产前产后一体化诊治大动脉转位畸形5例

目的 总结产前和产后一体化诊治大动脉转位畸形(TGA)的经验.方法 5位孕妇在产前诊断中心确诊胎儿TGA,愿意继续妊娠.孕妇平均年龄(28.4±3.0)岁,产前诊断时胎龄(28.4±4.4)孕周.妊娠(36.5±1.8)孕周分娩,新生儿体重(2468±442)g.新生儿接受超声心动图复查,TGA合并室间隔缺损2例,室间隔完整3例.针对严重缺氧患儿,给予前列腺素和呼吸机辅助呼吸.完善术前准备,均在中低温体外循环下完成大动脉调转术,同时矫治合并心脏畸形.结果 患儿生后2～19天,平均(9.0±6.2)天手术.生存3例.死亡2例,1例早产低体重(1770 g)儿,术后第2天心搏骤停,复苏失败;1例Apgar评分低早产儿术前使用呼吸机和前列腺素,生后第2天急诊手术,术后顽固性低心排血量,第3天死亡.结论 TGA产前和产后一体化诊治有利于减少患儿术前缺氧,避免长途转运,但是需要多科室合作,任何环节的不足将会抵消产前诊断给TGA患儿带来的益处.

Abstract：

Objective To summarize primary experiences of integrated fetal diagnosis and postnatal treatment for the transposition of the great arteries (TGA). Methods Five fetus were diagnozed as TGA at(28.4 ±4.4) weeks of gestation via fetal echocardiography. The mean age of the pregnant women was (28.4 ±3.0) years old. Delivers were taken by caesarean at (36.5 ±1.8) weeks of gestation. The body weight of neonates was (2468 ±442) grams. All neonates were transported to the department of neonatology and re-checked by echocardiography. 3 cases were TGA with intact ventricular septum, 2 cases were TGA with ventricular septal defect. Prostaglandin and mechanical ventilation were applied if oxygen saturation was lower. The standard arterial switch procedure was performed under cardiopulmonary bypass with moderate hypothermia. Results The mean age for patients at surgery was (9. 0 ±6. 2) days ( ranged 2-19 days). Three neonates survived, 2 preterm neonates died. One with body weight 1770 g, 2 days after operation was died of sudden heart arrest and failure of resuscitation. Another was treated by mechanical ventilation and prostaglandin after delivery and underwent operation at the second postnatal day, the neonate appeared low cardiac output and high serum lactate postoperatively and died in the third day. Conclusion The integrated fetal diagnosis and postnatal treatment for TGA could prevent severe cyanosis and emergency transportation after parturition. The lack of any link in the cooperation among the multidisciplinary team could affect the benefits for the TGA neonates provided by prenatal diagnosis.     

羊水降温诱导低温阻断主动脉对胎羊脑部的影响

目的 观察不同温度下阻断主动脉对胎羊脑部的影响,寻求一种安全的胎羊心脏手术操作平台.方法 14只孕羊,通过改变羊水温度来改变胎羊的体温,对比不同温度下阻断主动脉对胎羊脑部影响的不同,判断低温是否会对缺血、缺氧的胎脑提供保护作用.结果 常温组胎羊有1只死亡.胎羊血压基本稳定,阻断主动脉后血压下降(P＜0.05),但组间差异无统计学意义(P＞0.05).胎羊心率平稳,各时点、两组间差异无统计学意义(P＞0.05).两组胎羊血中肌酸磷酸激酶脑型同工酶BB(CKBB)、神经特异性烯醇化酶(NSE)和S100B蛋白都进行性升高,常温组比低温组上升得快,幅度大,组间差异有统计学意义(P＜0.05).结论 对胎羊心脏进行手术操作,会对胎羊脑部会造成伤害,通过宫内羊水降温然后进行胎羊心脏手术,可以减轻这种损害.

Abstract：

Objective To study weather relatively mild hypothermia can protect fetal brain during aortic across-clamping period. Methods Fourteen ewes at 120-140 days of gestation were randomly divided into normal temperature group ( NT group n = 7 ) and low temperature group ( LT group, n = 7 ). The fetal lambs were exposed by uterotomy and underwent median stemotomy. We changed the temperature of fetus by changing the temperature of amniotic fluid. When the temperature of fetal lamb reached the set point,the aorta was across-clamped. Fetal mean blood pressure and heart rate were recorded at different time points. The fetal plasma creative phosphokinase isoenzyme BB (CKBB), neuron specific enolase (NSE)and protein S100B were assayed. Results The weight of pregnant sheep in NT group and LT group was (25.93 ± 4. 68 ) and (24. 00 ± 3. 29 ) kg and that of fetal lamb in NT group and LT group was ( 1.43 ±0. 45 ) and ( 1.48 ± 0. 28 ) kg, respectively. There are no significant difference between two groups ( P ＞0. 05). All fetuses were alive except one in NT gruop. The mean blood pressure and heart rate in both groups showed no changes during the study period. CKBB and NSE in both groups was increased remarkably throughout the study period (P ＜ 0. 05 ). The changes of plasma CKBB, NSE and S100B protein in NT group were more significant than those in LT group ( P ＜ 0. 05 ). Conclusion The experiment would hurt the brain of the fetal lamb. The injury of fetal brain would be alleviated when the fetal temperature was reduced during the experiment.     

