peking Union Medical College Hospital from January 1998 to August 2006 and identified 24 patients who subsequently underwent noncardiac surgery.Results There were no intraoperative cardiac events.Postoperative cardiac events were identified in 3 patients including 1 death due to acute myocardial infarction and 2 episodes of transient hypotension.Conclusions The risk of anesthesia and noncardiac surgery is low in patients with hypertrophic cardiomyopathy.During the perioperative period,beta-blockers and/or calcium channel blockers should be given;vasodilator and inotropic agents should be avoided due to the side effects on hemodynamics.

Minimally Invasive Perventricular Device Closure of Ventricular Septal Defect: a Comparative Study in 80 Patients

Objective To evaluate the efficacy of minimally invasive perventricular device closure of ventricular septal defect(VSD). Methods Between September 2011 and February 2013, we collected 40 patients who underwent perventricular closure via a small lower sternal incision(minimally invasive group), aged 15.5±3.5 years(12 months to 32 years) with a body weight of 24.2±7.5 kg(10.8-58.0 kg). The mean size of VSD was 5.6±0.5 mm(2-14 mm). Another 40 patients were included as the surgical group, receiving the conventional surgical repair of VSD. The device of the minimally invasive group was released under the guidance of transesophageal echocardiography. Success rate, cardiac indicators, and clinical outcomes of the 2 groups were compared. Results The patients in the surgical group and those in the minimally invasive group showed similar results in success rate(both 97.5%). The procedure time, intensive care unit stay, hospital stay, and postoperative recovery time in the minimally invasive group were significantly shorter than those in the surgical group(58±21 minutes versus 145±26 minutes, 2±1 days versus 8±3 days, 5±1 days versus 16±6 days, 3±1 days versus 90±20 days, all P<0.05). The minimally invasive group had a higher incidence of conduction anomalies(17.5% versus 2.5%, P<0.05). In the follow-up period of 3-12 months, there was no new residual shunt, noticeable aortic regurgitation, significant arrhythmias, or device failure except for new complications in the surgical group. Conclusions The success rate of minimally invasive perventricular device closure of VSD under transesophageal echocardiography guidance is similar to that of conventional surgical repair, but the short-term outcomes of the minimally invasive approach is much better. Long-term follow-up is necessary to confirm the effectiveness of this technique.

Factors Influencing Pleural Effusion after Fontan Operation:an Analysis with 95 Patients

Objective To investigate the association between preoperative,operative,and postoperative factors and persistent pleural effusion after the extracardiac Fontan procedure. Methods Ninety-five consecutive patients diagnosed with univentricular heart underwent extracardiac connection using Gore-Tax conduits at the Department of Children’s Heart Centre,Justus-Liebig-University Giessen in Germany from June 1996 to July 2007. The outcome measures were duration and volume of chest tube drainage after surgical intervention. The investigated factors included age and weight at the time of operation,anatomical diagnosis,preoperative oxygen saturation,mean pulmonary artery pressure,ventricular end-diastolic pressure,fenestration,cardiopulmonary bypass time,conduit size,postoperative pulmonary artery pressure,administration of angiotensin-converting enzyme inhibitors,and postoperative infection. Associations between these factors and persistent pleural effusion after the extracardiac Fontan procedure were analyzed. Results Every patient suffered postoperative effusion. The median duration of postoperative chest tube drainage was 9 days (range,3-69 days),and the median volume was 12 mL·kg-1·d-1 (range,2.0-37.5 mL·kg-1·d-1). Thirty-seven (38.9%) patients had pleural drainage for more than 15 days,and the volume in 35 (36.8%) patients exceeded 25 mL·kg-1·d-1. Nineteen (20%) patients required placement of additional chest tubes for re-accumulation of pleural effusion after removal of previous chest tubes. Fifteen (17.8%) patients were hospitalized again due to pleural effusion after discharge. The median length of hospital stay after the operation was 14 days (range,4-78 days). Multivariate analysis results showed that non-fenestration,low preoperative oxygen saturation,and postoperative infections were independent risk factors for prolonged duration of pleural drainage (P<0.05). Long cardiopulmonary bypass time,non-fenestration,small conduit size,and low preoperative oxygen saturation were independent risk factors for excessive volume of pleural drainage (P<0.05).Conclusions For reduing postoperative duration and volume of pleural drainage following Fontan procedure,it seems to be important to improve the preoperative oxygen saturation,use large size of conduit,shorten cardiopulmonary bypass time,and make fenestration during the operation,as well as avoid postoperative infections.

