2017年 · 第33卷第11期

aortic dissection (AD) is a critical cardiovascular disease that threatens the life and health of Chinese people. In recent years, with the improvement of medical staff's understanding of aortic diseases and the advancement of imaging diagnosis, cardiovascular surgery, anesthesia and cardiopulmonary bypass technology, the diagnosis rate of AD has been increasing, and the incidence of surgical death and complications has decreased significantly. However, due to the lack of large-scale prospective randomized controlled studies on the treatment of AD in the world, there are still many controversies in the industry about the diagnosis and treatment of this disease.

Patients with renal disease who need to rely on hemodialysis for a long time have basic loss of renal function and obvious kidney pathological changes (end-stage renal disease, ESRD). Studies have shown that 44% of ESRD patients eventually die of heart disease, and acute myocardial infarction is the most important cause of death in such patients^[1,2]。 At present, with the aging of the population, the number of ESRD patients is increasing year by year, and some of them are complicated with severe coronary stenosis, which needs to be actively treated^[3,4,5]。 When renal disease progresses to the terminal stage, the probability of patients with vascular disease will greatly increase, especially coronary atherosclerosis, and the probability of patients with chronic renal failure with aortic calcification will also increase. These patients will have electrolyte disorder, edema, and pH imbalance in the later stage, and the function of platelets will be inhibited, eventually leading to coagulation disorder^[6]However, some difficult cardiac surgery operations need to be completed with the help of cardiopulmonary bypass, which undoubtedly increases the difficulty and risk of the operation, and a little carelessness may lead to failure of the operation. Such patients are regarded as high-risk groups of cardiac surgery, which are patients with contraindications for surgery^[7]。 We summarize the matters that should be paid attention to in patients with ESRD during the perioperative period and the experience of management and treatment, as well as the follow-up results, which are reported below.

Tracheal diverticulum is rare, and it is found accidentally by multiple clinical CT examinations. In recent years, with the application of thin-slice CT, the detection rate of tracheal diverticulum has improved obviously. From January 2015 to September 2015, 3 patients with tracheal diverticulum were surgically treated in our hospital, and the curative effect was satisfactory. The summary report is as follows.

The method of deep hypothermic circulatory arrest combined with selective cerebral perfusion is mostly used in total arch replacement for type A aortic dissection. Because deep hypothermic circulatory arrest may cause internal environment disorder, coagulation disorder and multiple organ injury, it is an important strategy in total arch replacement to shorten the time of deep hypothermic circulatory arrest as much as possible. We applied aortic balloon endovascular occlusion of descending aorta in 3 cases of acute Stanford type A aortic dissection who underwent total arch replacement and stent elephant trunk surgery, which significantly shortened the time of deep hypothermia circulatory arrest. The methods and curative effects are summarized and reported as follows.

The patient was a 53-year-old female. Small nodule in the dorsal segment of the lower lobe of the left lung, size 1.0 cm ×1.0 cm, CT value-35hu. Thoracoscopic pulmonary nodulectomy was decided with preoperative hook-wire positioning. Type of positioning needle: 20G ×90 mm breast puncture positioning needle (Ponomax). CT-guided positioning: local scan with the lesion as the center, determine the needle insertion point and design the needle insertion route; Through the lung tissue adjacent to the lesion, the positioning needle was pricked into the lung on the distal side of the lesion about 1.5 cm, the inclined surface of the needle tip was withdrawn from the shell toward the lesion, and the steel hook was bounced open; Cut the tail filament 2 cm from the body surface, dressed and fixed. A small amount of hematoma was seen around the steel hook after positioning, and there was no pneumothorax (Figure 1,Figure 3,Figure 3)。 The patient had no symptoms of discomfort. Positioning took about 11 min.

A 64-year-old male suffered from progressive eating choking for more than 1 month. Physical examination showed no obvious abnormalities. Gastroscopy at the local hospital revealed: hyperplastic lesions 25-37 cm from the incisors, central ulcers. Biopsy showed squamous cell carcinoma. Routine blood test: white blood cells 38.00×10⁹/L, neutrophils 47.46×10⁹/L, lymphogranulocytes 1.44×10⁹/L, anti-inflammatory treatment was given, and the white blood cells were greater than 38.00×10 in multiple reexaminations within 2 weeks⁹/L. Bone marrow biopsy showed that the degree of nucleated cell proliferation of bone marrow was roughly normal, and the granule/red ratio was slightly increased; Granulocyte proliferation was slightly obvious, mainly partial mature cells, and a few partial naive cells; The erythroid is dominated by middle and late young erythrocytes, megakaryocytes are slightly rare, the cell body is small, the lobes are few, the lymphocytes are scattered a few, and the bone marrow interstitium does not see fibrosis. Consider leukemia-like reactions.

