39例大型房间隔缺损 室间隔缺损并发肺炎婴儿早期手术治疗的临床分析

目的：婴儿大型房间隔缺损(ASD)室间、隔缺损(VSD)难以自愈,需要尽早手术纠治,以免影响发育甚至导致死亡。但是这类患儿往往并发严重的肺部感染,且反复发作,很难等到肺部感染完全治愈时进行手术纠治。同时患儿需要反复治疗肺炎,费用较高且易延误手术时机。因此,该文研究婴儿大型房间隔缺损、室间隔缺损并发肺炎的早期手术治疗的手术时机选择、治疗的可行性以及减少并发症的处理。方法：2003年1月至2008年 1月,收治大型ASD, VSD并发肺炎39例婴儿,36例在肺炎控制后进行早期手术治疗,3例再行儿科保守治疗。结果：手术病例中, 33例婴儿手术成功, 2例婴儿死于气管狭窄, 1例死于严重低心排, 死亡率8.3%。儿科保守治疗病例中,1例在治疗中因心肺衰竭死亡 ;2 例好转出院,择期行手术治疗成功。结论：把握手术时机和适应证,做好围术期处理,在肺炎控制后对大型ASD,VSD的婴儿进行早期手术治疗是可行的,可提高和改善治疗效果并减少患者费用     

并发肺炎和呼吸衰竭的非限制性室间隔缺损的治疗

目的改进并发肺炎和呼吸衰竭的非限制性室间隔缺损的治疗方案,探讨早期外科治疗的适应证及可行性。方法2000年1月~2005年4月,并发肺炎和呼吸衰竭的单纯非限制性室间隔缺损患儿35例,早期手术20例,内科保守治疗15例。结果20例早期手术中术前需呼吸机辅助通气11例;术后残余分流者3例;再次气管插管3例;并发肺不张5例。不完全性右束支传导阻滞5例,结性心律2例,室上性心动过速2例。15例内科保守治疗者术前需呼吸机辅助通气10例,死于呼吸衰竭8例,放弃治疗2例,等待手术3例,手术2例。结论早期手术治疗并发肺炎和呼吸衰竭的非限制性室间隔缺损具有可行性。     

婴儿大型室间隔缺损并心肺功能不全手术治疗65例

目的探讨6个月以下婴儿大型室间隔缺损并心肺功能不全的早期手术适应症、手术及手术前后处理方法。方法2005年2月至2009年2月本院共收治年龄6个月以下婴儿大型室间隔缺损并心肺功能不全患儿65例,其中3例并发呼吸衰竭。均于气管插管呼吸机辅助通气下带机直接手术。结果62例治愈出院。死亡3例,死亡原因：2例为术后低心排综合症,1例为肺出血。结论6个月以下婴儿大型室间隔缺损并心肺功能不全在术前充分准备、把握手术时机、加强术中及术后心肺功能维护的基础上,实施早期手术可取得满意的疗效和预后。     

大型室间隔缺损并肺炎婴幼儿的外科治疗

目的 探讨大型室间隔缺损(VSD)并肺炎婴幼儿早期手术治疗的可行性、手术时机、适应证以及术中术后的处理.方法　选择2009年10月-2010年7月本院收治的大型VSD并肺炎患儿19例.男11例,女8例;年龄3～15(7.3±2.8)个月;体质量5～12(7.6±1.4) kg .其中VSD并房间隔缺损5例、并动脉导管未闭1例;膜周部VSD 16例,肺动脉瓣下VSD 3例.患儿均在低温、体外循环、冷晶体停跳液灌注下行VSD直视修补术及并发畸形矫治.16例膜周部VSD患儿均经右房切口修补;3例肺动脉瓣下VSD患儿中,2例经肺动脉横切口修补,1例经右室流出道切口修补.19例患儿VSD修补均采用补片修补法,其中15例应用牛心包补片,4例应用自体心包补片(戊二醛固定).患儿术中均应用膜式氧合器和术中平衡超滤.结果　19例患儿手术均获成功,术后主要并发症为肺部感染3例,切口愈合不良2例,肺不张和室间隔少量残余分流各1例,无全身感染、肺动脉高压危象以及严重低心排病例,19例患儿均治愈出院.门诊随访2～6个月,上呼吸道感染显著减少,营养发育状况改善.结论　把握手术时机和适应证,早期手术、防治术中和术后肺损伤,是治疗大型VSD 并肺炎婴幼儿的有效方法.     

