2018年 · 第34卷第09期

In recent years, patients' requirements for quality of life have gradually increased, and biological mitral valve is widely used. However, the long-term failure of biological valve leads to the need for secondary replacement^[1]。 For patients who have a history of coronary artery surgery and need secondary mitral valve surgery, how to reduce the risk of re-operation is an important guarantee to improve the success rate of re-heart surgery^[2,3]。 Combined with the traditional right lower small incision approach, our department successfully performed mitral valve replacement without occlusion of ascending aorta under cardiopulmonary bypass in 3 patients with secondary coronary artery surgery. The clinical results are satisfactory, which are reported below.

Empyema after pulmonary resection is still a very serious complication after pulmonary surgery, and its incidence is 2% ~16%^[1]The course of the disease is often prolonged and leads to chronic refractory empyema. Clinically, the difficult factors in the treatment of chronic refractory empyema are mainly the persistence of abscess cavity, abscess cavity infection and bronchopleural fistula (BPF). Pleural fistulas can sometimes be cured by changing dressings, but bronchial fistulas are particularly difficult, and these bronchial fistulas cannot be cured by long-term conservative treatment. In response to these problems, we made a special occluder and successfully cured 5 cases of BPF, including 1 case of refractory empyema with a large fistula of 1.2 cm, which is reported below.

Female, 62 years old. In August 2012, he went to a hospital in northern Guangdong due to progressive dysphagia and was diagnosed with middle thoracic esophageal cancer. In February 2013, he underwent resection of left thoracic esophageal cancer, tubular gastroesophageal supraaortic arch anastomosis, and adjuvant radiotherapy and chemotherapy after operation. In March 2015, I went to a hospital in Dongguan due to right upper abdominal pain and fever. CT scan of the chest and abdomen showed a large amount of pericardial effusion, a small amount of bilateral pleural effusion and incomplete distension of the lower lobes of both lungs. Echocardiography showed a large amount of pericardial effusion. Then, in March 2015, pericardial effusion puncture and catheterization were performed, and yellow purulent liquid could be extracted. Later, due to poor drainage of the drainage tube, emergency median thoracotomy was performed on the same day. During the operation, the pericardium was full, and a large amount of light yellow thin turbid pus flowed out after incision. Part of the pericardium adhered and formed a separation, and more yellow cellulose-like substances adhered to the heart surface. Part of the pericardium was removed and a pericardial drainage tube was placed. Dark gray liquid was drained after operation, 500~1,000ml/day. The patient's postoperative drainage volume continued unreduced, and the presence of tubular gastropericardial fistula was confirmed after oral administration of a small amount of methylene blue diluted solution on the 8th day after operation. Electronic gastroscopy considered anastomotic fistula after esophageal cancer operation and placed a nasogastric small intestinal nutrition tube. The patient's condition aggravated and severe septic shock occurred, and he was transferred to our hospital for further treatment. Post-admission CT (Figure 1), upper gastrointestinal tract angiography (Figure 2) shows a tubular gastric (small curved side) -pericardial fistula. Symptomatic and supportive treatment such as anti-shock and anti-infection were immediately given, but the patient's condition did not improve significantly.

Male, age 4 days, body weight 3 kg. Physical examination: cyanosis of lips and extremities, percutaneous oxygen saturation of 0.75, auscultation heart rate of about 165 beats/min, uniform rhythm, and grade II/6 systolic blowing-like murmur can be heard between the costs of 2~3 on the left margin of the sternum, which is soft in nature. The liver is 3 cm below the right rib, in the middle of the mass, and the spleen is untouched. Echocardiography showed an abnormal band in the right atrium (Figure 1), the diastolic band causes right ventricular outflow tract obstruction (Figure 2)。 The diagnosis was tricuspid valve obstruction caused by Chiari mesh, atrial septal defect in foramen II (4 mm), small development of right ventricle, and pulmonary artery stenosis (external diameter of left and right pulmonary arteries were 3 mm).

Male, 1 month old. Cardiac murmur was found for 1 week and cough for 2 days. Echocardiography showed ventricular septal defect (perimembranous part), atrial septal defect (secondary foramen), and pulmonary hypertension (mild). Laboratory tests showed no obvious abnormalities. On physical examination, a grade 3/6 systolic blow-like murmur was heard in the precordial area, and P2 was hyperactive. After admission, anti-infection, cardiotonic, diuretic, tube expansion and other treatments were given.