心上型完全性肺静脉异位引流外科治疗24例临床分析

目的总结心上型完全性肺静脉异位引流的外科治疗经验。方法1995年7月至2004年6月,手术治疗心上型完全性肺静脉异位引流24例,其中男11例,女13例;年龄40d～35岁,其中6周岁以下23例,体重3．8～54．0kg。经右心房、房间隔切开左心房后壁和肺静脉共干吻合10例;横行切开双心房与肺静脉共干吻合8例;2例分别用人造血管补片和自体心包补片将垂直静脉入口和扩大的房间隔切口一并隔人左心房;1例行左心房后壁和肺静脉共干吻合的同时用自体心包补片将肺静脉共干人口和扩大的房间隔切口一并隔入左心房;3例行左心房顶和肺静脉共干吻合。术后呼吸机辅助呼吸,多巴胺、硝普钠辅助循环2～5d。结果手术死亡1例,死于低心排出量综合征;术后心包填塞1例,再次手术止血后治愈;心律失常6例,均治愈;急性肺水肿1例,二次手术重新开放垂直静脉延迟闭合治愈。术后随访3个月至7年,平均2．5年。术后2周严重室上性心律失常1例,治愈;远期因心包补片挛缩致肺静脉严重回流障碍二次手术1例,治愈;其余患者均未见远期并发症。结论心上型完全性肺静脉异位引流可采用不同的手术方法,正确的手术方法和对并发症的及时处理可以获得良好的治疗效果,单纯应用右心房内补片应选用合适的修补材料,左心房顶和肺静脉共干吻合法暴露好、操作简单、心律失常发生率低。     

应用无内膜接触缝合技术治疗心上型全肺静脉异位引流

目的 探讨无内膜接触缝合技术应用于初次心上型全肺静脉异位引流(TAPVC)的外科矫治,以顶防术后肺静脉梗阻发生的可行性.方法 自2007年12月至2008年12月,25例TAPVC病儿接受体外循环下畸形矫治手术,其中心上型TAPVC 9例手术中5例采用无内膜接触缝合技术.男2例,女3例;年龄为2个月～13岁;体重为4.5～21.0 kg,平均(7.9±6.4)kg.手术选择心包斜窦入路,沿共同静脉长轴横向剖开,并将此切口上延至垂直静脉的心包返折处,使用7-0 PDS缝线将左心房后壁切口与共同静脉切口周边的心包组织吻合,通过"控制性出血技术"将肺静脉回流的血液引流进入左心系统;部分结扎垂直静脉.结果 5例采用无内膜接触缝合技术进行外科矫治的病儿全部生存.1例病儿因术前并发双侧肺实变,术后机械辅助呼吸超过7天其他病儿均顺利康复,无并发症.术后行心脏超声随访,随访1～13个月,中位数为7个月,常规随访时间点分别设在出院前、术后3个月、半年及1年.至目前为止,5例病儿肺静脉回流通畅,血流速度0.65～0.85 m/s.结论 在治疗心上型全肺静脉异位引流方面,无内膜接触缝合是一项切实可行、易于操作的外科技术,可以预防术后早期肺静脉梗阻的发生;但其大宗病例的远期疗效,尚有待进一步的研究和探索.     

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.     

“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.     

心上联合径路手术治疗新生儿和婴幼儿心上型完全肺静脉异位引流

2004年6月至2006年4月我们采取心上联合径路吻合的手术方法矫治8例新生儿和婴幼儿心上型完全肺静脉异位引流（total anomalous pulmonary venous connection，TAPVC）者，现总结经验体会报道如下。     