婴儿巨大室间隔缺损的外科治疗

目的 探讨婴儿巨大型室间隔缺损VSD)的外科治疗。方法 对86例1岁以下VSD患儿在全麻体外循环下行补片修补VSD。其中并动脉导管未闭(PDA)5例，在深低温低流量下缝合动脉导管；并房间隔缺损(ASD)9例；三尖瓣中度及以上关闭不全12例，均同期予以矫治。结果 84例患儿痊愈出院，手术死亡2例。并发症为肺不张、脱离呼吸机困难、气胸。结论 巨大VSD婴儿宜尽早手术治疗，术中心肌保护和术后管理是手术成功的关键。     

婴幼儿室间隔缺损合并肺动脉高压的外科治疗

目的 报道婴幼儿先天性室间隔缺损(VSD)伴肺动脉高压的手术修补结果及体会。方法 1998年1月-2002年12月，对86例VSD伴肺高压的婴幼儿采用中深低温体外循环行手术治疗。术中术后加强心肌保护和呼吸道管理。结果 治愈出院83例，死亡3例，死亡率为3．49％(3／86)，均为肺高压临床4级病例。术后主要并发症为肺部感染、肺高压危象、低心排综合征。出院病人随访6月～5年，无死亡病例，心功能(NYHA)一级62例，二级18例，三级3例。结论 婴幼儿VSD合并肺动脉高压者，应积极早期手术。围术期的心肌保护和呼吸道管理是手术成败的关键。     

两种手术方法对肺动脉闭锁伴室间隔缺损预后影响的探讨

目的对近年来本院实施的肺动脉闭锁伴室间隔缺损(PA/VSD)一期根治术患儿手术方式及右室流出道重建方法进行总结,结合术后院内各项指标进行比较分析;对比同期一期姑息PA/VSD手术的术后生存率、并发症等情况,藉此对一期手术方案的选取进行评价。方法本院2008年1月至2014年3月施行单纯PA/VSD一期根治手术129例为根治组,收集患儿性别、手术时年龄、身高、体重、术前经皮氧饱和度、McGoon、Nakata指数、手术方式、右室流出道重建材料、术中体外循环、主动脉阻断时间、术后置CICU时间、住院时间、术后最大正性肌力药物评分、院内并发症及死亡率情况;另外收集本院120例P/VSD一期姑息手术患儿相应资料作为对比,为姑息组。结果一期根治组早期院内死亡10例,病死率7.8%;术前McGoon指数1.6±0.5,体外循环时间(130.0±45.6)min;主动脉阻断时间(77.2±23.5)min;呼吸机支持时间(87.0±92.8)h;住院时间(22.6±11.4)d。一期姑息组院内死亡11例,病死率9.2%;McGoon指数1.2±0.3,体外循环时间(89.7±46.4)min;呼吸机支持时间(47.4±50.5)h;住院时间(18.6±7.0)d;结论术前McGoon≥1.2,SpO_2≥75%可视为一期根治术的适应证;术中监测RVP/LVP比值是预防术后早期院内死亡的重要方法;对于伴有粗大主肺动脉侧支(MAPCAs)的患儿,提倡采取早期根治手术。     

婴儿室间隔缺损合并肺动脉高压急诊和亚急诊心脏手术的麻醉处理

目的 总结急诊和亚急诊手术治疗婴儿室间隔缺损(VSD)伴肺动脉高压(PH)的麻醉处理要点。方法 2002年10月～2004．年6月,采用急诊和亚急诊手术治疗61例VSD PH的婴儿,其中男48例,女13例,年龄27天～1岁。体重3．0～8kg。分析术中术后麻醉处理中,注意事项及并发症的防治。结果 主动脉开放后55例自动复跳,6例除颤后复跳,5例出现术后并发症,5例有残余小VSD,58例痊愈出院。结论 术中良好的呼吸管理,保持血流动力学的稳定,术中术后重视肺动脉高压危象的防治,可使VSD PH婴儿安全渡过手术期。     

婴幼儿室间隔缺损合并肺动脉高压的外科治疗

目的 总结婴幼儿大型室间隔缺损（Ventricular Septal Defects,VSD）合并肺动脉高压的外科治疗经验.方法 2008年10月至2009年5月共收治婴幼儿大型VSD 98例,男56例,女42例,年龄4～24个月,体重5.1～15.3 kg;均为单发,其中合并房间隔缺损（Atrial Septal Defect,ASD）26例,合并三尖瓣关闭不全（Tricuspid Insufficiency,TI）18例,动脉导管未闭（Patent Ductus Arteriosus,PDA）12例.患儿均在全麻低温体外循环下实施一期矫治术.结果 治愈95例,死亡3例,术后并发症16例,其中低心排出量综合征6例,肺不张4例,肺炎3例,心律紊乱2例,气胸1例,术后早期复查彩超,除5例有少量残余分流外,其余患儿心功能及瓣膜关闭均正常,患儿均痊愈出院.结论 低体重、低年龄的大型室间隔缺损应尽早手术根治;术中尽量减轻体外循环损伤,保护脏器功能;术后加强呼吸道管理、预防低心排出量综合征和肺动脉高压危象是降低死亡率的关键.     

