2017年 · 第33卷第04期

In patients with functional ischemic mitral regurgitation, mortality increases exponentially in patients with moderate to severe mitral regurgitation after myocardial infarction^[1,2,3]。 Ischemic mitral regurgitation is caused by left ventricular remodeling after myocardial infarction, increased left ventricular volume, enlarged mitral valve annulus, lateral leaflet bias, restricted movement of chordae tendineae, etc. These changes lead to poor leaflet alignment. At the same time, the degree of mitral regurgitation is also affected by left ventricular volume status, heart rate, afterload and ischemic area. Ischemic mitral regurgitation has normal mitral valve leaflet function, and the etiology mainly occurs in the myocardial layer. Therefore, that therapeutic strategy of functional mitral regurgitation is different from that of mitral degeneration^[4]。

Isolated atrial fibrillation refers to atrial fibrillation without other organic heart disease. Thoracoscopic assisted minimally invasive radiofrequency ablation is a new method for the treatment of atrial fibrillation^[1,2]。 In China, it is mainly concentrated in a few large heart centers, and grass-roots hospitals have less development due to technical constraints. Since May 2014, our hospital has carried out 21 cases of thoracoscopic assisted radiofrequency ablation combined with left atrial appendage closure to treat isolated atrial fibrillation. The summary experience is reported below.

Pulmonary hypertension is one of the difficult problems in surgical treatment of congenital heart disease, especially severe pulmonary hypertension (mean pulmonary pressure>50 mmHg (1 mmHg =0.133 kPa) is an important factor affecting the outcome and prognosis of surgical treatment. Adult congenital heart disease (CHD) is often complicated with pulmonary hypertension (PH), the disease is complicated, and the death rate of surgical treatment increases^[1]。 From June 2009 to September 2015, our department surgically or interventionally treated 60 adults over 18 years old with CHD combined with severe PH, with satisfactory results. The treatment experience report is summarized as follows.

Morgagni hernia is a special type of diaphragmatic hernia, which has no obvious clinical symptoms and signs in the early stage, and is easy to be misdiagnosed and missed. From August 2007 to October 2014, we treated a total of 5 patients with Morgagni hernia and performed surgical treatment, with satisfactory results. The experience is summarized and reported below.

The left main coronary artery "sandwich" malformation is a congenital coronary artery lesion belonging to the Anomalous aortic origin of a coronary artery (AAOCA). Its anatomical features are that the left coronary artery is at the opening position of the aorta (usually originating from the right coronary sinus) and runs abnormally. The abnormal coronary artery runs between the two major arteries, forming a "sandwich"-like lesion, and the abnormal coronary artery mostly runs in the aortic wall, and then leaves the aorta at the correct left coronary sinus wall. This malformation is one of the most important causes of sudden cardiac death. From 2013 to 2016, we treated 3 cases of "sandwich" malformation of the left main coronary artery, and now summarize the clinical characteristics and diagnosis and treatment experience of this disease.

The heart center of our hospital performs more than 200 cases of infant heart surgery every year. Some infants have abnormal rib movement after the median sternum incision, and even form chicken breast or pectus excavatum, which affects the rehabilitation and appearance of cardiopulmonary function in severe cases. Polylactic acid internal fixation materials have good mechanical strength and tissue compatibility, and are recognized as the most effective alternative to metal internal fixation materials^[1,2]。 In recent years, poly-L-lactic acid (PLLA) absorbable bone fixation system has been used in various fracture surgery and has obtained satisfactory clinical results^[3,4,5,6]。 However, there are no literature reports to analyze the clinical efficacy of PLLA absorbable bone fixation system in sternum reinforcement after neonatal heart surgery. We retrospectively analyzed the clinical data of 74 newborns who underwent cardiac surgery through the median sternal incision in our hospital from April 2014 to April 2015, which are reported below.

Endovascular thoracic aortic repair (TEVAR) is the main treatment for thoracic aortic aneurysm and Stanford type B aortic dissection, with adequate proximal anchoring area and appropriate aortic arch morphology^[1,2]It is the key to reduce the incidence of postoperative type I endoleak. The opening of partial branch vessels of the aortic arch, i.e., the left common carotid artery (LCA), the left subclavian artery (LSA), limits the length of the proximal anchor zone. Complete or partial closure of the left subclavian artery is one way to increase the proximal anchoring area, but patients have postoperative left upper limb dysfunction, vertebrobasilar ischemia, left subclavian artery stealing, and spinal cord injury possible^[3,4,5]。 Chimney technique can preserve LSA and LCA blood flow, but due to the existence of a space between the aortic stent and the chimney stent, the incidence of postoperative type I endoleak is high, and there is a risk of stenosis or occlusion due to insufficient radial support of the chimney stent^[6,7,8]。 The technique of fenestration and slotting plus branch stent can preserve the physiological and anatomical blood supply of LCA and LSA, and avoid the above complications to the greatest extent. The existing commercial fenestration stents and branch stents need personalized customization, and the customization time period is long and the cost is high, which limits their routine clinical application. We targeted cases of thoracic aortic aneurysm and aortic dissection with poor proximal anchorage (length of anchorage<15 mm, or aortic arch with angular deformity), according to the preoperative aortic CTA data of the patient, intraoperative extracorporeal stent pre-fenestration and grooving, combined with branch artery stent insertion technique, achieved good short-term clinical results.

Male, 49 years old. Chest pain and cough for 2 months, aggravated for 7 days. Physical examination: General condition is acceptable. Chest enhanced CT examination showed a mass shadow about 4.2 cm ×3.8 cm in size in the right diaphragmatic angle area, with uneven density and clear boundary, and mild enhancement after enhanced scan (Figure 1)。 Among the tumor markers, carcinoembryonic antigen was 3.08 ng/ml, and alpha-fetoprotein, CA125, CA153, CA199 and β-human villus gonadotropin were all negative.

Male, 37 years old. Physical examination found that the left upper lung occupied space for more than 1 month. The patient had a smoking habit, 20 cigarettes/day ×10 years, and did not quit smoking. Physical examination showed no obvious abnormalities. Chest CT examination of left upper lung (parahilar) showed a soft tissue shadow with a size of about 1.2 cm ×2.0 cm, clear boundary, smooth surface and uniform density (Figure 1)。 Preoperative diagnosis: left upper lung nodule. Thoracoscopic wedge resection of the left upper lobe is proposed.

Female, 43 years old. Mitral valve replacement (mechanical valve, continuous suture) was performed 5 months ago due to mitral stenosis due to rheumatic heart disease. Paravalvular leakage of mitral valve was found by routine review 3 months after operation. Physical examination: Grade 4/VI systolic murmur was heard at apical auscultation. Laboratory test: total bilirubin 27.5 μ mol/L, direct bilirubin 4.37 μ mol/L; Rheumatoid factor, anti-"o" test and blood sedimentation negative. Plain chest X-ray showed enlargement of left atrium and ventricle. Transesophageal echocardiography revealed a 5 mm ×20 mm crescent leak adjacent to the mitral valve annulus at 9 o'clock in the short axis section of the left ventricle (Figure 1), medium-massive reflux at the leak, left ventricular end-diastolic diameter 52 mm ×34 mm, left atrium 43 mm.