先天性心脏病合并重度肺动脉高压的外科治疗(1)
【摘要】 目的 探讨先天性心脏病合并重度肺动脉高压的外科治疗经验。方法 34例患者均在体外循环下手术治疗,均采用胸部正中切口。房间隔缺损(直径>1.5 cm)、室间隔缺损(直径>1. 0 cm)均采用涤纶片修补;动脉导管未闭在并行循环下切开肺动脉,于导管置入Foley氏尿管注水暂时堵住血流,采用涤纶片修补或双头针褥式缝合。术前给予吸氧、高压氧及前列腺素E1等治疗,术中应用抑肤酶及低温肺保护液肺动脉灌注等手段。结果 32例手术顺利,术后肺动脉压下降3.2~5.5kPa。2例术后早期死于不可复性心功能衰竭。死亡率5.9%。结论 正确掌握手术适应证,术中减少心肌及肺血管损伤,充分的围术期处理是手术成功的关键。
【关键词】 先天性心脏病;肺动脉高压;外科,手术
Surgical treatment of congenital heart disease combined with pulmonary hypertention
ZHAO Guo-chang, BAI Yu, CHEN Zhi-jun, et al.The Department of Heart and Chest Surgery, The First AffiliatedHospital of Xinxiang Medical College,Hennan 453100, China
【Abstract】 Objective To explore the surgical treatment of congenital heart disease combined with severe pulmonary hypertension.Methods 34 patients received surgical repairs under cardiopulmonary bypass (CPB). Mid-sternal thoracotomy was performed in all cases. Atrial septal defect(ASD),more than a diameter of 1.5 cm) and ventricular septal defect(VSD, more than a diameter of 1.0 cm) were repaired with dacron patch.With the arterial duct being patent and through the pulmonrary incision under parallel CBP,the blood flow was temporarily blocked by a Foley’s urinary catheter with water-infused balloon and the Dacron patch repair or mattress suture with double ended needle was made in operation.All patients were treated pre-operatively with oxygen inhalation therapy, hyperbaric oxygenation, prostaglandin E1 respectively according to the degree of pulmonary hypertension. During cardiopulmonary bypass, pulmonary artery perfusion was performed with protective solution containing aprotinin for lung protection.Vasoactive drugs were routinely administrated postoperatively. Results 32 cases underwent the surgical treatment successfully with their postoperative pulmonary artery pressure decreased by 3.2~5.5kPa and 2 cases died of heart failure. The mortality was 5.9%.Conclusion The key to this kind of surgical treatment is to define the surgical indications correctly,to reduce the intraoperative myocardial and pulmonary vascular injuries and to take good measures in perioperative treatment.
【Key words】 Congenital heart disease;Pulmonary hypertention;Surgical treatment
作者单位:453100新乡医学院第一附属医院胸外科(赵国昌 陈志军 王永连 王忠民);新乡医学院病理科(白玉)
肺动脉高压是先天性心脏病外科手术治疗中较难处理的问题之一。,尤其是重度肺动脉高压(肺动脉平均压>50 mm Hg)是影响外科治疗效果和预后的重要因素。自2006年4月至2009年11月,笔者在体外循环下手术治疗先天性心脏病合并重度肺动脉高压34例,效果满意,现总结如下。
1 临床资料
34例患者中男19例,女15例,年龄1.1~29.0岁,病种包括室间隔损(VSD)15例,房间隔缺损(ASD)9例,动脉导管未闭(PDA)3例,VSD+ASD 4例,PDA+VSD 3例。均有不同程度的活动后心慌、气短,5例于静息状态下口唇发绀,18例有活动后发绀,心功能(NYHA)Ⅱ级20例、Ⅲ级9例、Ⅳ级5例。心电图双室肥厚23例,完全性右束支传导阻滞4例。X线胸片示肺纹理均有不同程度增多,心胸比率为0.61~0.73,平均0.64±0.04。右心导管检查肺动脉收缩压(Pp)65.2~83.7 mm Hg(1 mm Hg=0.133 kPa),肺动脉平均压(mPAP)40.2~77.4 mm Hg, 彩色多普勒超声心动图示缺损部位均为左向右为主的双向分流。
2 手术方法及围手术期处理
术前均给予吸氧,口服卡托普利,静脉滴注前列腺素E1,8~15 μg/d,7~10 d,口服强心、利尿药,心功能较差者给予静脉推注西地兰、速尿,必要时使用多巴胺(5~10 μg/kg•min)+硝酸甘油 (按3∶1),常规使用心脏极化液。34例患者均在体外循环下行手术矫治,8例采取了心脏不停跳下修补术;12例行常规心脏畸形矫治手术,采用间断缝合或涤纶补片修补(房间隔缺损直径>1.5 cm、室间隔缺损直径>1. 0 cm);15例室间隔水平双向分流平衡的患者进行了单向活瓣VSD修补术;PDA在体外循环直视下开肺动脉缝合, 2例室间隔缺损及3例动脉导管未闭畸形矫治后将卵圆孔打开,造成ASD以减轻右心室前负荷。手术完成心脏复跳后,即持续使用硝普钠1~2 μg/kg•min,多巴胺5~10 μg/kg•min,酚妥拉明1~2 μg/kg•min,米力农0.75~1.0 μg/kg•min。呼吸机辅助呼吸24 h以上,在此期间保持动脉血二氧化碳分压(PaCO2)28~35 mm Hg,pH维持7.40~7.55,呼吸道充分湿化。, 百拇医药(赵国昌 白 玉 陈志军 王永连 王忠民)
