新生儿梗阻型完全性肺静脉异位引流的治疗

目的 评估新生儿完全性肺静脉异位引流( TAPVC)不同类型矫治手术方法和预后.方法 1999年至2011年,共收治68例新生儿梗阻型TAPVC急诊手术治疗,平均年龄16天,其中心上型21例,心内型8例,心下型36例和混合型3例.心上型和心下型TAPVC是将肺静脉共汇与左心房后壁作侧侧吻合,心内型TAPVC在心房内将扩大的冠状窦去顶将异位的肺静脉隔入左心房.结果 术后早期死亡2例,占2.9％.随访6个月至3年,经超声心动图随访,肺静脉吻合口均无明显狭窄,血液流速1.10 ～ 1.42 m/s.结论 早期的梗阻型TAPVC的纠治中左心房后壁与肺静脉共汇的侧侧吻合远期效果良好,肺静脉的梗阻情况需要远期进一步随访.     

外科治疗完全性肺静脉异位连接31例

目的 总结31例完全性肺静脉异位连接(TAPVC)患者的外科治疗经验.以提高手术疗效.方法 31例患者均在中度低温体外循环下行TAPVC矫治术.其中心上型16例,心内型13例,混合型2例.所有患者均合并继发孔型房间隔缺损,合并动脉导管未闭4例,肺动脉瓣狭窄1例,二尖瓣关闭不全1例,三尖瓣关闭不全15例.结果术后无早期(30 d)死亡,发生并发症8例(25.8%),其中阵发性结性心律1例,Ⅰ度房室传导阻滞1例,频发性房性早搏、短阵性房性心动过速1例;肺部感染2例,肺不张1例,气胸1例,左侧膈肌麻痹并肺部感染二次插管1例,均经治疗出院.本组31例均获得随访,随访时间2.8±1.5年.随访期间1例心上型患者于术后8个月死于心力衰竭,生存的30例患者中28例(93.3%)手术效果良好,心功能基本正常,生活工作无明显受限;治疗效果较差2例,为反复发作房性心律失常,经内科治疗无效.结论 TAPVC手术方式的选择依据TAPVC畸形的特点而不同,手术的关键是完全矫治,避免出现远期肺静脉梗阻和心律失常,其治疗效果满意.     

完全性肺静脉异位引流术后肺静脉狭窄手术干预9例近中期结果北大核心CSCD

目的总结阜外医院过去10年完全性肺静脉异位引流(TAPVC)术后肺静脉狭窄(PVS)患者行再次手术干预的近中期结果。方法纳入2009~2019年于阜外医院完成手术治疗的9例TAPVC术后PVS患者,其中男4例、女5例,手术时年龄(5.10±5.00)岁。根据肺静脉成形手术方式将患者分为2组:无缝线缝合(sutureless)组(n=3)和非无缝线缝合(non-sutureless)组(n=6)。分析患者的临床资料。结果本组患者原发TAPVC类型包括:心上型4例,心内型2例,心下型1例,混合型2例。全组患者中位体外循环时间95(63,208)min,中位主动脉阻断时间58(30,110)min,术后中位ICU滞留时间24(24,2 136)h。早期院内死亡1例(11.1%)。1例(11.1%)合并单心室患者发生住院并发症,术后行血液滤过治疗。随访时间11.9(2.2,18.0)个月,随访期间死亡2例,死因分别为肺静脉再狭窄及脑卒中。Sutureless组与non-sutureless组术后结果及随访结果差异无统计学意义(P>0.05)。结论外科手术是TAPVC术后出现PVS的有效治疗手段,但仍存在较高的并发症发生率及死亡率,sutureless缝合技术在此类患者中应用的优势仍有待验证。     