完全型肺静脉异位引流的诊断和外科矫正

目的总结完全型肺静脉异位引流(TAPVD)的诊断和外科治疗经验.方法回顾近16年收治TAPVD17例,其中男10例,女7例;年龄2～37岁.心上型11例,心内型6例.心上型者经右、左心房联合切口矫正,心内型者切除肺静脉共干与左心房之间的组织,补片修补房缺.同时矫正合并畸形.结果超声检查误诊4例,其中3例为心内型,外院曾误诊为纵隔肿瘤1例.造影检查除3例心内型者均明确诊断.2例术中始发现合并的动脉导管未闭(PDA),1例心上型者再次手术矫正.1例术后死于呼吸衰竭.16例随访1.5～17.5年,心功能良好.结论超声心动检查是诊断本病的主要手段,但有时需行心血管造影,甚至经术中探查方可确诊.本病确诊后应尽早手术,术中应常规探查和处理PDA,及早切开肺静脉共干引流,同时完全矫正心内畸形.手术成功率较高,远期效果良好.     

全肺静脉异位引流心内修复术后护理

全肺静脉异位引流,是指左、右肺静脉未能直接与左心房相连,而与右心房或体静脉相连接。致使全肺静脉的氧合血,直接流入右心房。其发病率占全部先天性心血管畸形的1～4％。我院自1975年9月～1986年9月,对20例全肺静脉异位引流患者,进行了手术治疗。术后护理得法、无一例死亡。效果满意。一、临床费料全肺静脉异位引流心内修复术20例。其中男性6例、女性14例。年龄4～23岁;心上型13例、心内型7例。有紫绀症状者17例。二、护理要点 (一) 呼吸道的观察与护理全肺静脉异位引流病人,术前因肺静脉氧合血直接或间接的流到右心房,X线照片均示肺静脉充血,加之心上型和心下型手术需将肺静脉总干与左心房作一大的侧侧吻合,并闭合房间隔缺损和结扎垂直静脉。心内型需用人工补     

完全性肺静脉异位连接的外科治疗

目的　总结 18例完全性肺静脉异位连接的外科治疗经验。　方法　全组均在全身麻醉中度低温体外循环下进行手术 ,11例心上型患者除早期 1例经后径法矫治外 ,其他 10例经右心房切口径路矫治 ;7例心内型采用自体心包片将冠状静脉窦口经扩大的房间隔缺损隔入左心房 ,后 5例用 5 - 0 Prolene线连续缝合房间隔粗糙面后再矫治。结果　无手术死亡 ,2例心内型患者术后 6个月和 8个月再次手术 ,发生心律失常 7例 ,一过性肺水肿 2例 ,经治疗均痊愈。 16例随访 4个月～ 5年 ,心功能正常。　结论　提高手术成功率和远期疗效的关键为 :术中吻合口要足够大 ,术后及时处理心律失常、肺水肿和低心排血量 ,心内型矫治时消除房间隔粗糙面可防止术后肺静脉梗阻。     

左心房内吻合治疗心下型肺静脉异位引流效果分析

目的探讨左心房内吻合术治疗心下型完全性肺静脉异位引流的效果。方法对32例心下型完全性肺静脉异位引流新生儿实施深低温体外循环下左心房内吻合术。结果本组手术顺利,23例患儿术后延迟关胸,无手术死亡病例。5例心脏复跳后心率较慢安装临时心脏起搏器,术后1~5 d心率恢复正常。除2例因低心排综合征于术后早期死亡,其余患儿均治愈出院。3例患儿术后反复出现肺部感染,2例出现气胸,给予抗感染,胸腔闭式引流均匀恢复。1例心脏超声提示发现主动脉弓有缩窄,再次手术解除主动脉弓缩窄,痊愈出院。28例随访3个月~5 a,行心脏超声、胸片检查。患儿心功能良好,吻合口血流速度正常。结论对心下型完全性肺静脉异位引流新生儿实施左房后壁心内吻合手术,吻合口充分,有利于提高术后恢复效果。     

