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1、心脏外科现况和进展 广东省中医院心脏中心 阮新民,心脏外科的现况,中国: 冠脉搭桥 5000 0-60% 瓣膜外科 10000 20-30% 先天心 20000 60-65% 其它 1000,The Future of Cardiac Intervention (National Health Council),Stent and intravascular intervention expected to double over next 3 years CABG volume to decline about 10% with cardiac surgery primarily expan
2、ding in EPS and CHF such as ablative surgery, biventricular pacing, LV remodeling, and cardiac muscle augmentation. Valvular volume to increase about 20% by 2005,Vascular Intervention PTCA PDA ASD VSA AA AAA,Cardiac Surgery Need Refinement. WHY?,Challenges of aging population. Recurrent diseases. In
3、creasing competent edge of PTCA/STENTS. Cost of surgery. Morbidity associated ,Most of The Morbidity is Associated With what?,CPBAortic Manipulation. Midline sternotomy. Hypothermia. Heart Arrest .,WHAT DO YOU THINK IS THE FUTURE OF CARDIAC SURGER?,Minimal invasive,MIDCAB OPCAB PA(PORT-EXCESS) ENDO-
4、CABG,Minimal invasive CABG,OPCAB The New Standard of Care!,Video-assistant Thoracoscopy Surgery,PDA Pericardial CABG AF,Endoscopic IMA Mobilization,HEARTSTRINGTM Proximal Seal System,OPCAB,Due Diligence,A process of evaluation of two robotic systems,Fly by Wire Technology,HEART VALVE SURGERY,ATS Mec
5、hanical,Evolution-Improvements Over Time,Hancock II Design Overview,Flexible, reduced-profile Supra-annular stent T6 surfactant treatment Minimized porcine muscle shelf,Implantability,Assembled from 3 noncoronary aortic leaflets taken from 3 porcine valves,No Dacron or artificial annular support,Sup
6、ra - annular implantation,Cryo Life - OBrien,Personal Predictions 2004,Biological Ross autograft Allograft Xenograft - “Perimount” pericardial - Stentless valve Mechanical valve Swing back to some popularity Change in model usage,Conclusions,Mechanical valves may become a more common choice Easy tec
7、hnical implantation A/C complications accepted as inevitable Some recent studies reducing A/C levels ? future new anticoagulant medication regime Xenografts for the elderly Both autografts and allografts may be superior but availability, technical implantation and reoperation are major problems Tiss
8、ue engineered valves still to be fully developed and evaluated,Chronic Atrial Fibrillation,Affects 2 million people in the US alone with a 9% 5 year morbidity from anticoagulation and a 5% / year risk of stroke As high as an 80 % risk of stroke at 8 years Available treatment modalities include surgi
9、cal “Maze”, cryotherapy, radio frequency, irrigating radio frequency, microwave, and laser Surgical Maze success best overall but Microwave has the least complications and the best ease of use,Maze III Procedure,Right Side Maze Lesions,Maze III Procedure,Left Side Maze Lesions,术中消融能源种类,射频消融(Radiofre
10、quency) 灌流射频消融(Irrigated RF) 无灌流射频消融(Non-irrigated RF) 冷冻消融(Cryothermal) 微波消融(Microwave) 超声波(Ultrasound) 激光(Laser),左心房心内膜消融路线,10- 15 patients per subgroup Microwave = 91% (11/12 NSR) Radiofrequency = 65% Cryoablation = 55% 7 to 12 month follow-up,Presented at EACTS - 2001,Dr. Graffigna - Trento, Ita
11、ly (Arrested Heart),Microwave Ablation: 3000 patients,Open Heart 2300 patients 75% success - 0 to 4 year follow up,Beating Heart Off-Pump 700 patients 80% success - 0 to 2 year follow up,No adverse events,MIS Off-Pump Mini Thoracotomy 3 cases Robotic 2 cases Thoracoscopy 2 cases,Aortic Surgery,Valve
12、 condiut replacement,AORTIC ARCH REPLACEMENT,Aortic stenting,Acute Heart failure,IAB Inflation,Extra corporeal membrane oxygenation (ECMO),Application of ECMO,Post-cardiotomy shock CPR AMI with shock Acute myocarditis: VAD vs ECMO ARDS, sepsis Lung transplantation Pulmonary embolectomy,ECMO success
13、need :,1. underlying problem soon reversible 2. no severe 2nd organ damage 3. no complication from ECMO use,Indication and Timing of ECMO for Cardiac Support,Inotropic score 60 ug/kg/min and persistent low output (urine 50 ug/kg/min and with IABP support and persistent low output (urine 0.5 ml/kg/hr
14、) Repeated epinephrine bolus to keep BP Under CPR,Chronic heart failure,Asincrinized therapy: double ventricle pacing Mycardial cells transplant Gene therapy:Bio-CABG EDGF,VEGF,FGF Volume reduction,ACORN JACKET,.,动力性心肌成形术,8,8,Ventricle assistant device(VAD),End-stage heart failure EF90 days Peak exercise O212ml/kg/min,人工心脏安置术,8,b,8,8,8,