心上型完全性肺静脉异位连接的手术方法与效果分析

目的总结心上型完全性肺静脉异位连接（S-TAPVC）矫治手术的经验,探讨不同手术方法的治疗效果。方法1985年5月至2007年12月,我们共完成86例S—TAPVC矫治手术,其中男49例,女37例;年龄7个月～35岁,平均年龄9．6岁;体重4．9～68．0kg,平均体重23．8kg。根据采取的不同手术方法将患者分为3组：组Ⅰ为经心房内切口吻合,20例;组Ⅱ为经左、右心房横切15吻合,49例;组Ⅲ为经左心房顶切口吻合,17例。肺静脉共干和左心房切口均采用间断连续吻合,用自体心包修复房间隔缺损（ASD）。术后肺静脉压≤15mm Hg则完全结扎垂直静脉,〉15mm Hg的完全开放或部分结扎垂直静脉。结果本组86例S—TAPVC矫治术,无早期死亡。术后3组左心房压分别为9．3±3．2mm Hg,9．9±2．9mm Hg和11．6±3．8mm Hg,开放或部分结扎垂直静脉例数分别为0例（0％）、7例（14．3％）和2例（11．8%）,发生心律失常例数分别为5例（25．0％）、15例（30．6％）和1例（5．9％）,严重低心排血量综合征分别为1例、0例和1例,二次开胸止血分别为2例、0例和0例。组Ⅲ术后早期心律失常发生率明显低于组Ⅱ（P=0．042）。结论S—TAPVC手术效果满意。经左心房顶切口吻合可以防止术后心律失常,特别适用于婴幼儿;经左、右心房横切口吻合手术视野显露良好,可以保证吻合口的大小,适合于大龄儿童或成年人。     

完全性肺静脉异位引流的外科治疗

目的 报道完全性肺静脉异位引流(total anomalous pulmonary venous drainage)的外科治疗疗效和体会. 方法 27例患者中(心上型19例、心内型8例),18例采用全身麻醉体外循环心脏停搏下手术,9例采用心脏不停跳手术.心上型横切右心房和左心房后壁,纵行切开肺总静脉,切口3.5～5.0 cm,与左心房后壁吻合,用自体心包片修补房间隔缺损(ASD),停机后结扎垂直静脉;心内型切开ASD与冠状静脉窦口之间的残余房间隔壁,以扩大ASD,自体心包修补ASD,并将肺静脉异位连接口与冠状静脉窦一并隔入左心房. 结果 结性心律4例,呼吸衰竭3例,全身水肿1例,大量胸腔积液5例;早期死亡1例,死亡原因为低心排血量综合征.其余患者均痊愈出院,随访6个月～10年,恢复良好,无吻合口狭窄发生. 结论 完全性肺静脉异位引流手术治疗的关键在于左心房与肺总静脉吻合口应足够大,避免狭窄,该手术对早晚期病变疗效均良好.     

完全性肺静脉异位引流的外科治疗及疗效

１９８８年１１月至１９９５年１２月外科治疗１１例完全性肺静脉异位引流（ＴＡＰＶＣ）病人，其中心上型７例，心内型４例。术后死亡１例。术后１０例生存者心功能较术前明显恢复，无远期吻合口狭窄和肺静脉梗阻发生。ＵＣＧ检查发现右房、右室内径较术前明显缩小（Ｐ≤０．０００１），左室舒张末期内径明显增大（Ｐ＜０．００２），心脏指数和射血分数较术前明显提高（Ｐ＜０．０００１）；左房内径略有增大但无统计学意义，共同肺静脉干术后无明显变化。结论：ＴＡＰＶＣ外科治疗成功的关键取决于术前左心室发育及其顺应性；手术吻合口通畅和无远期吻合口狭窄或肺静脉梗阻     

切割球囊治疗完全性肺静脉畸形引流术后肺静脉狭窄1例

病婴女,3.0 kg.生后口唇发绀.经皮血氧饱和度(SpO2)0.84.超声心动图示心上型完全性肺静脉畸形引流(TAPVC),动脉导管未闭、房间隔缺损,垂直静脉节段性狭窄,肺动脉压(PAP)55 mmHg(1 mm Hg=0.133 kPa).生后22 h手术,术后恢复顺利.超声心动图示肺静脉共干与左房吻合口流速1.0 m/s,残余房水平分流3 mm.PAP 47mm Hg.术后7个月因肺炎合并心衰再入院,此时体重4.5kg.超声心动图见房水平分流3 mm,肺静脉共干与左房吻合口流速1.8m/s,PAP 50mm Hg.双源CT示左侧肺静脉融合后注入左房,开口2.04 mm.右上肺静脉开口1.37 mm.肺静脉共干与左房吻合口4.07 mm,未见肺静脉弥漫性狭窄.     