【关键词】 先天性心脏病;肺动脉高压;外科,手术
Surgical treatment of congenital heart disease combined with pulmonary hypertention
ZHAO Guo-chang, BAI Yu, CHEN Zhi-jun, et al.The Department of Heart and Chest Surgery, The First AffiliatedHospital of Xinxiang Medical College,Hennan 453100, China
【Abstract】 Objective To explore the surgical treatment of congenital heart disease combined with severe pulmonary hypertension.Methods 34 patients received surgical repairs under cardiopulmonary bypass (CPB). Mid-sternal thoracotomy was performed in all cases. Atrial septal defect(ASD),more than a diameter of 1.5 cm) and ventricular septal defect(VSD, more than a diameter of 1.0 cm) were repaired with dacron patch.With the arterial duct being patent and through the pulmonrary incision under parallel CBP,the blood flow was temporarily blocked by a Foley’s urinary catheter with water-infused balloon and the Dacron patch repair or mattress suture with double ended needle was made in operation.All patients were treated pre-operatively with oxygen inhalation therapy, hyperbaric oxygenation, prostaglandin E1 respectively according to the degree of pulmonary hypertension. During cardiopulmonary bypass, pulmonary artery perfusion was performed with protective solution containing aprotinin for lung protection.Vasoactive drugs were routinely administrated postoperatively. Results 32 cases underwent the surgical treatment successfully with their postoperative pulmonary artery pressure decreased by 3.2~5.5kPa and 2 cases died of heart failure. The mortality was 5.9%.Conclusion The key to this kind of surgical treatment is to define the surgical indications correctly,to reduce the intraoperative myocardial and pulmonary vascular injuries and to take good measures in perioperative treatment.
【Key words】 Congenital heart disease;Pulmonary hypertention;Surgical treatment
作者单位:453100新乡医学院第一附属医院胸外科(赵国昌 陈志军 王永连 王忠民);新乡医学院病理科(白玉)
肺动脉高压是先天性心脏病外科手术治疗中较难处理的问题之一。,尤其是重度肺动脉高压(肺动脉平均压>50 mm Hg)是影响外科治疗效果和预后的重要因素。自2006年4月至2009年11月,笔者在体外循环下手术治疗先天性心脏病合并重度肺动脉高压34例,效果满意,现总结如下。
1 临床资料
34例患者中男19例,女15例,年龄1.1~29.0岁,病种包括室间隔损(VSD)15例,房间隔缺损(ASD)9例,动脉导管未闭(PDA)3例,VSD+ASD 4例,PDA+VSD 3例。均有不同程度的活动后心慌、气短,5例于静息状态下口唇发绀,18例有活动后发绀,心功能(NYHA)Ⅱ级20例、Ⅲ级9例、Ⅳ级5例。心电图双室肥厚23例,完全性右束支传导阻滞4例。X线胸片示肺纹理均有不同程度增多,心胸比率为0.61~0.73,平均0.64±0.04。右心导管检查肺动脉收缩压(Pp)65.2~83.7 mm Hg(1 mm Hg=0.133 kPa),肺动脉平均压(mPAP)40.2~77.4 mm Hg, 彩色多普勒超声心动图示缺损部位均为左向右为主的双向分流。
2 手术方法及围手术期处理
术前均给予吸氧,口服卡托普利,静脉滴注前列腺素E1,8~15 μg/d,7~10 d,口服强心、利尿药,心功能较差者给予静脉推注西地兰、速尿,必要时使用多巴胺(5~10 μg/kg•min)+硝酸甘油 (按3∶1),常规使用心脏极化液。34例患者均在体外循环下行手术矫治,8例采取了心脏不停跳下修补术;12例行常规心脏畸形矫治手术,采用间断缝合或涤纶补片修补(房间隔缺损直径>1.5 cm、室间隔缺损直径>1. 0 cm);15例室间隔水平双向分流平衡的患者进行了单向活瓣VSD修补术;PDA在体外循环直视下开肺动脉缝合, 2例室间隔缺损及3例动脉导管未闭畸形矫治后将卵圆孔打开,造成ASD以减轻右心室前负荷。手术完成心脏复跳后,即持续使用硝普钠1~2 μg/kg•min,多巴胺5~10 μg/kg•min,酚妥拉明1~2 μg/kg•min,米力农0.75~1.0 μg/kg•min。呼吸机辅助呼吸24 h以上,在此期间保持动脉血二氧化碳分压(PaCO2)28~35 mm Hg,pH维持7.40~7.55,呼吸道充分湿化。, 百拇医药(赵国昌 白 玉 陈志军 王永连 王忠民)