主动脉弓缩窄球囊扩张联合体外循环下室间隔缺损修补术治疗小儿主动脉缩窄合并室间隔缺损的临床效果分析

目的分析主动脉弓缩窄球囊扩张联合体外循环下室间隔缺损修补术治疗小儿主动脉缩窄合并室间隔缺损的临床效果。方法选取本院2016年2月至2018年10月收治的60例主动脉缩窄合并室间隔缺损患儿作为研究对象,按照手术方式的不同分为A组(40例,采用主动脉弓缩窄球囊扩张术)、B组(11例,采用体外循环下室间隔缺损修补术)、C组(9例,采用主动脉弓缩窄球囊扩张联合体外循环下室间隔缺损修补术)。比较三组患者临床效果。结果 C组患儿的主动脉阻断时间、体外循环时间、DHCA应用、延迟关胸例数及术后机械通气时间、ICU滞留时间明显低于A、B两组,差异具有统计学意义(P0.05);C组患儿围术期并发症发生率明显低于A组和B组,差异具有统计学意义(P0.05)。结论主动脉弓缩窄球囊扩张联合体外循环下室间隔缺损修补术治疗主动脉缩窄合并室间隔缺损患儿疗效好,可有效缩小患儿术后恢复时间并降低并发症发生率。     

浅低温脑灌注在体外循环下小儿室间隔缺损修补术中的应用

目的探讨浅低温脑灌注在体外循环下小儿室间隔缺损修补术中的应用效果。方法回顾性分析2017年2月至2018年7月我院收治的81例行体外循环下小儿室间隔缺损修补术患儿的临床资料,将术中采用浅低温脑灌注治疗的43例患儿设为浅低温组,术中采用中低温下脑灌注治疗的38例患儿设为中低温组。对比2组患儿术中最低鼻咽温度,术中最低直肠温度,术中体外循环时间,术中主动脉阻断时间,术后呼吸支持时间,术后心包和纵隔引流量,麻醉前(T0)、麻醉后10 min(T1)、手术开始后20 min(T2)、手术结束时(T3)血压(BP)及心率(HR)水平变化,术中室颤,术后低血压,术后心律失常及术后短暂性神经功能障碍发生率。结果浅低温组术中最低鼻咽温度、术中最低直肠温度均高于中低温组,差异有统计学意义(P<0.05),2组术中体外循环时间、术中主动脉阻断时间、术后呼吸支持时间、术后心包和纵隔引流量比较差异无统计学意义(P>0.05);各时刻2组间收缩压(SBP)、舒张压(DBP)、HR组间比较差异无统计学意义(P>0.05),且2组SBP、DBP和HR水平均先下降后升高,其中T1、T2、T3时刻BP和HR水平均明显低于T0时刻(P<0.05),T2时刻BP和HR水平均明显低于T1时刻(P<0.05),T3时刻BP和HR水平均明显高于T2时刻,差异均有统计学意义(P<0.05);浅低温组术后心律失常发生率与中低温组均相近,差异无统计学意义(P>0.05),浅低温组术中室颤、术后低血压、术后短暂性神经功能障碍发生率均显著低于中低温组,差异有统计学意义(P<0.05)。结论在体外循环下小儿室间隔缺损修补术中,应用浅低温脑灌注治疗可减少术中室颤、术后低血压及术后短暂性神经功能障碍。     