新生儿完全性肺静脉异位连接手术治疗结果

目的:分析预测新生儿完全性肺静脉异位连接(total anomalous pulmonary venous connection,TAPVC)矫治术预后相关危险因素。方法:回顾性分析2009年1月至2018年1月收治的105例接受TAPVC手术治疗的新生儿。心上型42例(40%,42/105)、心内型21例(20%,2...     

“翻盖式”吻合矫治心上型完全性肺静脉异位连接

完全性肺静脉异位连接(total anomalous pulmonary venous connection,TAPVC)较少见,自然病程预后差,生后第1年内病死率约为80％,需早期手术治疗[1].心上型TAPVC是完全性肺静脉异位连接的最常见类型,约占TAPVC总数的50％,其手术治疗的关键是肺总静脉和左心房的吻合口足够大.现总结我们采用"翻盖式"吻合技术矫治44例心上型TAPVC的经验,探讨此技术的临床价值.     

新生儿完全性肺静脉异位引流的矫治及预后相关危险因素分析

目的评价单中心的新生儿完全性肺静脉异位引流(total anomalous pulmonary venous connection,TAPVC)外科矫治情况,评估手术的危险因素。方法纳入2002年9月至2014年3月在我院行TAPVC外科矫治的新生儿患者74例,其中男59例、女15例,中位手术年龄10.5 d。心上型35例(47.3%)、心内型16例(21.6%)、心下型17例(23.0%)、混合型6例(8.1%)。采用Cox多因素分析死亡的危险因素,用Binary logistic回归分析术后吻合口或肺静脉狭窄的危险因素。结果共有18例患儿死亡。不同分型的死亡率:心上型占25.7%(9/35),心内型占18.8%(3/16),心下型占17.6%(3/17),混合型占50.0%(3/6)(P=0.413)。术后早期发生吻合口或肺静脉狭窄13例,心上型占17.1%(6/35),心内型占12.5%(2/16),心下型占17.6%(3/17),混合型占33.3%(2/6)(P=0.700)。术后发生吻合口或肺静脉狭窄21例,10例患儿死亡[47.6%(10/21)vs.15.1%(8/53),P=0.003],差异有统计学意义。手术后死亡的独立影响因素为体重3 kg(P=0.036)。术后吻合口或肺静脉狭窄的发生与使用Sutureless与否(P=0.010)及机械通气时间相关(P=0.000)。结论 Sutureless技术可有效降低术后吻合口或肺静脉狭窄的几率,术后发生吻合口或肺静脉狭窄的患儿死亡率明显增高,体重3 kg是术后死亡的独立危险因素,应引起临床医生的高度重视。     

Reperfusion pulmonary edema after pulmonary endarterectomy

Pulmonary artery thromboendarterectomy is a potentially curative procedure in chronic, major vessel thromboembolic pulmonary hypertension. However, persistent pulmonary hypertension and unrelenting reperfusion edema have serious complications, often requiring prolonged mechanical ventilation. A 50-year-old man who was diagnosed with a thromboembolism in both pulmonary arteries underwent a bilateral pulmonary endarterectomy. He received O2-isoflurane-fentanyl anesthesia. When the lungs were reperfused with CPB weaning, massive hemorrhage occurred in the left lung. After the operation, the patient was taken to the intensive care unit. Mechanical ventilation was performed immediately and then both inhaled NO and i.v. furosemide therapies were administered. The patient was discharged from ICU 15 days postoperation.     

Massive pulmonary hemorrhage after pulmonary thromboendarterectomy

Pulmonary thromboendarterectomy, the most common surgical treatment of chronic thromboembolic pulmonary hypertension, is being performed with increasing frequency throughout the world. Massive pulmonary hemorrhage is a potentially fatal complication of this procedure. In this report of three such cases, the diagnosis, clinical course, and possible treatments are discussed. Anesthesiologists involved in the care of patients receiving pulmonary thromboendarterectomy must be aware of the possibility of this complication, as well as the various techniques available for its treatment.     

Retrograde pulmonary embolectomy in massive pulmonary embolism

The purpose of this study was introduction and evaluation of efficacy and safety of retrograde thromboembolectomy in acute massive pulmonary emboli. The method is described in a 56-year-old woman with acute massive pulmonary thromboemboli. Postoperative course was uneventful. The described surgical technique is not a panacea and definitely not the whole answer, but is a big part of the solution and may be accompanied with less adverse effects. Additionally, there is a need of being reviewed further in large experimental studies and measurements before it could be used safely as a new technique.     

