2018年 · 第34卷第04期

Rheumatic mitral valve disease is one of the most common heart valve diseases in China^[1,2]However, there is very little discussion of rheumatic mitral valve disease in European and American national valve disease guidelines, and surgery is also supported by older literature mainly based on valve balloon dilation and valve replacement^[3]。 Many Asian countries have achieved great achievements in rheumatic mitral valve surgical treatment technology and research, especially in rheumatic mitral valve repair and early surgical treatment to avoid severe heart failure^[4,5,6]At present, China still lacks expert diagnosis and treatment standards in this field. In view of this, many domestic experts in the field of heart valve disease jointly discussed and in-depth discussed, and finally reached a consensus on the indications for surgical treatment of rheumatic mitral valve disease in China. This consensus only provides indications for surgical treatment of rheumatic mitral valve disease to help clinicians make medical decisions, but in clinical practice, physicians should formulate individualized diagnosis and treatment plans according to the patient's condition. In addition, some of the treatment indications put forward in the consensus are not supported by sufficient evidence-based medical evidence. In the future, the expert group will regularly update and improve the content of the consensus.

Infants with non-restrictive ventricular septal defect often lead to a sharp increase in left-to-right shunt in the heart under the resistance of small pulmonary vessels 2 to 3 months after birth, which is prone to pneumonia and even cardiac insufficiency. At present, many surgeons still continue the concept of curing pneumonia first and then performing surgery in selecting surgical indications. However, for such patients, the effect of simple internal medicine in controlling pneumonia is often unsatisfactory, and even the condition is repeatedly worsened and the opportunity for surgery is lost. If emergency surgery is chosen at this time, the mortality rate and complication rate in the perioperative period are significantly increased. In response to this problem, we have adopted the protocol of preoperative clustered intervention and then surgery since October 2015, and achieved good results, as reported below.

total anomalous pulmonary venous connection (TAPVC) accounts for 1.0% to 1.5% of congenital heart diseases^[1]。 Postoperative pulmonary vein stenosis is one of the serious complications after complete anomalous pulmonary vein drainage, and it is also a very difficult problem in clinical practice. Postoperative pulmonary venous stenosis in children with pulmonary venous stenosis measured by echocardiography increased pulmonary venous flow velocity, pulmonary venous obstruction, pulmonary congestion and edema appeared. Can lead to reoperation or poor prognosis; Children with severe obstruction are prone to recurrent infection at the same time, and even die of pulmonary infection^[2,3]。 Timely and correct assessment of the presence of congestion, edema and secondary infection in the lungs is crucial for the treatment of children with TAPVC. Chest X-ray is the most commonly used way to assess fluid retention in the lungs, but it is not accurate and timely and radioactive. In recent years, studies have shown that lung ultrosonography (LUS), especially ultrasound lung comets (ULCs), can be used as a new diagnostic reference for pulmonary edema and become a more perfect alternative to chest X-ray examination^[4,5]And echocardiography^[6]。 The purpose of this study was to observe the changes of pulmonary ultrasound images in children with TAPVC, and to explore the value of LUS, especially ULCs, in the evaluation of pulmonary congestion in children with TAPVC.

minimally invasive direct coronary artery bypass (MIDCAB) is used to complete coronary artery bypass grafting through a small incision in the chest wall under direct vision under the beating of the heart. It is mostly suitable for single-branch anastomosis between left internal mammary artery (LIMA) and left anterior descending artery (LAD). It has the characteristics of less trauma, fast recovery and beautiful incision. The advantage of high long-term patency in blood supply of descending artery before internal mammary artery reconstruction^[1]。 We have attempted to obtain unilateral or bilateral internal mammary arteries (BIMA) through a small left anterolateral incision since June 2015 for revascularization in patients with multi-vessel lesions, and the early experience is reported below.

With the increase of minimally invasive surgery for esophageal cancer and the application of tubular stomach, there are more and more anastomoses in the neck of esophageal cancer, and anastomotic leakage in the neck occurs from time to time. It has been reported that the incidence of cervical anastomotic leakage is higher than that of intrathoracic anastomosis^[1]。 Most patients with neck anastomotic leakage can be cured after disassembling the neck suture, unobstructed drainage, repeated dressing change, and controlling the infection for about 1 month. A small part of the neck anastomotic fistula does not heal for a long time, forming a sinus tract, which affects the postoperative rehabilitation of patients. From May 2014 to April 2016, 5 patients with cervical anastomotic fistula with sinus formation after esophageal cancer resection were treated in our department. The summary report is as follows.

PatientMale, 54 years old. Two months ago, there was dull pain in the left chest without inducement, and there was a mass in the left chest wall. Chest CT examination showed a soft tissue density shadow of the left chest wall with unclear boundary, about 8.0 cm ×4.5 cm, and local rib destruction (Figure 1), without further treatment. Now the chest wall mass is enlarged and tenderness is obvious. When we went to our hospital for physical examination, we saw a mass on the left posterior axillary line about the 7th intercostal area, about 10.0 cm ×6.5 cm in size, with a smooth surface, no redness, swelling, fever, no fluctuation, slightly hard texture, unable to push, positive tenderness, and no superficial lymph node swelling in the whole body. After admission, the tumor index of carbohydrate antigen 125 (CA125) was 46.92 KU/L. Chest enhanced CT showed that the tumor was enlarged compared with the previous, about 9.8 cm ×6.0 cm. After enhancement, it was unevenly enhanced, and local ribs showed entomophageous destruction. No abnormal enlarged lymph nodes were found in the mediastinum (Figure 2)。 Bone scan showed a concentrated focus in the left 6th-8th ribs, which was considered to be a malignant tumor.