右进胸垂直小切口在体质量15 kg以下患儿室间隔缺损修补术中的应用

目的 探讨右进胸垂直小切口(VRAMT)入路应用于体质量15 kg以下患儿室间隔缺损(VSD)修补术的临床疗效。方法 回顾性研究。纳入2017年1月-2019年11月在中国科学技术大学附属第一医院84例经心脏彩超确诊为VSD并且体质量小于15 kg患儿的临床资料,其中男41例、女43例,月龄3~34(15.17±7.26)个月,体质量5~15 (9.64±2.54) kg。84例患儿均行VSD修补术。按手术入路不同分为两组:VRAMT组38例,采用右进胸垂直小切口入路;MS组46例,采用正中切口入路。记录并比较两组患儿主动脉阻断时间、体外循环时间、重症监护病房(ICU)时间、机械辅助通气时间、住院时间、残余分流发生率、Ⅲ度房室传导阻滞发生率、术后出血二次手术发生率、术后6个月心功能分级。结果 两组患儿的年龄、性别、体质量、缺损类型、缺损直径、跨缺损压差、左心室射血分数等基线资料比较,差异均无统计学意义(P值均>0.05)。患儿均手术顺利,未发生Ⅲ度房室传导阻滞及二次手术,术后均获随访6个月。两组患儿体外循环时间、手术时间、术后机械辅助通气时间、主动脉阻断时间、术后残余分流发生率以及术后6个月心功能分级比较,差异均无统计学意义(P值均>0.05);但VRAMT组患儿ICU时间和住院时间[(24.23±5.48)h和(15.37±3.91)d]均较MS组短[(39.23±9.86)h和(17.41±4.55)d],差异均有统计学意义(P值均<0.05)。结论 VRAMT入路用于体质量在15 kg以下儿童VSD修补术相较于正中切口入路,更有助于减少ICU时间和住院时间,利于患儿快速恢复,在先天性心脏病外科中有一定的推广价值。     

小儿室间隔缺损术后并发完全性房室传导阻滞8例治疗

目的 探讨小儿室间隔缺损术后出现完全性房室传导阻滞(CAVB)的治疗及预后。方法 回顾性分析2005年1月—2014年12月南京儿童医院心脏内科收治的8例室间隔缺损术后出现CAVB患儿的临床资料。结果 8例CAVB患儿中内科介入封堵术后2例,外科修补术后6例。内科封堵2例患儿于术后第3～5天出现心功能不全症状,1例给予地塞米松和白蛋白等药物治疗1周后心电图恢复正常,1例术后第3天转外科取出封堵器半月后恢复正常,分别随访4年和7年,心功能和心电图正常。外科修补6例患儿均为迟发性CAVB,3例存在心功能不全(其中2例出现频繁阿-斯综合征发作),3例心功能正常;2例接受永久起搏器治疗,起搏模式为右室心尖部心内膜单腔永久性起搏,随访3～5年,左室射血分数>50%,左室舒张末期内径下降至正常范围;拒绝接受起搏器4例患儿给予甲基泼尼松龙琥珀酸钠治疗无效,存在心功能不全的1例患儿术后4个月死亡,3例定期临床随访。结论 对于室间隔缺损内科介入封堵术后早发性CAVB,在给予肾上腺皮质激素、白蛋白等药物治疗同时,应考虑外科取出封堵器以防复发;外科修补术后迟发性CAVB可定期临床随访,如存在频繁阿-斯综合征发作或心功能不全应接受永久起搏器治疗。     

小儿室间隔缺损伴肺动脉高压的围手术期治疗

目的 探讨小儿室间隔缺损(VSD)伴肺动脉高压(PH)外科治疗的围手术期治疗效果.方法 回顾性分析2002年10月至2007年10月我科收治的97例小儿室间隔缺损伴肺动脉高压患儿围手术期的临床资料.结果 术后死亡5例;术中并发Ⅲ度房室传导阻滞4例,再次阻断主动脉停循环后拆除隔瓣处转移针,心脏复跳后转为窦性心律;术后出现肺动脉高压危象2例,行二次气管插管呼吸机支持治疗后好转;术后肺不张9例,经纤支镜吸痰、拍背、刺激咳嗽等方法处理后肺复张;肺部感染17例,调整抗生素治疗后治愈.结论 小儿室间隔缺损伴肺动脉高压的患儿围术期注重降低肺动脉压,加强围手术期综合治疗是手术治疗成功的关键.     

46例室间隔缺损合并动脉导管未闭的外科治疗

目的 本文总结了46例室间隔缺损合并动脉导管未闭的诊断和外科手术治疗体会.方法 全部在体外循环辅助下施行手术治疗,其中男性25例,女性21例,年龄9个月～40岁;合并畸形有房间隔缺损,所有病例均经肺动脉切口缝合;合并畸形均同期手术矫治.结果 全组病例无死亡,手术治疗后效果满意.结论 室间隔缺损合并动脉导管未闭一旦明确诊断,应该早期手术治疗;室间隔缺损合并动脉导管未闭临床上易与单纯室间隔缺损相混淆,术前容易漏诊、误诊而导致术中发生灌注肺.为术中避免打遭遇战,应加强术前诊断、术中探查和术后加强呼吸道管理.     