肺小结节胸腔镜解剖性肺段切除术初步报道

目的探讨胸腔镜解剖性肺段切除术的可行性及安全性。 方法回顾性分析解放军总医院第一医学中心胸外科2017年3月至2018年12月行胸腔镜解剖性肺段切除术的86例临床资料。手术均为3切口。对术后住院时间、术后并发症发生率等情况进行总结,对解剖性肺段切除术的现况、优势及适应证进行分析。 结果86例患者顺利施行了胸腔镜解剖性肺段切除术,手术顺利,无中转开胸或改行肺叶切除病例。平均手术时间(160.59±42.43)min,平均术中出血量(27.06±1.23)ml,平均淋巴结清扫数量(6.78±3.54)枚,平均胸腔闭式引流管留置时间(4.84±2.12)d,平均术后住院时间(6.53±1.41)d。术后病理：腺癌78例,鳞状细胞癌1例,黏液腺癌1例,良性结节6例,其中原发非小细胞肺癌均为Ⅰa期。术后均未出现严重并发症、复发及死亡。 结论解剖性肺段切除术创伤小、恢复快、术后住院时间短,其远期预后效果缺乏前瞻性数据支持,必须严格把控肺段切除术的适应证。     

Idiopathic pulmonary artery aneurysm with pulmonary regurgitation

Idiopathic pulmonary artery aneurysms are rare and need a multidisciplinary approach to diagnosis and treatment. Surgery is the treatment of choice, especially when the aneurysms are large and when they are associated with pulmonary regurgitation. This report highlights a case in which successful surgical repair preserved the native pulmonary valve after pulmonary artery reconstruction.     

Fatal intra-alveolar pulmonary bleeding complicating pulmonary embolectomy

Two patients are reported in whom fatal alveolar pulmonary haemorrhage occurred after pulmonary embolectomy. Possible causes and methods of prevention are discussed.     

Chronic thromboembolic pulmonary hypertension and pulmonary thromboendarterectomy

Chronic thromboembolic pulmonary hypertension results from incomplete resolution of a pulmonary embolus or from recurrent pulmonary emboli. Its incidence is underappreciated, and it is currently an undertreated phenomenon. Pulmonary thromboendarterectomy is currently the safest and most effective treatment for this condition. The surgery involves midline sternotomy, profound hypothermic circulatory arrest, and complete endarterectomy of the pulmonary vascular tree. Success depends on effective coordination of multiple medical teams, including pulmonary medicine, anesthesiology, and surgery. This review, based on the past 30 years of experience at University of California San Diego Medical Center, includes information about the clinical history, diagnostic workup, anesthesia, surgical approach, and postoperative care. Outcome data are discussed, as are avenues for future research.     

One-stage bilateral pulmonary resections for pulmonary metastases

Objective

We analyze the safety and efficacy of one-stage bilateral pulmonary resections for pulmonary metastases via a bilateral approach.

Methods

We retrospectively analyzed 154 cases with pathologically verified pulmonary metastases which underwent curative pulmonary resection. Intraoperative and perioperative variables were evaluated.

Results

One hundred and thirty cases underwent unilateral pulmonary metastasectomy (group U), and the other 24 cases with bilateral pulmonary metastases underwent one-stage bilateral pulmonary resections (group B). Operation time in group B was significantly longer than in group U (354 ± 132 vs. 203 ± 110 min; p < 0.001), but was not longer than double that in group U (407 ± 219 min; p = 0.540). Operative blood loss was not significantly greater in group B than group U (113 ± 158 vs. 76 ± 138 ml; p = 0.069). Neither duration of postoperative hospital stay nor incidence of postoperative complications differed between the two groups. Hospitalization costs in group B were significantly greater than in group U (257 ± 120 × 10⁴ vs. 168 ± 69.2 × 10⁴ yen; p < 0.001), but they were significantly less than double those in group U (336 ± 138 × 10⁴ yen; p < 0.001).

Conclusions

We consider one-stage bilateral pulmonary metastasectomy to be safe for bilateral pulmonary metastases. Moreover, it may offer an economic benefit by avoiding the expenses associated with a two-stage operation.