间歇性增加脑部逆灌压对深低温停循环脑保护的研究

目的探讨间歇性增加脑部逆灌压对深低温停循环脑保护的作用。方法 15头山羊随机分为深低温停循环组（A组,N=5）、深低温低压逆灌组（L组,N=5）和深低温间歇性高压逆灌组（H组,N=5）。三组动物均经历深低温（15-18℃）停循环2 h,期间A组未行脑部逆行灌注,L组和H组经上腔静脉逆行灌注,L组逆灌压控制在20-25 mm Hg,H组基础逆灌压为20-25 mm Hg,每隔10 min用40-45 mm Hg的逆灌压灌注5 min,随后恢复至基础逆灌压。分别在体外循环前,深低温停循环前,复温开始,体外循环结束时记录平均动脉压、脑脊液压力和静脉血气值。用眼底镜观察羊的视网膜动静脉充盈情况。留取脑脊液标本,检测S-100含量。结果三组转流过程中平均动脉压、脑脊液压力、颈静脉血氧饱和度没有显著差异。三组颈静脉血乳酸值含量总体差异显著,H组低于L组和A组（P〈0.05）。配对t检验显示A组和L组体外循环结束后S-100含量明显高于体外循环前水平（P〈0.05）,但是H组没有显著变化。A组眼底视网膜血管没有血流,L组视网膜血管不充盈,H组在高流量灌注时视网膜血管充盈。结论间歇性增加脑逆灌压能够增加深低温停循环期间脑组织灌注,减少无氧代谢,对脑组织有保护作用。     

复杂先天性心脏病产前诊断和产后治疗“一体化”模式的探讨

目的先天性心脏病(先心病)居广东省出生缺陷首位,是导致围产儿死亡的主要原因之一。随着产前诊断技术的进步,胎儿先心病能够产前诊断;同时小儿心脏外科技术不断提高,复杂先心病能在新生儿期完成手术治疗。本文探讨复杂先心病产前诊断和产后治疗"一体化"模式的成效。方法回顾性分析2005年1月至2009年12月在广东省人民医院产前诊断及出生的孕产妇11 716人(包括活胎及引产),产前诊断胎儿先心病85例,其中复杂先心病48例,活产17例,有16例在新生儿期接受手术治疗。产前诊断大动脉转位畸形7例,肺动脉闭缩6例,左心发育不良综合症1例,法鲁四联症1例,完全性肺静脉异位引流1例。产前诊断时孕妇平均年龄(29.3±3.0)岁,平均孕龄(28.6±3.6)孕周,妊娠(37.0±1.85)孕周分娩,新生儿体重(2 569±477)g,男13例,女3例。出生后转新生儿科,接受超声心动图复查,监测经皮血氧饱和度。严重缺氧患儿给予保达新,维持经皮氧饱和度在80%以上。完善术前准备,均在体外循环下矫治心脏畸形。结果产前和产后主要心脏超声诊断相符。手术在生后2～27 d进行。除1例急诊手术患儿外,其余术前均无明显缺氧、酸中毒。死亡3例,2例是大动脉转位畸形矫治术后,1例肺动脉闭缩术后;其中2例术后凝血机制紊乱,术后第2天心脏骤停,复苏失败而死亡;另1例急诊手术,术后出现顽固性代谢性酸中毒和高乳酸血症,术后第3天死亡。结论产前诊断和产后治疗"一体化"模式有利于提高复杂先心病的矫治能力,降低复杂先心病围产期病死率。     

华法林抗凝之外作用的研究进展

华法林是目前世界上使用最广泛的抗凝血药物。其抗凝血活性基于对正常血液凝固所必需的多种维生素K依赖性(vitamin K-dependent,VKD)凝血因子合成的抑制作用。华法林还可影响与止血无关的VKD蛋白的合成,其中包括某些促进骨骼生长和血管钙化的蛋白。华法林抗肿瘤的作用部分源于其抗血栓的能力,另一部分则源于其对非止血性VKD蛋白以及与VKD蛋白无关的其他蛋白质功能的影响。华法林的炎症和免疫调节作用表明了该药物在疾病的生理和病理过程中具有更广泛的前景。本文根据已发表的数据概述了华法林除抗凝血之外的生物学作用。     