室间隔缺损体外循环下的外科治疗

目的：总结先天性室间隔缺损（Ventricular septal defect,VSD）体外循环（Cardiopuhnonary Bypass,CPB）下外科手术治疗经验。方法：1996年5月至2007年5月手术治疗VSD675例,均在低温体外循环下（CPB）手术。直接缝合392例,补片修补283例。结果：术后死亡6例,并发症发生率6．7％。结论：手术治疗VSD效果满意,正确诊断、适应症的掌握、手术技术改进、室缺肺高压围术期的处理是影响预后的重要因素。     

纤支镜治疗时机对支原体肺炎患儿的疗效及对SAA、CRP等炎性指标的影响研究

目的探讨纤支镜治疗时机对支原体肺炎患儿的疗效及对SAA、CRP等炎性指标的影响。方法选取我科收治的80例MPP患儿,根据治疗方式的不同,分为研究组及对照组两组,其中研究组(早期纤支镜治疗)39例和对照组(晚期纤支镜治疗)41例,比较2组患者的临床疗效等差异。结果治疗后研究组患者的临床总有效率(92.3%)高于对照组患者(70.7%)(P<0.05);治疗前两组患者的相关血气分析指标比较差异无统计学意义(P>0.05),而治疗后研究组患者的相关血气分析指标均较对照组改善明显(P <0. 05);治疗后研究组患者的住院时间、肺部啰音消失时间、体温恢复时间及咳嗽消失时间均显著少于对照组患者(P<0. 05);治疗前两组患者的相关血清炎性指标比较差异无统计学意义(P>0.05),而治疗后研究组患者的相关血清炎性指标均较对照组改善明显(P<0.05)。结论早期纤支镜治疗MPP患儿的疗效显著,不仅在改善其肺功能同时还可减轻其炎性反应程度,最终利于患儿康复,值得临床推广应用。     

室间隔缺损患者修补术围手术期护理研究

目的：探讨室间隔缺损患者修补术的护理方法和要点。方法以我科行室间隔缺损修补术的患者22例为例,研究的护理方法和要点。结果通过采用规范的术前护理、术后护理以及并发症的预防及护理,所有22例病患均得于康复出院,均未发生不良并发症。结论做好室间隔缺损患者的围手术期护理可有效控制并发症及死亡率的发生。室间隔缺损修补术的护理对至关重要。     

血清PCT、sTREM-1水平与重症肺炎患者纤支镜肺泡灌洗治疗预后的关系研究

目的:分析血清降钙素原(PCT)、可溶性髓样细胞触发受体-1(sTREM-1)水平与重症肺炎患者纤支镜肺泡灌洗治疗预后的关系.方法:选取本院2018年12月至2020年12月收治的86例重症肺炎患者作为研究对象.所有患者均行纤支镜肺泡灌洗治疗.根据患者28d生存情况评估治疗预后,并根据预后情况分为预后不良组(28 d内病死)、预后良好组(28 d后仍存活).检测患者治疗前血清PCT、sTREM-1、白细胞(WBC)、中性粒细胞(NE)等实验室指标,分析血清PCT、sTREM-1水平与重症肺炎患者纤支镜肺泡灌洗治疗预后的关系.结果:纳入的86例重症肺炎患者,经纤支镜肺泡灌洗治疗后,预后不良组占39.53％.预后不良组急性生理与慢性健康评分(APACHEⅡ)、WBC,血清PCT、sTREM-1水平均显著高于预后良好组,NE显著低于预后良好组(P<0.05).COX回归分析结果显示,重症肺炎患者纤支镜肺泡灌洗治疗预后不良与血清、sTREM-1过表达有关(P<0.05).绘制受试者工作特征(ROC)曲线,血清PCT、sTREM-1单独及联合预测重症肺炎患者纤支镜肺泡灌洗治疗预后不良的曲线下面积(AUC)分别为0.789、0.789、0.816.结论:血清PCT、sTREM-1过表达对预测重症肺炎患者纤支镜肺泡灌洗治疗预后不良具有一定价值.     

