2017年 · 第33卷第10期

mechanical hemolytic anemia (MHA) is a serious complication after heart valve surgery. If improperly treated, it can cause multiple organ failure and lead to death. The mechanism of its generation has been reported in the literature^[1,2,3]。 In the past, the incidence of MHA was high, but with the improvement of valve fabrication technology and histocompatibility of materials used, the incidence of MHA has been significantly reduced. MHA due to technical problems and histocompatibility is rare in clinical practice when the heart valve functions normally, but it is not uncommon to occur in the case of mitral valvuloplasty (MVP), residual regurgitation after valvuloplasty, or paravalvular leakage of prosthetic valves, etc. It is one of the important reasons leading to the need for reoperation after heart valve replacement or plasty^[2,4,5,6]。 At present, MHA after heart valve surgery is rare, and the experience in diagnosing and managing mechanical MHA after surgery is relatively insufficient, which easily leads to misdiagnosis and mistreatment. The incidence, harm, diagnosis and treatment of MHA after MVP are discussed, and the treatment experience is summarized in order to reduce the disability rate and mortality rate.

Chronic tuberculous empyema is more common in clinic, and pleural fibroplatectomy is the main surgical treatment^[1]The results were satisfactory, but the surgical trauma was large and the postoperative pain was obvious. With the development and improvement of video-assisted thoracoscopic surgery (VATS) technology, minimally invasive methods have been reported for the treatment of chronic tuberculous empyema^[2,3,4]。 Whether fiberboard stripping can be performed under VATS is controversial at present.

Mediastinal metaplastic thymoma is a rare clinical occurrence. It is a thymic epithelial tumor with unique clinicopathological features. It was first developed by Suster et al.^[1]Reported in 1997. It was previously called sarcomatoid stromal thymoma, low-grade malignant metaplastic thymoma, low-grade metaplastic carcinoma, biphasic differentiation thymoma, etc. In 2004, WHO officially named it metaplastic thymoma^[2]。

Stanford type A aortic dissection is a critical condition in the surgical field. In 2015, the International Multicenter Large Sample Study (IRAD) reported that 18% of the deaths were treated by surgery^[1], thanks to Sun's operation^[2]Promotion, domestic surgical deaths account for about 10%^[3]。 In patients with Stanford type A aortic dissection, surgery is more complicated with aortic insufficiency, and postoperative death increases.

Since September 2014, we have carried out subxiphoid single-port thoracoscopic surgery, which is widely used in the diagnosis and treatment of bullae, mediastinal tumors and early lung cancer. The subxiphoid incision can treat bilateral lesions simultaneously, and it has obvious advantages over intercostal incision for simple surgery such as double bullae resection or double lung nodule biopsy^[1,2]。 Since 2016, we have attempted to use this incision to perform simultaneous bilateral lobectomy for the treatment of early lung cancer, and 2 cases have been successfully performed, which are reported below.

The patient was a 33-year-old male. Throat pain for 3 months, fatigue and chest tightness after progressive sexual activity for half a month. Electrocardiogram showed sinus tachycardia 104 beats/min, left ventricular hypertrophy. Echocardiogram showed: abnormal echo on the aortic valve, considering the possibility of vegetation; Aortic insufficiency (severe), considering no coronary valve perforation possible; Whole heart enlargement, pulmonary hypertension (mild); Effective cardiac volume decreased; Small amounts of pericardial effusion.

The patient was a 40-year-old female. Fever for 4 months, with the highest body temperature of 40℃. The local hospital diagnosed it as "suspicious typhoid fever". Oral antipyretic drugs and intravenous cephalosporin antibiotics were given for 5 days, and the body temperature could drop to normal. After stopping the drug, the fever appeared again. Blood culture in the local hospital showed positive bacillus infection, and the specific bacterial strain was unknown. Vancomycin 1.0 g once/day and Shupushen 1.5 g twice/day were given. The body temperature gradually stabilized, but the source of infection was not found. Then, he was transferred to our hospital for echocardiography: congenital bileaf aortic valve malformation, aortic valve and left ventricular outflow tract neoplasm formation, and moderate aortic regurgitation. The initial diagnosis was infectious endocarditis, and the replacement medication was daptomycin 0.5 g once/day.

The child was a 6-year-old male. Five years ago, a heart murmur was found due to a cold, and the echocardiogram showed right ventricular mass occupation. Physical examination showed that there was no cyanosis in the lips, no tremor in the precordial area, the heart boundary increased to the right, the rhythm was uniform, and a Grade 2/6 systolic murmur could be heard in the 3rd to 4th intercostal area on the left margin of the sternum. Echocardiography showed an echo mass of approximately 53 mm ×28 mm ×43 mm in the right ventricular outflow tract (Figure 1), the blood flow was still unobstructed, the right ventricular outflow tract flow rate was 105 m/s, and the left ventricular ejection fraction was 0.71. X-ray chest radiograph showed no obvious abnormalities in both lungs, and the heart shadow was slightly enlarged. Electrocardiogram showed sinus rhythm, heart rate 117 beats/min, right deviation of electric axis. Cardiac magnetic resonance imaging examination showed: a mass of isot2 signal shadow in the anterior wall of the right ventricle, the signal was slightly lower than that of normal myocardium, the largest axial cross section was about 20 mm ×27 mm, one end was located at the outlet of the right ventricular outflow tract, and the right ventricular outflow tract was slightly compressed; The enhanced scan showed uniform enhancement of right ventricular space, and the enhancement amplitude was slightly higher than that of ventricular wall, showing benign signs.

The patient was a 53-year-old female. Physical examination revealed cardiac mass for 1 week. Echocardiography showed abnormal space-occupying echoes in the right atrium, with a pedicle connected to the atrial septum. Previous history of uterine fibroids for more than 3 years, untreated. Physical examination showed that a murmur was smelled in the precordial area, and a mass was palpable in the lower abdomen, about 18cm ×22cm in size.

The patient was a 53-year-old male. Cough and chest tightness for more than 1 month. Chest enhanced CT (Figure 1) showed central lung cancer of the left lower lobe with obstructive pneumonia and left atrial involvement. Echocardiography showed a mass-like mass extending from the left inferior pulmonary vein and invading the top of the left atrium, with a diameter of about 0.8 cm and a diameter of 3.7 cm. Whole body PET-CT showed a malignant tumor near the hilar of the left lower lung with an average SUV of 3.6. There were no signs of metabolic increase in hilar and mediastinal lymph nodes, and no distant metastasis.

Case 1 female, 46 years old. Physical examination revealed anterior mediastinal mass for 2 months without discomfort. Chest enhanced CT examination showed a massive soft tissue density shadow in the anterior and middle mediastinum with clear boundaries, moderate enhancement of the mass after enhancement, and clear surrounding fat layer (Figure 1)。 There were no positive signs on physical examination, and no obvious abnormalities were found in blood, urine and stool routine, blood biochemistry and coagulation function tests. Perfect other auxiliary examinations to exclude contraindications for surgery.