Gender differences in the efficacy of cardiovascular rehabilitation in patients after cardiac surgery procedures

Cardiac rehabilitation （CR） programs are well known to improve patients＇ functional status after cardiac surgery and are recommended by current guideline. In fact, they pro- mote not only structured physical exercises but also a complete secondary prevention determining an overall reduction in recurrent cardiac events and an improvement in functional, psychosocial status and survival.

Depression, anxiety, and cardiac morbidity outcomes after coronary artery bypass surgery： a contemporary and practical review

Research to date indicates that the number of coronary artery bypass graft （CABG） surgery patients affected by depression （i.e., major, minor, dysthymia） approximates between 30% and 40% of all cases. A longstanding empirical interest on psychosocial factors in CABG surgery patients highlights an association with increased risk of morbidity in the short and longer term. Recent evidence suggests that both depression and anxiety increase the risk for mortality and morbidity after CABG surgery independent of medical factors, although the behavioral and biological mechanisms are poorly understood. Though neither depression nor anxiety seem to markedly affect neuropsy- chological dysfunction, depression confers a risk for incident delirium. Following a comprehensive overview of recent literature, practical advice is described for clinicians taking into consideration possible screening aids to improve recognition of anxiety and depression among CABG surgery patients. An overview of contemporary interventions and randomized, controlled trials are described, along with suggestions for future CABG surgery research.

Use of video-assisted thoracoscope in 121 cases of cardiac surgery

Objective: To sum up 121 cases of heart disease operations with the help of thoracoscope from May to August in 2000. Among these cases, 48 cases were atrial septal defect (ASD); the average age of patients is 20±10 years old; average weight is (43±16) kg. 67 patients with ventricular septal defects (VSD), average age13±9 years old; one male patient, 44 years old with Ebstein malformation; one female patient (21 years old) partial atrioventricular canal combined with cor triatriatum; one male (21 years old) with ruptared aneuryem of aortic sinus. 3 cases(all females ) with mitral stenosis combined with mitral valve incompetence. One male patient(aged 16)with pericardiun effusion after trauma. Methods: During operations, a patient with supine position, and his/her right shoulder was padded 30°higher. Tracheal cannula was inserted and air was piped in with high frequency jet ventilation. Three mini thoracotomies with a diameter of 2 to 3 cm were made in the 4th intercostals space of the right par sternum and the 4th and 7th intercostals spaces of the right middle axillary line respectively. An periphera extra corporeal circulation was made. the aortic clamp was clamped, cannula for cold perfusion. After the heart was sliced and a reformative operation was performed. The process of the operation of defects repairs was finished under the thoracoscope. The other operations were performed with the help of thoracoscope. 3 rheumatic heart disease patients got 25# mechanical mitral valve prosthesis. A 30# tricuspid plasty ring was applied to The Ebstein malformation patient. Results: all 121 patients were successfully operated on without death. Two VSD cases appeared transient third degree atrialventricular block.Because 4 cases had more chest drainage, so they were stanched bleeding twice. After the operation, heart murmur vanished, and ultrasonic inspection showed no diffluence inside the heart. Conclusion: Our experience showed that all atrium, ventricular septal defects can be repaired under the thoracoscope. This scope-assisted technology is more accepted by patients because of tiny incisions and also provides an alternative solution for cardiac surgeons.

