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婴儿复杂先天性心脏病的外科治疗

时间:2017-09-15 20:00:10 来源: 代写硕士论文

            作者:乔彬,王同建,张锋泉,宁岩松,吴莉莉,朱萌

【摘要】  目的总结婴儿复杂先天性心脏病一期根治手术的效果。方法2001年 1月至 2005年 6月,手术治疗婴儿复杂先天性心脏病204例,男136例,女68例。年龄23h~12m(5.3±3.8)m。新生儿58例,1~3m 54例,3~6m 45例;体重1.5~13.5(6.2±2.2)kg,小于3 kg 10例,3.1~4 kg 23例,4.1~5 kg 32例,5.1~10 kg 134例,大于10 kg 5例。其中:法洛四联症(TOF)107例,合并肺动脉闭锁(PA)15例;大动脉转位(TGA)38例;完全性房室隔缺损(TECD)21例;主动脉弓中断(IAA)16例;完全性肺静脉异位连接(TAPVC)12例;永存动脉干(PTA)10例。全组均一期根治,急诊手术67例,择期手术137例。手术均在体外循环下完成,中度低温(26℃~28℃)110例,深低温(16℃~18℃)停循环67例,深低温低流量[50ml/(kg?min)]27例。结果本组早期(术后30 d)死亡15例(7.3%)。死亡原因:1例TGA主动脉吻合口出血, 另1例右冠状动脉损伤,余均为严重低心排和/或肾功能衰竭。术后主要并发症:低心排和/或肾功能不全、低钙血症、低氧血症、肺不张、感染。189例存活者随访 2~72个月:死亡1例,为心内型TAPVC患儿,术后1年因呼吸道感染在其他医院治疗过程中死亡,死因不详;右心功能不全1例,为Ⅰ型PTA患儿,出院后6m出现肝大、腹水,对症治疗一周后症状明显改善;余患儿心功能Ⅰ级168例、Ⅱ级19例。结论婴儿复杂先天性心脏病特别是呼吸循环不稳定和/或重度低氧血症者,一经确诊应及时手术。术前不利因素的积极纠治和精心的手术设计,为手术成功提供了有力保障。

【关键词】  心脏缺损;先天性心脏病;婴儿;外科手术

  Surgical Therapy for Complicated Congenital Heart Disease in Infants

  Abstract: OBJECTIVE To assess the effect of surgical treatment of complex congenital heart disease of infants.  METHODSTwo hundreds and four infants(male 136,female 68) who had complex congenital heart disease were admitted and operated in our hospital from January 2001 to June 2006. Their ages ranged between 23 hours and 12 (mean 5.3±3.8) months. Their body weight ranged between 1.5 and 13.5 (mean 6.2±2.2)kg. The preoperative diagnosis included:  tetralogy of Fallot(TOF) (107 cases), complete transposition of the great arteries(TGA) (38), total endocardial cushion defect (TECD)(21),interrupted aortic arch(16), total anomalous pulmonary venous connection (TAPVC)(12),and persistent truncus arteriosus(PTA)(10). All patients were operated one-stage, including 67 emergency operations and 137 selective operations. 110 operations under moderate hypothermia(temperature ranged from 26℃ to 28℃), 27 operations under deep hypothermia(temperature ranged from 16℃ to 18℃) and low flow (50ml/(kg?min)), and 67 operations under deep hypothermia circulation arrest. RESULTS15 death(7.3%) occurred in earlier postoperative period(within 30 days). Causes of death included: reconstructive aortic stoma bleeding within 12 hours after operation (1case), right coronary artery damnificated (1), and severe low cardiac output syndrome and/or renal failure (13). The main postoperative complications were low cardiac output, renal failure, hypoxemia, hypoglycemia, hypocalcemia, atelectasis and infection. In the follow-up of 189 survivors duration ranged from 2 to 72 months, 1 patient with intracardiac TAPVC died after one year,1 patient with PTA of type Ⅰ had right heart failure 6 months later. Other survivors had no long-term death and complication occurred, their heart function were grade Ⅰ (166 patients) and grade Ⅱ  (19). CONCLUSIONInfants who had complicated congenital heart disease, especially with severe heart failure and/or hypoxemia, should be operated when diagnosed definitively. Exact operation design and efficient preoperative management can ensure operative succeed. 