三个月以内婴儿室间隔缺损的外科治疗

目的　总结手术矫治 3个月以内婴儿室间隔缺损的效果。方法　 1999年 6月～ 2 0 0 1年 11月手术治疗 2 0例先天性心脏病室间隔缺损伴肺动脉高压婴儿 ,其中男 12例 ,女 8例。年龄 34～ 10 4d ,平均 (74.6 5± 9.70 )d。体重 3.35～ 7.0 0kg ,平均 (4 .93± 0 .94)kg。室间隔缺损均为单发 ,其中膜周型 16例 ,肺动脉瓣下 4例。 2例合并动脉导管未闭 (PDA) ,1例合并房间隔缺损 (ASD)、PDA及主动脉缩窄 (CoA) ,1例合并ASD和右冠状动脉 右室瘘。所有患儿均在全麻低温体外循环下行Ⅰ期矫治术。结果　术后早期 (30d内 )死亡 1例 (病死率 5 .0 % )。发生并发症者 10例 ,发生率5 0 .0 %。肺不张 4例 ,低心排 2例 ,心律失常 2例 ,肺炎 2例 ,胸腔积液 1例 ,渗漏综合征 1例 ,经治疗后痊愈出院。结论　反复肺炎和肺动脉高压的室间隔缺损婴儿应尽早手术根治。术后应注重呼吸道的管理和出入量的调整     

Ventricular septal defect and sudden death in early childhood

A 21/2 year old boy collapsed at home and was taken immediately to the local hospital in cardiorespiratory arrest where attempted resuscitation was unsuccessful. At autopsy, massive cardiomegaly was found associated with a large membranous ventricular septal defect. There was also an early acute bronchopneumonia. Although growth parameters indicated failure to thrive, no specific health problems had been noted by the family apart from an apparent mild ‘upper respiratory infection’ prior to death. While the occurrence of sudden and unexpected death in cases of undiagnosed isolated ventricular septal defect has not been emphasized in the literature, this case demonstrates that sudden death may be a problem in early childhood. This is particularly so in cases of untreated large defects with cardiomegaly when additional stresses such as acute infection occur.     

Ventricular septal defect secondary to a unique mechanism of blunt trauma: a case report

We report the case of an adolescent boy who had progressive respiratory distress and cardiovascular compromise after striking his chest against his bicycle handlebars. An echocardiogram in the emergency department revealed a large ventricular septal defect. The boy did well after emergent operative repair and subsequent replacement of a torn tricuspid valve. The characteristics of ventricular septal defects from blunt trauma are briefly discussed.     

新生儿小婴儿先天性心脏病围术期肺炎的临床特征

目的 总结新生儿小婴儿先天性心脏病嗣术期肺炎临床特征,提高该类型肺炎诊治水平.方法 回顾性分析2006年10月至2009年9月,体重≤5 kg和/或年龄≤3个月病例309例,其中男196例,女113例,包括室间隔缺损206例,房间隔缺损126例,单纯动脉导管未闭18例,中重度肺动脉高压160例,完全性大血管错位37例,肺动脉闭锁11例,完全性肺静脉畸形引流9例,完全型心内膜垫缺损7例,主动脉弓离断5例,右室双出口5例.根据术前、术后呼吸道症状、体温、氧合指数、血白细胞计数、X线胸片等诊断肺炎.结果 全组围术期肺炎患病率58.9%(182/309),总病死率7.1%(13/182),机械通气(47.44±38.0)h,术后ICU(5.2±4.1)d.Logistic回归分析提示早产儿、营养不良、反复感染史、肺高压、复杂先天性心脏病、急诊手术、阻断>60 min、延迟关胸、术后低氧、肺不张、气胸或大量胸腔积液、二次气管插管、插管>4 d等与患病密切相关.结论 新生儿小婴儿围术期肺炎患病率高,临床表现复杂,术前在内科治疗的基础上尽早手术,术后早期诊断,加强综合防治,并发心衰应积极处理.     