Comparison of plasma NSE, protein S-100b and EEG changes in traditional arrested-heart procedures and on-pump beating-heart procedures

Objective: To assess the cerebral injury in on-pump beating-heart procedures under mild hypothermia in comparison with traditional on-pump arrested-heart procedures under moderate hypothermia. Methods: Forty patients, 20 with congenital heart disease (CHD) and 20 of rheumatic heart disease (RHD) , were divided into 2 groups: Control group (group A, n =20) including 10 patients suffering from CHD as group Al and the left 10 from RHD as group A2; and experiment group (group B, n =20) which consisting of group B1 (10 with CHD) and group B2 (10 of RHD). The patients in group A underwent traditional arrested-heart procedures, and those in group B were operated on with beating-heart procedures. Arterial blood samples were collected at preoperation (time A) , 20 min after cardiopul-monary bypass (CPB) starting (time B) , 1 h after CPB (time C) and 24 h postoperation (time D) respectively. Plasma contents of neuron-specific enolase (NSE) and protein S-100b were measured with sensitive ELISA. All the patients received echoencephalography (EEG) before and 1 week after operation. Results: The plasma contents of protein S-lOOb were increased very significantly at time B, C and D in comparison with those at time A (P<0.01) , and that of patients in group Al was significantly higher than that in group B at time B (P < 0. 05 ). There was no significant difference at other time points. At time B, the plasma contents of NSE were significantly higher in group A than in group B, and in group Al and Bl than in group A2 and B2. What's more, at time B, the former fell back to their pre-operative levels, but the latter remained still higher levels than the preoperative ones ( P < 0.01). No significant difference was found in the abnormality rates of postoperative EEG between 2 groups. Conclusion: The perioperative plasma contents of NSE and protein S-100b are not significantly higher in group B than in group A. On-pump beating-heart procedures do not make more serious cerebral dysfunction than the traditional arrested-heart procedures.

Median sternotomy closure:review and update research

Cardiac surgery is a very common operation nowadays all over the world.Median sternotomy is a routine procedure required for cardiac access during open heart surgery.The complications of this procedure after the cardiac surgery range from 0.7% to 1.5% of all cases,and bear a high mortality rate if they occur.Every individual surgeon must pay great attention on every detail during the sternal closure.This article shows the details as to conventional information and updated progress on median sternotomy closure.The update contents involve in biomechanics,number of wires twists,biomaterial and so on.According to our experience,we recommend four peristernal single/double steel wires for sternal closure as our optimal choice.

Effects of beating-heart and arrested heart intracardiac procedure on the inflammation induced by cardiopulmonary bypass

Objective：To evaluate the effects of beating-heart and arrested heart intracardiac procedure on the expression of tumor necrosis factor alpha （TNF-α mRNA in myocardium. Methods： Thirty congenital ventricular septal defect （VSD） patients aged from 5 to 10 years old were randomly divided into 2 groups equally. Group A underwent traditional arrested heart intracardiac procedures ; group B underwent beating-heart procedures. Specimens of myocardium were obtained at the onset （baseline） and the end of cardiopulmonary bypass （CPB） for the determination of TNF a mRNA. Concentration of TNF-α was respectively measured after anesthetic induction （T1）, 20 min after the beginning of CPB （T2）, at the end of CPB （T3） and 6, 12, 24 h after CPB （T4-6） in all patierits： After separating polymorphonuclear leucocyte （PMN）, we distilled nuclear protein and mensurated the activation of nuclear factor-κB （NF-κB） by elec-trophoretic mobility shift assay （EMSA）. Results ：Compared with baseline, the expression of TNF-κ mRNA significantly increased in both groups （P〈0. 05）. TNF-α mRNA level of group A was significantly higher than that of group B at the end of CPB （P〈0.05）. The plasma concentration of TNF-α and neutrophil NF-κB activity in group A was significantly higher than that of group B at T,4-6（P〈0.05）. Conclusion：Compared with traditional arrested CPB, beating heart intracadiac procedure can effectively reduce the expression and release of TNF-α; it will benefit the protection of pediatric myocardial during CPB.

PERITONEAL DIALYSIS AFTER REPAIR OF CONGENITAL HEART DISEASE IN CHILDREN

Objective. To investigate the effect of peritoneal dialysis on fluid balance and outcome in childrenwho receive cardiac operation.Methods. From July to Dec. 2000, 12(2.08%) patients of 576 consecutive children who underwentheart operation required peritoneal dialysis because of acute renal failure. The mean age of these 12 pa-tients was (2.9±2.0) years (range, 5 months～7 years) and the mean body weight was (12±3) kg (range,7.4～18.5 kg ).Results. The interval between the operation and the initiation of peritoneal dialysis was (21.2±11.4)hours (4.4～42 hours). The duration of peritoneal dialysis was (6.3±4.8) days (0.47～15 days). Mortality inthese 12 patients was 25%. Fluid removed by peritoneal dialysis was(34.7±17.8) ml@kg1@day-1@ Asymop-tomatic hypokalemia, thrombocytopenia and hyperglycemia were frequent complications, which were easilymanaged. Hemodynamics and pulmonary function improved during the study period.Conclusion. The early initiation of peritoneal dialysis is an effective and safe method totreat acute renal failure after cardiac operation in children.