PatientFemale, 36 years old. The tumor and pain in the anterior chest wall (near the sternal angle) lasted for 2 months. There was no obvious improvement after oral antibiotics, and the tumor showed an increasing trend. CT examination of the chest revealed a mass before the sternal angle and bone destruction. Physical examination: The tumor is located in front of the sternum, about 5 cm ×5 cm ×4 cm in size, hard in texture, immobile, with clear surrounding boundaries, no obvious inflammatory changes around the skin, and there is a softening area of about 1 cm ×1 cm at the top of the tumor. The preoperative HIV, tuberculin test, blood tuberculosis DNA, CEA, CA199 and other related tests were all negative. Whole body PET/CT examination showed obvious radioconcentration and bone destruction (SUV max: 17.1), and no obvious distant metastasis. The patient had no previous history of trauma and no recent history of close contact with birds.

Example 1Female 46 years old. During physical examination, nodules in the posterior segment of the upper lobe of the right lung were found for 2 weeks. PET-CT showed that the size of the nodule was 2.5 cm ×2.0 cm ×2.0 cm, and the maximum standard uptake value (SUVmax) was 5.60, which was considered as right upper lobe cancer. In September 2013, the nodule in the posterior segment of the upper lobe of the right lung was resected by thoracoscopy under general anesthesia. The frozen pathological result was adenocarcinoma. Thoracoscopic upper lobe resection of the right lung and dissection of mediastinum, hilar and interlobar lymph nodes were performed. The oblique fissure between the lower lobe and the middle lobe was well developed during operation (Figure 1)。 The patient started to have fever (38.0℃ ~38.9℃), dyspnea, hemoptysis (black and red, 24 h volume about 160 ml) on the second day after surgery, and white blood cells 15.60×10⁹/L, arterial blood gas is normal. On the 4th postoperative day, chest CT showed large atelectasis and consolidation in the upper part of the right chest cavity (Figure 2)； Bronchoscopy examined bronchial stenosis in the middle lobe of the right lung, showing "fish's mouth sign", and bronchoscopy could not enter (Figure 3), the middle segment and lower lobe bronchi of the right lung were normal, and torsion of the middle lobe was diagnosed. On the fifth day after operation, thoracoscopic exploration of the original incision under general anesthesia revealed that the middle lobe of the lung was obviously swollen, blue-purple, transposed counterclockwise from the root about 180 °, and the middle lobe veins and bronchi were severely torsed, showing a completely "closed" state. The middle lobe vein was clipped and the right middle lobe resection was performed. Pathological report: Severe congestion, edema and venous thrombosis in the middle lobe of the right lung. The patient recovered well after surgery and was cured and discharged on the 9th day after the second operation. After 3 years of follow-up, there was no abnormality in the chest CT findings.

PatientMale, 63 years old. Admission for cardiac cancer. After completing the relevant examinations, subtotal gastrectomy through proximal left thorax + gastroesophageal subaortic anastomosis was performed, and the operation was smooth. The patient started to eat on the 7th day after operation. After eating, the patient had no complaints of discomfort, fever, abdominal pain, abdominal distension and other discomfort. On the 12th postoperative day, the patient had abdominal distension, abdominal pain and other discomfort, no nausea or vomiting, and the body temperature was 38.3℃, but there was still exhaust and defecation, and the abdominal distension was relieved after defecation. On the 13th day after operation, digestive tract angiography and CT examination of thorax and abdomen showed that the anastomosis healed well, and no contrast spillage was observed; Flatulence of jejunum and colon, concentric circle structure can be seen in the ascending colon, consider the possibility of intussusception; Colonoscopy showed multiple erosion of the colonic mucosa, red in color, and no obvious intussusception. After dredging, feces poured into the colon from the ileum, and 700~800 ml of watery light yellow loose stools were aspirated. No abnormalities were found in the ileum. The patient's abdominal bloating symptoms were relieved. In the evening, obvious symptoms of abdominal distension appeared again, together with chest tightness, shortness of breath, and decreased blood oxygen saturation. On the 14th postoperative day, abdominal distension was significantly aggravated, blood pressure dropped, and pale red bloody ascites was punctured in the right lower abdomen. Considering the possibility of intestinal necrosis or intestinal volvulus, emergency exploratory laparotomy was performed. A large amount of pale bloody ascites was seen, and about 3 000 ml was aspirated. The transverse colon was severely dilated, and the color from the ileocecal region to the transverse colon was dark purple. No intestinal peristalsis was seen, and the formation of mesenteric embolus was seen. Considering that mesenteric thrombosis led to colon necrosis, ascending and transverse colonectomy + ileoabdominal wall fistula was performed. Postoperatively, blood pressure decreased, anuria, multifunctional organ failure and death continued.