功能性单心室全腔静脉-肺动脉连接术后管理

目的:探讨全腔静脉-肺动脉连接术(total cavopulmonany correction,TCPC)治疗功能性单心室的术后管理经验。方法:2012年1月~2013年6月我院共行TCPC手术60(男43,女17)例;年龄(5.5±1.7)岁,体质量(18±4)kg。术前脉搏血氧饱和度(80±7)%,血色素(181±17)g/L。术前射血分数(EF)(64±7)%,平均肺动脉指数(371±234)mm2/m2,Mcgoon比(2.2±0.7),术前平均肺动脉压(12±4)mm Hg。60例患者均在全身麻醉、体外循环并行辅助下手术,5例因同期行心内畸形矫治需阻断主动脉。心外管道为直径18~22 mm Gore-tex血管,术毕开窗25例(42%)。为保证患者术后顺利恢复,治疗方面必须注意以下几点:1降低肺血管阻力。2保证足够的容量负荷。3增加心肌收缩力。4控制心律失常。5妥善处理胸腔积液。6术后常规抗凝。结果:患者住院期间有2例(3%)死亡。55例并行循环手术患者体外循环时间(112±52)min。5例患者需要停循环修补心内畸形,主动脉阻断时间30~52 min。呼吸机使用时间(19±6)h。术后住ICU时间(5.1±2.1)d。术后胸液引流时间(15±12)d。术后住院天数(24±12)d。本组患者术后10例出现低心排综合征。5例出现急性肾功能衰竭,行腹膜透析或血液滤过治疗,其中2例死亡,余治愈出院。20例出现顽固性胸腔积液(胸引时间大于2周),25例乳糜试验阳性,1例患儿出现蛋白丢失性肠病,最终并发肺部感染死亡。4例术后出现心律失常,心律表现为短阵房性心动过速,交界性心动过速等,其中1例难以矫治的室上性心动过速导致低心排、多脏器衰竭、死亡。10例并发术后肺部感染。所有存活患儿术后腔静脉压力下降明显(12±4)mm Hg vs.(9±3)mm Hg,P0.05],氧饱和度改善明显(80±7)%vs.(97±4)%,P0.01],血色素恢复正常(181±17)g/L vs.(125±29)g/L,P0.01]。结论:根据TCPC术后病理生理的改变,制定合理的治疗方案,可提高TCPC术后成功率和减少术后并发症。

Postoperative management of total cavopulmonary correction in patients with single functional ventricle

AIM：To summarize the experiences of postoperative management of total cavopulmonary correction （TCPC） in patients with single functional ventricle. METHODS： Between January 2012 and June 2013, 60 patients with functional univentricular complex congenital heart disease underwent Fontan operation in Beijing Fuwai Hospital. Patients were diagnosed by echocardiogram and angiography. Their mean age was （5.5±1.7） years, weight was （18±4） kg, SpO2 was （80±7）%, preoperative EF was （64±7）%, Nakata index was （371±234） mm2/m2, McGoon ratio was （2.2±0.7）, and preoperative PAP was （12±4） mmHg. For better postoperative recovery, pulmonary vascular resistance was reduced, enough capacity load was maintained, myocardial contraction force was increased, arrhythmia was controlled, pleural effusion was properly handled and regular postoperative anticoagulation was applied for the treatment. RESULTS： Cardiopulmonary bypass time was （112±52.4） min, aortic cross-clamping time was 30-52 min and duration of mechanical ventilation was （19±6） h. Postoperative thoracic fluid drainage was （15±12） days, ICU length of stay （LOS） was （5.1±2.1） days and total LOS was （24±12） days. Postoperative low cardiac output syndrome occurred in ten cases. Five cases with acute renal failure were treated with peritoneal dialysis or hemofiltration, of whom two cases died （40%）. Intractable pleural effusion （chest drainage 〉2 weeks） occurred in 20 cases, chylothorax in 25 cases and protein leakage bowel disease in one patient who eventually died of pulmonary infection. Postoperative arrhythmia occurred in four cases and postoperative pulmonary infection in ten cases. Postoperative vena cava pressure significantly dropped after TCPC （12±4） vs.（9±3） mmHg, P〈0.05], oxygen saturation markedly improved （80±7） vs.（97±4）%, P〈0.01] and hemoglobin returned to normal （181±17） vs.（125±29） g/L, P〈0.01]. CONCLUSION： Proper postoperative management