Surgical Removal of a Giant Vegetation on Permanent Endocavitary Pacemaker Wire and Lead

PACEMAKER lead infections are rare.There are only about 0.4％-1.1％ of the patients who have been implanted permanent pacemakers suffering from serious infections which lead to endocarditis.1 Generally,removal of the infected pacemaker wire and lead,long-term anti-infection therapy,and implantation of a new pacemaker to another anatomic site are accepted approaches for these patients.

RELEASE OF SERUM TROPONIN I AND ITS RELATIONSHIP TO MULTIFACTORS FOLLOWING OPEN HEART SURGERY IN CHILDREN

Objective To be released specifically after myocardial damage. The goal of this study was to measure serum cardiac troponin I levels after open heart surgery in children, and to evaluate relevance between TnTi and perioperative multi-factors. Methods Fifty-seven consecutive pediatric patients undergoing elective correction of congenital heart diseases were divided into group A （ TOF, n =31 ） and group B （ VSD, n =26）. Blood sampies were drawn preoperatively, 5min（ T0 ） , 6h（ T6 ） , 12h（ T12 ） , 24h（ T24 ） , 48h（ T48 ） , 72h（ T72 ） after removal of aortic cross clamping. Myocardial protection consisted of moderate systemic hypothermia （ 30℃- 32℃ ）, cold crystalloid cardioplegia and topical cooling. Demographic information, cardiac defect, repair procedure, duration of bypass （ CPBT） , cross-clamping time （ CCT） , clinical score for cardiac function, electrocardiographic changes and outcomes were recorded. Results Compared with the baseline value, serum concentration of troponin I peaked at T0 （ P 〈 0. 01 ）, and fell to normal level at T72 （ P 〉 0. 05 ）. Peak CTnI was 118 and 55 times higher than the baseline value, respectively in group A and group B. There was a positive correlation between peak CTnI and CPBT, CCT （ r = 0. 51 ; P 〈 0. 01 ）, myocardial operative injury after ventriculotomy and muscle resection （ r = 0. 35, P 〈0. 01 ）. Also the peak CTnl value was correlated to the clinical score for cardiac function （r = -0. 52; P 〈0. 01）. 2.3μg/L was a cutoff value which was highly predictive for postoperative recovery and inotropic support. Conclusion Postoperative serum troponin I is a highly specific and sensitive marker for myocardial ischemia and injury; therefore, its measurement may contribute to the assessment of recovery and outcome after open heart surgery.

REVIEW OF RIGHT VENTRICULAR FAILURE:GENERAL CONSIDERATION

Right ventricular failure(RVF)is a complicated syndrome with multiple etiologies.RVF relates to pulmonary hypertension,left ventricle failure,and congenital heart diseases.The origin of its pathway is based on pathological gene expression and concomitant diseases.Diagnosis of RVF is a serious problem for clinicians,but none of the criteria in current clinical practice provides uncontaminated information on either systolic or diastolic function.Perioperative assessment and bedside monitoring of right ventricle function have to be revised and widely used.Right ventricle function in transplant patients demands different evaluation using biomarkers or/and autopsy.Treatment of RVF has surgical and non-surgical approaches;both are still in development and need further clarification.

Two case of preoperative bridging therapy for patients undergoing non- cardiac surgery after coronary stent implantation

It has been reported that up to 12% of patients underwent non-cardiac surgery or invasive procedures within the first year after the coronary stent implantation. Premature dis- continuation of antiplatelet therapy is associated with a sig- nificant increase in mortality and major adverse cardiac events, in particular, stent thrombosis. Thus, postpone- ment of elective surgery is advocated during the first year after the coronary stent implantation.