经胸超声在Amplatzer封堵器介入治疗先天性房室间隔缺损中的临床应用

目的探讨经胸超声在AmpLatzer封堵器介入治疗先天性房间隔缺损、室间隔缺损中的临床应用价值。方法术前应用经胸超声筛选封堵术适应证36例先心病,其中26例房间隔缺损、10例室间隔缺损。术中用经胸超声监测指导释放封堵器,即刻观察疗效。于胸骨旁四腔观、房间隔短轴观、心尖四腔观、心尖五腔观、大动脉短轴观、剑突下四腔心观分别观察封堵器的形态,瓣膜反流及封堵器周围分流情况。术后进行定期复查。结果26例房间隔缺损、10例室间隔缺损封堵成功,总成功率100%。其中16例出现二、三尖瓣反流或残余分流,经调整封堵器的位置和方向后,10例反流即刻消失,6例术后1个月消失。结论经胸超声可用来筛选房间隔缺损、室间隔缺损封堵术病例,术中指导Amplatzer封堵器定位和释放,疗效评估和预后评价方面有不可替代的临床应用价值。     

室缺并重度肺高压的围手术期处理

目的 探讨室缺合并重度肺动脉高压的围手术期处理方法。方法 手术前静脉应用前列腺素E1一周；术中应用顺单向活瓣补片修补室缺；术后再静脉应用前列腺素E1两周。结果 符合诊断的病人21例，围术期死亡2例，19例安全渡过围手术期出院。结论 术前静脉应用前列腺素E1,术后应用前列腺素E1等药物和呼吸机治疗是该类病人顺利恢复的重要因素.     

Assessment of right atrial and right ventricular size in children after percutaneous closure of secundum atrial septal defect with Amplatzer septal occluder

Introduction

The aim of this study was to evaluate the right atrial (RA) and right ventricular (RV) size, and the speed of their normalization, in children after percutaneous closure of secundum atrial septal defect with the Amplatzer septal occluder.

Material and methods

The study group consisted of 42 children, aged 4.5 to 18.5 years. The following measurements (indexed to body surface area) were performed using 2D echocardiography: longitudinal, transverse axis and area of RA, RV inflow dimensions at one-third, and halfway between the tricuspid annulus and the apex (in the apical 4-chamber view), short axis and M-mode RV diastolic dimensions. All measurements were obtained 24 h and 1, 3 and 12 months after the procedure, then annually over 4 years of follow-up, and compared with the values obtained from the control groups.

Results

A significant decrease in all RA and RV values was observed after 24 h. Right ventricular transverse dimension normalized after 1 month, the RA longitudinal axis and area and the RV inflow dimensions after 3 months, and the RA transverse axis and M-mode RV diastolic dimension after 2 years, but the ratio of transverse to longitudinal RA axis remained significantly higher.

Conclusions

Right atrial and right ventricular measurements decrease rapidly during the first 24 h, and most of them normalize within a 3-month period. M-mode RV diastolic dimension does not capture the real RV changes. Amplatzer septal occluder closure of ASD influences the RA geometry, which is reflected by the higher transverse to longitudinal RA axis ratio.     

ECG Conduction disturbance in the first-degree relatives of children with ventricular septal defect

A detailed cardiological examination was made in the first-degree relatives of 94 index patients with ventricular septal defect and in 94 matched control cases. Incomplete or suspect right bundle branch blocks were found in 18.3 % and in 4.1 %, respectively, of first-degree relatives of index and control groups. The difference is highly significant. These intraventricular conduction disturbances may be subthreshold signs of septal defects.     

The carotid bodies in a case of ventricular septal defect

A woman of 62 years with Turner's syndrome died in congestive cardiac failure secondary to a large ventricular septal defect with biventricular hypertrophy. During her last few months the lifelong left-to-right shunt underwent reversal exposing her carotid bodies to hypoxaemia. The carotid bodies were not enlarged, thus demonstrating that hyperplasia of glomic tissue is not brought about by increased myocardial mass per se. They were, however, abnormally cellular with more dark cells ( a variant of chief cells), many of which were abnormally large and showed ultrastructural features of metabolic activity. These changes may represent the earliest histological response of the carotid body to hypoxaemia and later, the dark cells may mature into the more familiar and common light variant. It seems likely that this dark cell activity precedes, probably by a long period, the sustentacular cell hyperplasia and proliferation of nerve axons which we have reported elsewhere as the chronic reaction of the carotid bodies to hypoxaemia.     