Optimal timing of surgery in common left to right shunts

Left to right shunts like atrial septal defect, ventricular spetal defect and patent ducts arteriosus are commonly encountered congenital malformations of the heart. With advances in diagnostic and therapeutic technology over the last three decades the recognition and management of these lesions has markedly improved. Currently, the surgical procedures are being performed in infants and neonates with the hope that long term results would be better. Children with atrial septal defects are usually asymptomatic or midly symptomatic and closure of the defect is best performed at 3–4 years of age. Large ventricular septal defects, on the other hand, may produce symptoms like congestive heart failure in early infancy and early closure is recommended for these babies. These defects are also known to close spontaneously and therefore in mildly symptomatic cases without pulmonary arterial hypertension, one may wait for a natural reduction in size. Surgical ligation of a patent ductus arteriosus is a safe and simple procedure and all these cases must undergo closure of the duct.     

Cardiovocal syndrome in infancy

Chronic hoarseness is a rare presenting or accompanying sign of congestive heart failure in infancy. Two infants had a paralyzed left vocal cord, secondary to traction on their left recurrent laryngeal nerve. Both had significant underlying congenital heart disease (type 2 aortopulmonary window, ventricular septal defect, patent ductus arteriosus; large ventricular septal defect). After surgical repair of their congenital heart defect, both infants had normal vocal cord function. Direct laryngoscopy is necessary to diagnose the cause of persistent hoarseness in infancy. If a paralyzed left vocal cord is found, a comprehensive cardiovascular diagnostic work-up is warranted.     

Cardiac surgery in infants with very low birth weight

Congenital heart defects in low birth weight infants are typically managed with supportive therapy or palliative surgery, and definitive repair is delayed. However, the morbidity of such an approach has been shown to be high. Recent reports emphasize early surgical repair with good results in low birth weight and premature babies. However, there are no data on the outcomes in infants with very low birth weight (<1,500 g). Since 1990, the authors performed complete repair of congenital heart defects (other than isolated patent ductus arteriosus) in 20 infants weighing 1,500 g or less. Defects included aortic coarctation (n = 6), ventricular septal defect (n = 5), tetralogy of Fallot (n = 2), transposition of great arteries (n = 2), truncus arteriosus (n = 2), total anomalous pulmonary venous return (n = 1), double outlet right ventricle (n = 1), and pulmonary atresia with intact ventricular septum (n = 1). Preoperative morbidity was more common in patients who were referred late for corrective surgery. Modification of techniques of neonatal cardiopulmonary bypass were used. There were 2 early deaths (10%) caused by foot gangrene (n = 1), and pulmonary complications (n = 1). No patient had evidence of postbypass intracranial hemorrhage. At a median follow-up of 40 months, there was 1 late death, and 4 patients underwent a total of 5 surgical and catheter reinterventions. There was no evidence of neurological sequelae attributable to surgery. In most cases, delaying repair of congenital heart defects in low and very low birth weight infants does not confer any benefit and is associated with a higher incidence of preoperative morbidity. Complete repair of both simple and complex congenital heart lesions can be performed successfully in such patients with good early and medium-term results. Postoperative growth after repair approximates the normal growth curve for low birth weight infants without congenital heart disease. It is recommended that with few exceptions, such infants, especially when symptomatic, undergo early surgical correction rather than prolonged medical management or other forms of palliation.     

Outcome of ventricular septal defect repair in a developing country

OBJECTIVES: To examine the impact of nutrition and lung infection on outcome early after ventricular septal defect (VSD) repair in infants in a developing country. STUDY DESIGN: One hundred consecutive infants (age, 7.4 +/- 3.3 months) with large VSD(s) who underwent surgical repair at one institution in South India from July 1998 to June 2000 were analyzed. Primary outcome variables were postoperative death, duration of mechanical ventilation, intensive care unit (ICU) stay, and hospital stay. Preoperative variables analyzed included age, weight and length Z scores, and lung infection. RESULTS: Preoperative nutrition was poor (weight Z score, -2.8 +/- 1.3), and 25 patients had pneumonia. Six patients died after repair. No preoperative variable was associated with death. Mechanical ventilation, ICU stay, and hospital stay were longer for younger patients (r (s) for ventilation, -0.23, P =.02; for ICU stay, -0.33, P <.001; for hospital stay, -0.27, P =.007) and for those with preoperative pneumonia (median ventilation duration, 46 vs 24 hours, P <.001; median ICU stay 7 vs 4 days, P <.001; median hospital stay 10 vs 7 days, P =.001). Preoperative weight and length Z scores were not associated with any outcome variable. CONCLUSIONS: Poor nutritional status, preoperative pneumonia, and age do not increase mortality rates after VSD repair. Repair of large VSDs should not be delayed because of these preoperative characteristics.