完全型静脉异位引流的诊断和外科矫正

目的 总结完全型肺静脉异位引流（TAPVD）的诊断和外科治疗经验。方法 回顾近16年收治TAPVD17例,其中男10例,女7例;年龄2－37岁。心上型11例,心内型6例。心上型者经右、左心房联合切口矫正,心内型者切除肺静脉共干与左心房之间的组织,补片修补房缺。同时矫正 合并畸形。结果 超声检查误诊4例,其中3例为心内型,外院曾误诊为纵隔肿瘤1例。造影检查除3例心内型者均明显诊断。2例术中始发现合并的动脉导管未闭（PDA）,1例心上型是再次手术矫正。1例术后死于呼吸衰竭。16例随访1．5－17．5年,心功能良好。结论 超声心动检查是诊断本病的手段,但有时需行心血管造影,甚至经术中探查方可确诊。本病确诊后应尽早手术,术中应常规探查和处理PDA,及早切开肺静脉共干引流,同时完全矫正心内畸形。手术成功率高,远期效果良好。     

Vasopressor hormone response following mesenteric traction during major abdominal surgery

Background : We investigated the vasopressor hormone response following mesenteric traction (MT) with hypotension due to prostacyclin (PGI₂) release in patients undergoing abdominal surgery with a combined general and epidural anesthesia. Methods : In a prospective, randomized, placebo-controlled study we administered 400 mg ibuprofen (i.v.) in 42 patients scheduled for abdominal surgery. General anesthesia was combined with epidural anesthesia (T4-L1). Before as well as 5, 15, 30, 45, and 90 min after MT we recorded plasma osmolality, hemodynamics and measured 6-keto-PGFlα (stabile metabolite of PGI₂), TXB₂ (stabile metabolite of thromboxane A₂) active renin, and arginine vasopressin (AVP) plasma concentrations by radioimmunoassay. Catecholamine levels were assessed by high-pressure liquid chromatography (HPLC) with electrochemical detection. Results : Following MT, arterial hypotension occurred along with a substantial PGI₂ release. This was completely abolished by ibuprofen administration. Although plasma levels of 6-keto-PGF_1α (1133 (708) vs. 60 (3) ng/L, median (median absolute deviation), P=0.0001, placebo vs. ibuprofen) remained significantly elevated, blood pressure was restored within 30 min after MT in the placebo group. At the same point in time plasma concentrations of TXB² (164 (87) vs. 58 (1) ng/L, P=0.0001), epinephrine (46 (33) vs. 14 (6) ng/L, P=0.001), AVP (41 ± (18) vs. 12 (7) ng/L, P=0.0004), and active renin (27 (12) vs. 12 (4) ng/L, P = 0.001) were significantly higher in placebo-treated patients. Conclusion : Under combined general and epidural anesthesia arterial hypotension following MT due to endogenous PGI₂ release is associated with enhanced release of AVP, active renin, epinephrine and thromboxane A₂, presumably contributing to hemodynamic stability within 30 min after MT.     

A Teaspoon Pump for Pumping Blood with High Hydraulic Efficiency and Low Hemolysis Potential

Abstract: Virtually all blood pumps contain some kind of rubbing, sliding, closely moving machinery surfaces that are exposed to the blood being pumped. These valves, internal bearings, magnetic bearing position sensors, and shaft seals cause most of the problems with blood pumps. The original teaspoon pump design prevented the rubbing, sliding machinery surfaces from contacting the blood. However, the hydraulic efficiency was low because the blood was able to "slip around" the rotating impeller so that the blood itself never rotated fast enough to develop adequate pressure. An improved teaspoon blood pump has been designed and tested and has shown acceptable hydraulic performance and low hemolysis potential. The new pump uses a nonrotating "swinging" hose as the pump impeller. The fluid enters the pump through the center of the swinging hose; therefore, there can be no fluid slip between the revolving blood and the revolving impeller. The new pump uses an impeller that is comparable to a flexible garden hose. If the free end of the hose were swung around in a circle like half of a jump rope, the fluid inside the hose would rotate and develop pressure even though the hose impeller itself did not "rotate"; therefore, no rotating shaft seal or internal bearings are required.     