A new anatomic approach of the ventricular septal defect in the interruption of the aortic arch

The aim of this study was to analyse the anatomy of the ventricular septal defect (VSD) in heart specimens with interruption of the aortic arch (IAA) in order to explore the hypothesis of different embryologic mechanisms for the different anatomic types of IAA. We examined 42 human heart specimens, 25 with IAA as the main disease with concordant atrioventricular and ventriculo‐arterial connections and two distinct great arteries, and 17 hearts with IAA associated with other malformations [six common arterial trunk (CAT), five double‐outlet right ventricle (DORV), three transposition of the great arteries (TGA), three atrioventricular septal defect (AVSD)]. The interruption was classified according to Celoria and Patton. We focused on the anatomy of the VSD viewed from the right ventricular side. There were 15 IAA type A, 27 type B, no type C. The VSD in IAA type B was always an outlet VSD, located between the two limbs of the septal band, with posterior malalignment of the outlet septum in hearts with concordant ventriculo‐arterial connections, without any fibrous tricuspid‐aortic continuity. In addition, the aortic arch was always completely absent. Conversely, the VSD in IAA type A could be of any type (outlet in six, muscular in four, central perimembranous in two, inlet in three) and the aortic arch was either atretic or absent. In addition, IAA type B, when found in the setting of another anomaly, was always associated with neural crest‐related anomalies (CAT and DORV), whereas IAA type A was found in association with anomalies not related to the neural crest (TGA and AVSD). These results reinforce the hypothesis that different pathogenic mechanisms are responsible for the two types of IAA, and the inclusion of IAA type B in the group of neural crest defects. Conversely, IAA type A could be due to overlapping mechanisms: flow‐related defect (coarctation‐like) and neural crest contribution.     

室间隔缺损儿童心房中Ⅰ和Ⅲ型胶原蛋白的表达

目的　探讨室间隔缺损儿童心房Ⅰ型和Ⅲ型胶原蛋白表达的变化。方法　应用SP免疫组化和数字图像分析方法 ,观测 6例正常儿童和 12例室间隔缺损儿童心房Ⅰ型和Ⅲ型胶原蛋白的表达。结果　 (1)正常心房Ⅰ型胶原为粗、细不等的条状纤维 ,彼此连接成网 ;Ⅲ型胶原纤维呈散在的斑片状分布 ;(2 )室间隔缺损心房Ⅰ和Ⅲ型胶原表达 ,大多区域属于正常。仅部分区域发生极度重排 ,即Ⅰ型胶原呈现大斑块状增加、断裂或消失 ,Ⅲ型胶原呈条束状增加 ;(3)数字图像分析显示 :正常心房肌Ⅰ型胶原含量较Ⅲ型胶原多 ;室间隔缺损儿童心房肌Ⅰ、Ⅲ型胶原增加显著。结论　室间隔缺损儿童心房部分区域Ⅰ和Ⅲ型胶原纤维重排、含量显著增加。这可能是导致室间隔缺损儿童心功能异常的原因之一。     

Factors influencing the spontaneous closure of ventricular septal defect in infants

This study is to prospectively evaluate the potential value of maternal and infantile variables as predictors for the spontaneous ventricular septal defects (VSD) closure in infants. Methods: Consecutive infants less than six-month-old when diagnosed with VSD, were followed-up for at least 5 years. Demographic, clinical and maternal factors were evaluated for the possible associations of the incidence of spontaneous VSD closure Of the 425 eligible infants, 93 had spontaneous VSD closure, 78.50% of which occurred when the patients were under 3 years of age. Diameter of the defect (D_VSD), ratio between diameter of the defect and aortic root diameter (D_VSD/D_AR), left atrium sizes, left ventricle sizes, main pulmonary forward blood flow, infection scores, shunt ratio (Qp/Qs), VSD locations, and comorbidities including patent ductus arteriosus (PDA), and membranous septal aneurysm were independent predictors of spontaneous closure. However, maternal factors during the first 3 months of pregnancy and VSD infants with Down syndrome did not affect the spontaneous closure of infants with VSD. Conclusion: D_VSD, D_VSD/D_AR, left atrium sizes, left ventricle sizes, main pulmonary forward blood flow, infection scores, Qp/Qs, VSD location, comorbidities including PDA, or membranous septal aneurysm may be used as potential independent predictors of spontaneous VSD closure in infants.