  Key words:Heart defects;Congenital heart desease; Infant; Surgical procedures

  2001年 1月至 2006年 6月,济南军区心血管病医院一期手术根治婴儿复杂先天性心脏病204例。在近几年的临床工作中,总结出了一些经验,现报告如下。

  1资料与方法 

  1.1临床资料

  本组男 136 例,女 68 例。年龄23h~12 m(5.3±3.8)m,新生儿58例,1~3 m  54例,3~6m 45例,6~12 m 47例;体重1.5~13.5(6.2±2.2)kg,小于3 kg 10例,3.1~4 kg 23例,4.1~5 kg 32例,5.1~10 kg 134例,大于10kg 5例。术前静息紫绀91例,哭闹时紫绀32例,有缺氧发作史28例,反复呼吸道感染35例,术前行紧急气管导管25例。

  1.1.1病理解剖法

  洛四联症(TOF)107例,包括Ⅰ型肺动脉闭锁(PA )12例,Ⅱ型PA 3例,左肺动脉缺如1例;大动脉转位(TGA) 38例,新生儿23例;完全性房室隔缺损(TECD)21例,其中合并TOF 1例;主动脉弓中断(IAA)16例;完全性肺静脉异位连接(TAPVC) 12例;永存动脉干(PTA)10例。具体分型和患者情况见表1。表1各病种分型及例数(略)

  1.1.2合并畸形右位主动脉弓19例、卵圆孔未闭95例、房间隔缺损39例、左上腔静脉13例、动脉导管未闭59例、三尖瓣关闭不全29例。术前均经心电图、X线胸片、二维或三维超声心动图、心导管检查确诊。

  2.1手术方法

  急诊手术67例,择期手术137例。采用经鼻插入气管导管、静脉复合麻醉,胸部正中切口。根据不同的手术要求选择体外循环(extracorporeal circulation,ECC)方式:中度低温(26℃~28℃)ECC 110例;深低温(16℃~18℃)停循环67例;深低温低流量[50ml/(kg?min)]27例。

  2.1.1TOF手术单纯修复2例,肺动脉瓣下加宽3例,跨瓣环至左、右肺动脉开口处77例(77.4%),加宽左、右肺动脉至肺门25例,2005年以来有30例患儿采用0.1 mm  Gore-tex补片缝制单瓣,重建右室流出道。

  2.1.2TGA手术行大动脉调转术,建立ECC后分离结扎并切断动脉导管,充分游离主动脉和肺动脉,阻断主动脉后,先行左、右冠状动脉移植,然后吻合主动脉,开放后吻合肺动脉,合并室间隔缺损经右房修补。
 
  2.1.3TECD 手术单片法修补,首先确认前后桥瓣在左右房室瓣的交界标志,采用自体心包片在室间隔缺损下缘右室面用5-0 Prolene连续缝合,室间隔嵴后二分之一浅缝。用6-0 Prolene间断褥式将共同瓣左侧部分和右侧部分与心包补片呈“三明治”式缝合。修复房间隔缺损靠近近冠状窦区域,沿前缘缝合,以免损伤传导束。

  2.1.4IAA手术经升主动脉及主肺动脉插入“Y”形动脉灌注管,阻断左、右肺动脉后建立ECC并降温,停循环同时阻断头臂干及降主动脉,将动脉导管组织切除,近心端缝闭,远心端与主动脉弓行端侧吻合,如近心端狭窄用自体心包片加宽,吻合均用7-0 PDS缝线。

  2.1.5TAPVC手术心内型者充分扩大冠状静脉窦开口,切除部分房间隔,自体心包片连续缝合覆盖房间隔缺损及冠状静脉窦开口;心上及心下型将心脏上翻,充分游离肺静脉及其总干,经心后途径与左房后壁吻合,吻合口应尽量大。

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