The patient was a 43-year-old male. Suddenly encountered high-temperature liquefied aluminum water splashing, and suffered multiple burns all over the body. After initial treatment in the local hospital, he was transferred to our hospital. After admission, the burn wound debridement, analgesia, fluid rehydration, anti-shock and anti-infection were treated in the burn department. Twelve days later, the patient suddenly developed high fever, chest tightness, choking, chest pain and severe anemia, melena defecation, and vomiting of coffee-colored liquid. Consider gastrointestinal perforation and bleeding after esophageal burn. X-ray chest radiograph showed: round high-density shadow of the stomach, consistent with metal foreign body (Figure 1)。 Digestive tract angiography showed: the lower esophagus, gastric fundus and cardia mucosa were rough, twisted and blurred; Lower esophagus-right pleural fistula with right pleural effusion (Figure 2)。 He was diagnosed as esophageal perforation, and was given symptomatic treatment such as anti-shock and anemia correction, and transferred to thoracic surgery for continued treatment. Closed thoracic drainage was administered with approximately 1 000 ml of coffee-colored liquid, continuous thoracic irrigation and intravenous nutrition therapy. Abstain from eating and drinking, place nutrition tube and gastric tube under DSA, and perform enteral nutrition therapy. The metallic foreign body in the patient's stomach disappeared when CT was reexamined at 1 month. After 3 months, the patient's condition was stable, and digestive tract angiography showed: stenosis of the opening of the epiglottis esophagus; Laryngoscopy showed that the tissue of the piriform fossa of epiglottis was normal (Figure 3)。 Colonic replacement esophageal anastomosis was performed, and the left part of the transverse colon with splenic flexure was taken for reverse peristaltic colonic replacement esophageal anastomosis. The colon was lifted from the retrosternal space to the neck, and the left neck incision was made at the epiglottic piriform recess to cut the esophagus and anastomose the colon. I started to try a liquid diet 2 weeks after surgery and recovered well.

The patient was a 23-year-old female. Physical examination at the age of 10 revealed a heart murmur. Physical examination: developmental, mild cyanosis of skin and mucosa; The heart boundary is slightly larger, and a rough systolic jet-like murmur of grade 3/VI can be heard between the costs of 2, 3, and 4 on the left margin of the sternum, with pestle fingers. Echocardiography showed that the right ventricular wall thickness was 7 mm, multiple trabecular bulges were seen in the right ventricular outflow tract, resulting in outflow tract stenosis, with an inner diameter of 14 mm, a maximum flow velocity of 469 cm/s, a pressure difference of 88 mmHg (1 mmHg =0.133 kPa), a ventricular septal defect of 29 mm, a bidirectional septal shunt mainly from left to right, and an aortic riding rate of 46% (Figure 1)。 Chest X-ray showed a cardiothoracic ratio of 0.63, considering complex or compound malformed congenital heart disease. Cardiac CT showed absence of ventricular septum, a small amount of muscular tissue at the edge, single ventricle, and muscular stenosis of right ventricular outflow tract (Figure 2)。 Blood gas analysis: PaCO₂34 mmHg, PaO₂52 mmHg, Oxygen saturation 0.86.

The patient was a 46-year-old male. Sudden chest and back pain 8 h. Acute aortic dissection type A2C was diagnosed preoperatively, and the preoperative high-risk intercostal artery originated from the false lumen. In May 2015, the emergency department underwent Bentall + total arch replacement + elephant trunk stent placement under deep hypothermic circulatory arrest under general anesthesia. The operation was 516 min, cardiopulmonary bypass was 161 min, aortic occlusion was 91 min, deep hypothermic circulatory arrest was 31 min, and the minimum nasopharyngeal temperature was 20℃. On 3 days after operation, the muscle strength of both lower limbs was grade 0, and the command movement of both upper limbs was acceptable. Considered to be caused by delayed spinal cord ischemic injury, paraplegia was confirmed, cerebrospinal fluid drainage was performed, the drainage volume was 10~20 ml/h, and the cerebrospinal fluid pressure was maintained at 13~15 cmH₂O (1 cmH₂O =0.098 kPa). At the same time, anticoagulation, pressurization and microvascular dilatation were given, and the cerebrospinal fluid drainage tube was removed 8 days after operation. Three weeks after surgery, commanding movements were observed in the toes of the left lower limb, with muscle strength grade 1 and muscle strength grade 2 of the right lower limb. He was discharged 5 weeks after surgery. The muscle strength of both lower limbs recovered to grade 2~3 after 2 months of follow-up.

The patient was a 50-year-old male. Admitted for "old myocardial infarction". Two years ago, there was no obvious trigger to develop precardiac discomfort with palpitation. Electrocardiogram performed at the local hospital showed myocardial infarction. Coronary angiography showed: corrected transposition of the great arteries (functional), circumflex artery occlusion. The PCI operation was not successful, and he was transferred to our hospital for treatment. Electrocardiogram showed sinus rhythm, left deviation of ECG axis, extensive anterior myocardial infarction, complete left bundle branch block. X-ray chest examination showed no obvious abnormalities in heart and lung. Echocardiography showed: left atrium connecting right ventricle, right atrium connecting left ventricle, severe mitral regurgitation (Figure 1)。 Coronary angiography showed thick anterior descending artery, occlusion of circumflex artery, and distal development (Figure 2)。 CT examination showed that the left atrium was connected to dissect the right ventricle, the right atrium was connected to dissect the left ventricle, and the aorta was left anterior to the pulmonary artery (Figure 3)。 Admission diagnosis: functional corrected transposition of large arteries, old myocardial infarction, mitral insufficiency.

The patient was a 60-year-old female. Two months ago, there was no obvious trigger for lower limb weakness, accompanied by dizziness and nausea, without vomiting, syncope, chest tightness, shortness of breath, and palpitation. Oral Chinese medicine treatment (specific unknown), the symptoms did not improve. Admission physical examination: A systolic grade II jet murmur could be heard in the pulmonary valve area. The electrocardiogram showed no obvious abnormalities. Ultrasound examination showed atrial septal defect (central type), atrial horizontal left-to-right shunt, hyperechoic mass in the right ventricular outflow tract, and no obvious abnormalities in left ventricular function. Transesophageal echocardiography showed a 20 mm ×16 mm hyperechoic mass in the right ventricular outflow tract, with regular shape and uniform internal echo, attached to the wall (Figure 1)。