2017年 · 第33卷第06期

Recurrence of mitral regurgitation is an important factor affecting the long-term outcome of patients with primary Atrial septal defect (ASD)^[1]The mitral valvuloplasty ring implantation technique can clearly improve the long-term efficacy of mitral valve degeneration repair, but there is no clear consensus on whether mitral valve repair can be improved by mitral valvuloplasty ring implantation in patients with primary foramen ASD. We reviewed the medical records of adult patients with primary foramen type ASD in our center, and used the propensity score matching method to match patients 1:1 according to whether or not mitral valvuloplasty ring was placed, and analyzed the medium-and long-term efficacy of patients, which is reported below.

End-expiratory CO2 monitoring has become one of the routine monitoring methods in clinical anesthesia. Intraoperative end-expiratory CO2 partial pressure (PETCO₂) and the end-expiratory carbon dioxide waveform (EtCO₂) has important clinical significance. In thoracic surgery with single lung ventilation, the monitoring of end-expiratory carbon dioxide is particularly important. Now, the changes of end-expiratory carbon dioxide caused by pulmonary artery perfusion disorder in 3 cases of lobectomy in our hospital in the past 4 years and the management results are analyzed, and reported below.

aortic dissection (AD) is an integral part of acute aortic syndrome (AAS). It is a severe acute cardiovascular disease. Its clinical manifestations are complex and changeable, and its misdiagnosis rate and mortality rate are high. Early diagnosis and early intervention are the keys to reduce the mortality rate of AD. European and American countries have reported on the clinical characteristics of AD in Western populations, but due to racial differences, the clinical characteristics of AD in Western populations are not completely consistent with those of Chinese people. However, there are few research reports on the risk factors, clinical characteristics, classification and prognosis of AD in large sample size in China. The past medical history, general data, clinical manifestations, imaging diagnosis, treatment methods and risk factors of in-hospital death of 105 AD patients in emergency department of Tianjin Fourth Central Hospital and Tianjin Medical University General Hospital were retrospectively analyzed, and the relationship between clinical characteristics and prognosis of different types of AD patients was discussed. The high-risk risk factors of AD death were screened, so as to improve the understanding of AD, help to early detection, early diagnosis and treatment, improve the prognosis of patients and reduce the mortality rate.

Esophageal submucosal tumors account for less than 1% of all esophageal tumors. As a type of esophageal submucosal tumors, esophageal leiomyoma is the most common benign esophageal tumors, accounting for about 80% of the latter^[1]。 With the popularization and development of ultrasonic gastroscopy, more and more asymptomatic microscopic esophageal leiomyomas can be detected and treated. In recent years, thoracoscopic surgical techniques have been successfully used for the removal of esophageal leiomyomas, however, for some tiny (diameter<1.5 cm) esophageal leiomyoma, which is difficult to locate under thoracoscopy, can cause certain difficulties in surgery, and sometimes even convert to thoracotomy because of this^[2]。 How to facilitate the localization of microesophageal leiomyoma during operation has become a problem that the surgeon should think about. From August 2012 to September 2014, 12 cases of mini-esophageal leiomyoma removal assisted by esophagoscopy were performed in our department, and the clinical results were satisfactory. The summary report is as follows.

Male, 2 years 1 month old, weight 10 kg. Heart rate increased for 1 year and congenital heart disease was found for 2 months. Physical examination: Heart rate was 140 beats/min, and systolic murmur of grade 3/VI could be heard in intercostal area 3-4 on the left margin of the sternum in the precordial area. Electrocardiogram showed sinus rhythm, left atrial and right ventricular hypertrophy. Echocardiography showed interruption of the aortic arch, small aortic development, 0.36 cm inner diameter at the narrowest subvalvular point and 0.62 cm annulus (Figure 1)； Pulmonary hypertension 46 mmHg (1 mmHg =0.133 kPa); Ventricular septal defect 1.7 cm, perimembranous fusion type, bidirectional shunt; Patent ductus arteriosus, pulmonary end 0.75 cm, bi-directional shunt. Angiography showed that the pulmonary artery systolic, diastolic and mean pressures were 79, 41 and 59 mmHg, and the ascending aorta diameter was 7.1 mm. Diagnosis: Aortic arch interruption (type B), aortic stenosis, left ventricular outflow tract obstruction, ventricular septal defect, patent ductus arteriosus, pulmonary hypertension.