Microspheres Based Detoxification System: A New Method in Convective Blood Purification

Abstract: A variety of protein-bound or hydrophobic substances, accumulating as a result of pathologic conditions such as exogenous or endogenous intoxications, are removed poorly by conventional detoxification methods because of low accessibility (hemodialysis), insufficient adsorption capabilities (hemosorption), low efficiency (peritoneal dialysis), or economic limitations (high-volume plasmapheresis). Combining advantages of existing methods with microspheric technology, a module-based system was designed. Major operating parameters of the latter can be modified to allow for adjustment to individual clinical situations. An extracorporeal blood circuit including a plasmafilter is combined with a secondary high-velocity plasma circuit driven by a centrifugal pump. Different microspheric adsorbers can be combined in one circuit or applied in sequence. Thus, a prolonged treatment can be tailored using specially designed selective adsorber materials. Comparing this system with existing methods (high-flux hemodialysis, molecular adsorbent recycling system), results from our in vitro studies and animal experiments demonstrate the superior efficiency of substance removal.     

Tissue perfusion in relation to cardiac output during continuous positive-pressure ventilation and administration of propranolol or verapamil

Background : Our objective was to determine whether administration of propranolol or verapamil modifies the hemodynamic adaptation to continuous positive-pressure ventilation (CPPV), in particular the regional distribution of cardiac output (CO).
Methods : General hemodynamics and regional blood flows assessed by microsphere technique (15 (μm) were recorded in 16 anesthetized pigs during spontaneous breathing (SB) and CPPV with 8 cm H₂O end-expiratory pressure (CPPV8) before and after intravenous administration of propranolol (0.3 mg · kg⁻¹ followed by 0.15 mg · kg⁻¹ · h⁻¹, n=8) or verapamil (0.1 mg · kg⁻¹ followed by 0.3 mg · kg⁻¹ · h⁻¹, n=8).
Results : CPPV8 depressed CO by 25% without shifts in its relative distribution with the exception of a noteworthy increase in adrenal perfusion. Propranolol increased arterial blood pressure, and due to a fall in heart rate, CO dropped by 25%. The kidneys and, to a lesser extent, the splanchic region and central nervous system received increased fractions of the remaining CO at the expense of skeletal muscle flow. Similar patterns were seen during SB and CPPV8 such that the combination of propranolol and CPPV8 depressed CO by 50%. The circulatory effects of verapamil were less evident but myocardial perfusion tended to increase.
Conclusions : The combination of propranolol or verapamil with CPPV does not result in any specific hemodynamic interaction in anesthetized pigs, except that the combined effect of propranolol and CPPV may severely reduce CO.     

Volatile anaesthetics reduce adhesion of blood platelets under low-flow conditions in the coronary system of isolated guinea pig hearts

Background : Inhibitory effects of volatile anaesthetics on platelet aggregation have been demonstrated in several studies. However, the influence of volatile anaesthetics on intracoronary platelet adhesion has not been elucidated so far.
Methods : Isolated hearts of guinea pigs were perfused with buffer in the absence or presence of volatile anaesthetics (0.5 and 1 MAC) at constant coronary flow rates of 5 ml/min for 25 min, then 1 ml/min for 30 min and again 5 ml/min for 10 min. Before, during and after low-flow perfusion, a bolus of human platelets was applied into the coronary system. To simulate thrombogenic conditions, 0.3 U/ml human thrombin was infused during low-flow perfusion and reperfusion. The number of platelets sequestered to the endothelium was calculated from the difference between coronary in- and output of platelets. The myocardial production of lactate and consumption of pyruvate and coronary perfusion pressure were also determined.
Results : At a flow rate of 5 ml/min only about 3% of the applied platelets did not emerge from the coronary system, in any group. In contrast, 13.1±1.2% (mean±SEM) of infused platelets became adherent in low-flow perfusion in the control group without anaesthetic. The adherence was reduced with each 1 MAC isoflurane (to 6.2±1.2%), sevoflurane (to 4.4±0.9%) or halothane (to 3.2±1.5%) (each P <0.05 vs. control). Volatile anaesthetic, 0.5 MAC, did not inhibit platelet adhesion to a statistically significant extent in any case. Perfusion pressure and metabolic parameters were not statistically different between the control and the hearts exposed to anaesthetics.
Conclusion : Volatile anaesthetics in a concentration of 1 MAC can reduce the adhesion of platelets in the coronary system under reduced flow conditions. This action does not arise from vasodilation or inhibition of ischaemic stress.     

