2017年 · 第33卷第08期

Coronary atherosclerotic heart disease (CHD) is a disease in which coronary artery stenosis and insufficient blood supply result from coronary atherosclerosis, which causes myocardial ischemia and necrosis, and then changes the organic function of the heart. Coronary revascularization is an effective treatment for coronary heart disease, including percutaneous coronary Intervention (PCI), coronary artery bypass grafting (CABG) and hybrid coronary revascularization (HCR). However, the degree of coronary artery disease and individual clinical characteristics of patients are often the main factors in selecting revascularization strategies. In recent years, with the progress and development of internal and surgical treatment technology for coronary artery disease, the choice of revascularization treatment strategies and methods for complex coronary artery disease has once again aroused the discussion of cardiac surgeons and surgeons. At the same time, the concept that a cardiac team composed of cardiac surgeons and surgeons jointly executes clinical decisions so that patients can obtain the best treatment plan has gradually taken shape. The establishment of the cardiac team promoted the rapid development of coronary hybrid revascularization, and achieved good clinical results. At present, there are no guidelines and expert consensus on coronary hybrid revascularization at home and abroad. The choice of coronary hybrid revascularization strategies at home and abroad is mostly based on physicians' own experience, and there is a lack of unified standards and norms. Based on this current situation, this consensus compiling expert group combines nearly ten years of evidence-based medical evidence and domestic and foreign clinical practice experience, and compiles the Expert Consensus on Coronary Artery Hybrid Revascularization in China in Cardiac Medicine and Surgery, the Guidelines for Percutaneous Coronary Intervention in China (2016), the Consensus on Secondary Prevention of Coronary Artery Bypass Grafting in China, the Expert Consensus on Perioperative Antiplatelet Therapy of Coronary Artery Bypass Grafting, the Expert Consensus on Coronary Artery Rehabilitation and Secondary Prevention in China (2017 Edition), etc., to provide reference and basis for promoting and standardizing hybrid revascularization of coronary heart disease in the future.

The treatment of ruptured sinus of Valsalva aneurysm (RSVA) currently includes surgical and transcatheter interventional closure of RSVA. In recent years, with the development of transthoracic "perforation" minimally invasive closure technology of congenital heart disease, transthoracic "perforation" esophageal echocardiography (TEE) guided closure of RSVS has become possible. From May 2012 to February 2016, 11 patients with RSVA were admitted to our department, all of whom underwent transthoracic "punching" TEE-guided RSVA occlusion. The clinical data and experience of this method were summarized, and the feasibility and safety of this method in the treatment of RSVA were discussed. Previously, it provided a new clinical treatment method for clinical RSVA.

Case 1 female, 52 years old. Slow response, poor speech, and persistent headache for 4 days occurred without obvious triggers. The patient was conscious and had no symptoms such as vomiting, limb twitching, fever, cough and expectoration. The respiratory sounds of both lungs were slightly thick and there were no other obvious abnormalities. The patient had no history of chronic otitis media or other purulent lesions. Laboratory tests showed no abnormalities. The enhanced MR scan of the left basal ganglia showed a space occupying lesion with a cross-sectional size of about 28 mm ×27 mm, showing high T2WI and low T1WI signal changes, DWI showed obvious high signal, and a large edema signal band was seen on the periphery of the lesion. After enhancement, the lesion showed obvious annular enhancement (Figure 1，Figure 2，Figure 3，Figure 4）。 MR proposed diagnosis: brain abscess. Chest CT enhancement showed a tortuous stripe shadow in the anterior segment of the right upper lobe, and a mass shadow of about 42 mm ×27mm in the left upper lobe with clear edges. After enhancement, the lesion was significantly enhanced synchronously with the pulmonary artery, and there was a supply artery communicating with the pulmonary artery, a thick drainage vein, and the diameter of the supply artery was about 6 mm. CT diagnosis: multiple pulmonary arteriovenous fistulas in both lungs. Pathological diagnosis of intracranial surgery: brain abscess in the left basal ganglia region. Case 2 was a 52-year-old male. Sudden headache without obvious trigger, mainly in the left temporal region, was distended and painful, paroxysmal, and accompanied by speech difficulties for 3 days. The patient had no symptoms such as fever, nausea and vomiting, limb twitching and limb mobility disorder. On admission, the respiratory sounds of both lungs were coarse, and no obvious abnormalities were found. There were no abnormalities in the laboratory tests. The patient had no history of infection. The enhanced MR scan of the skull showed a cross-sectional space occupying focus of about 30 mm ×28 mm in the left parietal lobe. The uneven plain scan showed high T2WI and low T1WI signals. After enhancement, the lesion was irregular and annular enhancement, and there was a large edema signal band around the lesion (Figure 5，Figure 6，Figure 7，Figure 8）。 MR diagnosis: single metastatic tumor, cryptogenic brain abscess to be drained. Enhanced CT scan of chest showed that the tortuous dilated vascular shadow of the left lower lobe of lung communicated with the tumor sac, and there was a reflux vein connected with the left lower pulmonary vein. The blood supply vessel, tumor sac and pulmonary artery were enhanced simultaneously, and the diameter of the blood supply artery was about 5 mm. CT diagnosis: pulmonary arteriovenous fistula in the lower lobe of the left lung. Pathological diagnosis of intracranial surgery: intracranial inflammatory lesions with abscess formation.

A 51-year-old male suffered from foreign body sensation during swallowing for 2 months and aggravated for 10 days. He was admitted to hospital on 10 June 2011. Gastroscopy showed a mass 35-41 cm away from the incisors, and the pathological result was squamous cell carcinoma. No distant metastasis was found in relevant examinations, and the cardiopulmonary function was evaluated well. On 15 June, a radical esophagectomy was performed under general anesthesia through a posterolateral incision of the left thorax, and an end-to-side instrumental anastomosis of the sub-aortic arch esophagus-tubular stomach (Johnson anastomat 25cm) was performed. On the 9th day after operation, iodine water angiography showed anastomotic fistula, and symptomatic treatment such as anti-inflammatory, fluid rehydration, stomach protection, strengthening nutrition and unobstructed drainage were given. On the 15th postoperative day, an endometrial stent was placed under intervention to close the fistula. On the 24th day after operation, the patient vomited a small amount of blood, and was given conservative treatment such as hemostasis, acid suppression and stomach protection. Two days later, hematemesis occurred again, a small amount, bright red, and a large amount of hematemesis occurred when he got out of bed that night. He was immediately given bedside first aid, and finally died after the rescue failed. A necropsy revealed a fistula at the posterior wall of the stomach 1 cm below the anastomosis communicating with the aorta (Figure 1), the fistula is flat against the lower edge of the stent. Autopsy diagnosis: thoracogastric aortic fistula.