Female, 34 years old, weight 61 kg, 28 weeks pregnant. The fever was repeated for 2 weeks, and the maximum body temperature was 39.5℃. Blood pressure 86/54 mmHg (1 mmHg =0.133 kPa), heart rate 126 beats/min, sinus rhythm at admission. Preoperative transthoracic echocardiography showed: severe mitral regurgitation with rupture of anterior chordae tendineae, moderate tricuspid regurgitation, definite mitral neoplasm formation, left ventricular end-diastolic diameter (LVEDD) 5.3 cm, left ventricular end-systolic diameter (LVEDS) 4.7 cm:, left ventricular ejection fraction (LVEF): 0.60; Pulmonary artery pressure 60 mmHg. There were no results from preoperative blood cultures. Subacute infectious endocarditis, mitral insufficiency, tricuspid insufficiency were diagnosed. Preoperative NYHA cardiac function was classified as grade III.

Male, 64 years old, with pain, chills and bruises at the fingertips of both hands for more than 1 month. Chest CT showed that the right lung occupied space. Considering the possibility of lung cancer, he was treated with alprostadil, papaverine hydrochloride, cyclophosphamide and dexamethasone, but the fingertip symptoms were not relieved. The patient severed his right index finger due to trauma 28 years ago, smoked 25 cigarettes/day for 50 years, and had no history of diabetes. Admission physical examination: the index finger of the right hand is absent, the fingertips of the remaining nine fingers are blue and purple, and the thumbs of both hands are (Figure 1)。 CA125 92.10 U/ml, lupus anticoagulant factor test 1.38 (0.80-1.20), CRP 12.80mg/L, ANA (-), cryoglobulin (-), upper limb vascular color ultrasound (-) were examined on admission. Preoperative CT showed irregular nodular shadows in the upper lobe of the right lung, showing lobulation, multiple long and short burrs at the edge, and local pleural traction, considering the possibility of lung cancer (Figure 2)； Lymph nodes were enlarged in the 4R area of mediastinum, and multiple nodules in bilateral adrenal glands were observed, and metastasis was not excluded. The initial diagnosis was lung cancer with paraneoplastic acrovascular syndrome.

Female, 56 years old. Physical examination found that the right lung occupied space for 1 month, and he was admitted to hospital in June 2015. No history of tuberculosis, physical examination: percussion of both lungs showed voice-free; In auscultation, the breathing sound of the right lung was weak, the breathing sound of the left lung was clear, and no dry or wet rales were heard. Unpalpable enlargement of superficial lymph nodes throughout the body. Multi-slice CT (outer hospital) plain scan of the lung showed that the apical segment of the upper lobe of the right lung and the outer basal segment of the lower lobe showed patchy high-density shadows, pleural traction and short burrs were seen around it, and vacuolation signs were seen inside it. The larger one in the upper lobe of the right lung was about 2.4 cm ×1.7 cm in size. PET-CT showed peripheral lung cancer of the right upper lobe (Figure 1), ground glass patches in the lower lobe of the right lung, with low metabolism (Figure 2)。 Tumor marker examination: Carcinoembryonic antigen (CEA) 3.56 ng/ml.

Male, 45 years old. Accidentally falling into a well, severe chest pain occurred after the collision between the anterior chest wall and the wellhead. Anterior mediastinal hematoma was revealed on plain CT scan of the chest at a local hospital. At admission, the patient's heart rate was 112 beats/min and blood pressure was 96/62 mmHg (1 mmHg =0.133 kPa). Laboratory tests showed hemoglobin (Hb) 150 g/L, repeated 2 h later 110 g/L. Physical examination showed swelling of the anterior chest wall, obvious tenderness of the chest wall, and no obvious bone friction sound in the chest wall. After admission, CT of the chest showed anterior superior mediastinal hematoma, which was about 11.0 cm ×5.0 cm in size, and occupied obvious space. On enhanced scan, a flaky contrast medium spillover was seen in the hematoma (Figure 1)。 Traumatic pseudoaneurysm of the right internal mammary artery was considered in conjunction with the history of trauma. Emergency DSA arteriography showed signs of patchy contrast overflow in the branches of the right internal mammary artery (Figure 2), the right internal mammary artery pseudoaneurysm was diagnosed clearly. Leapfrog embolization of hemorrhagic internal mammary artery branches was performed by coil. The contrast spillover signs disappeared after embolization, and the embolization effect was satisfactory. Two days after surgery, reexamination of enhanced chest CT showed that the signs of spillage of the original contrast medium disappeared (Figure 3)。 The patient was successfully discharged 5 days after surgery. After 6 months of follow-up, no rebleeding occurred.