羊水降温诱导低温下阻断主动脉对胎羊心脏的影响

目的 探讨不同温度下阻断胎羊主动脉对胎羊心脏的影响,寻求一种安全的胎羊心脏手术操作平台.方法 14头孕羊,随机分为常温组和低温组,通过改变羊水温度来改变胎羊体温,分别在实验开始前、主动脉阻断前、主动脉开放前、开放后1 h、开放后2 h这5个时点测量胎羊的心率、血压、抽取胎羊静脉血,检测肌酸磷酸激酶心型同工酶MB和心肌钙蛋白Ⅰ.结果 常温组胎羊有一头死亡.常温组胎羊体重(1.43±0.45)kg,低温组胎羊体重(1.48±0.28)kg,两组胎羊体重没有显著差异(t=-0.258,P=0.801).常温组孕羊体重(25.93±4.68)kg,低温组孕羊体重(24±3.29)kg,两组孕羊体重没有显著差异(t=-0.845,P=0.416).实验过程中两组孕羊心率、血压基本稳定,重复方差分析显示两组之间没有显著差异.各时点之间,开放后孕羊心跳变快,其余各时点孕羊的心率、血压没有明显变化.阻断主动脉后胎羊血压下降(P＜0.05),但两组间没有差异(P＞0.05).胎羊心率平稳,各时点、两组间没有差异(P＞0.05).两组胎羊血中肌酸磷酸激酶心型同工酶MB和心肌钙蛋白Ⅰ都进行性升高,常温组比低温组上升得快,幅度大(P＜0.05).结论 对胎羊心脏进行手术操作,会造成损害,通过宫内羊水降温然后进行胎羊心脏手术,可以减轻这种损害.     

先天性冠状动脉瘘的治疗现状

先天性冠状动脉瘘(CCAF)是一种较为少见的心血管畸形。目前学者们普遍认为有症状患者应及早治疗,但对于该病的无症状患者的治疗时机与治疗方案的选择上尚不明确。迄今为止,在药物控制的基础上,除经典的手术治疗之外,还有介入治疗,目前对于该病临床治疗方案的选择尚无定论。本文通过复习相关文献,对该病的治疗方法进行综述,以期为临床治疗先天性冠状动脉瘘方案的选择提供一定依据。     

胎儿心脏外科研究进展

患有先天性心脏病的胎儿常宫内死亡或自发流产 ,因此宫内胎儿心脏畸形的发病率要高于活产婴儿的发病率。由于复杂畸形或病情严重 ,一些患有心脏畸形的患儿往往生后已失去手术时机 ,或仅为姑息手术 ,严重影响患儿的生存和生活质量。随着胎儿心脏超声诊断技术的提高 ,妊娠 12周就能准确发现心脏结构畸形[1] ,促使人们试图开展胎儿心脏外科以挽救生命。一、胎儿心脏畸形的外科治疗1.宫内心脏畸形的病理变化　胎儿早期心脏畸形改变心内正常的血流 ,引起心脏、大血管继发结构改变。肺动脉闭锁伴完整室间隔导致右室发育不全。三尖瓣发育不良、Ｅｂ…     

库存红细胞清洗在新生儿及小婴儿体外循环手术中的应用

Objective Priming blood in cardiopulmonary circuit is necessary for neonates and small infants. However, high concentration of potassium and lactate in pecked red blood cells transfused during cardiopulmonary bypass may have detrimental effects on meonstea and infants undergoing cardiac surgery. This study is to cornice the effects of trasfusing washed end unwashed peeked red blood cells for cardiopulmonary circuit on serum potassium and lactate concentrations preoperatively. Methods 30 neonates and small infants with complex congenitai heart disease undergoing open heart surgery were divided into 2 groups randomly. Unwashed group (n = 15) received unwashed pecked red blood cells and washed group (n=15) received packed red blood cells washed in a cell saver (Medtronic Autolog). Potasium and lactate concertrations were compared before, during and after bypass. Resuils Wash-packed red blood cells reduced donor blood [K+] from (19.3±0.9)mmd/L to (1.1 +0.3) mmol/L, and lactate from 15 mmo/L to (7.8±1.2) mmol/L (P<0.001). The [K+]in the prime solution was significantly higher [(9.0±0.5) mmol/L vs. (2.6±0.1) mmol/L, P<0.001] in umwashed group than that of washed group, so did the lactate [(9.5±2.6) mmol/L vs. (4.7±1.1) mmol/L, P相似文献   

库存红细胞清洗在新生儿及小婴儿体外循环手术中的应用

Objective Priming blood in cardiopulmonary circuit is necessary for neonates and small infants. However, high concentration of potassium and lactate in pecked red blood cells transfused during cardiopulmonary bypass may have detrimental effects on meonstea and infants undergoing cardiac surgery. This study is to cornice the effects of trasfusing washed end unwashed peeked red blood cells for cardiopulmonary circuit on serum potassium and lactate concentrations preoperatively. Methods 30 neonates and small infants with complex congenitai heart disease undergoing open heart surgery were divided into 2 groups randomly. Unwashed group (n = 15) received unwashed pecked red blood cells and washed group (n=15) received packed red blood cells washed in a cell saver (Medtronic Autolog). Potasium and lactate concertrations were compared before, during and after bypass. Resuils Wash-packed red blood cells reduced donor blood [K+] from (19.3±0.9)mmd/L to (1.1 +0.3) mmol/L, and lactate from 15 mmo/L to (7.8±1.2) mmol/L (P<0.001). The [K+]in the prime solution was significantly higher [(9.0±0.5) mmol/L vs. (2.6±0.1) mmol/L, P<0.001] in umwashed group than that of washed group, so did the lactate [(9.5±2.6) mmol/L vs. (4.7±1.1) mmol/L, P相似文献