Bariatric Surgery in Some "Central and East-European (former Eastern bloc)"Countries - Current Status and Prediction for the Next Millennium

Background: Obesity is increasing globallly, including in the formerly "Eastern Bloc" countries. Methods: A survey was made of obesity and bariatric surgery. Results: In the 8 East and Central European countries studied, with total population 300 million, roughly 43% of the population was overweight (BMI 25-30), 23% obese (BMI > 30), with about 15 million people morbidly obese (BMI > 40). From 0-10 morbidly obese individuals/100,000/year undergo bariatric surgery. Conclusion: Most countries were found to provide inadequate treatment for obesity.The majority of the morbidly obese are not treated effectively. However, health-care awareness of obesity and bariatric surgeons are slowly increasing.     

Synergistic interaction between the effects of propofol and midazolam with fentanyl on phrenic nerve activity in rabbits

Background: It has been shown that the depressive effects of both propofol and midazolam on consciousness are synergistic with opioids, but the nature of their interactions on other physiological systems, e. g. respiration, has not been fully investigated. The present study examined the effect of propofol and midazolam alone and in combination with fentanyl on phrenic nerve activity (PNA) and whether such interactions are additive or synergistic. Methods: PNA was recorded in 27 anaesthetised and artificially ventilated rabbits. In three groups, propofol, fentanyl and midazolam were administered intravenously in incremental doses to construct dose-response curves for the depressant effects of each one on PNA. In another two groups, the effect of pretreatment with either fentanyl 1 μg · kg^?1 i. v. or midazolam 0.05 mg · kg^?1 i. v. on the effects of propofol and fentanyl respectively on PNA were studied. Results: Propofol and fentanyl caused a dose-dependent depression of PNA with complete abolition at the highest total doses of 16 mg · kg^?1 i. v. and 32 μg · kg^?1 i. v., respectively. In contrast, midazolam in incremental doses to a total of 0.8 mg · kg^?1 reduced mean PNA by 63%, but approximately 12% of PNA remained at a total dose as high as 6.4 mg · kg^?1. The mean ED₅₀s, calculated from dose-response curves, were 5.4 mg · kg^?1, 3.9 μg · kg^?1 and 0.4 mg · kg^?1 for propofol, fentanyl and midazolam, respectively. Initial doses of either fentanyl 1 μg · kg^?1 i. v. or midazolam 0.05 mg · kg^?1 i. v. acted synergistically with subsequent doses of either propofol or fentanyl to abolish PNA at total doses of 8 mg · kg^?1 and 8 μg · kg^?1, respectively. Conclusion: Fentanyl has a synergistic interaction with both propofol and midazolam on PNA and hence potentially on respiration.     

Influence of dopexamine hydrochloride on haemodynamics and regulators of circulation in patients undergoing major abdominal surgery

Background: Catecholaminergic support is often used to improve haemodynamics in patients undergoing major abdominal surgery. Dopexamine is a synthetic vasoactive catecholamine with beneficial microcirculatory properties. Methods: The influence of perioperative administration of dopexamine on cardiorespiratory data and important regulators of macro- and microcirculation were studied in 30 patients undergoing Whipple pancreaticduodenectomy. The patients received randomized and blinded either 2 μg · kg^?1 · min^?1 of dopexamine (n=15) or placebo (n=15, control group). The infusion was started after induction of anaesthesia and continued until the morning of the first postoperative day. Endothelin-1 (ET-1), vasopressin, atrial natriuretic peptide (ANP), and catecholamine plasma levels were measured from arterial blood samples. Measurements were carried out after induction of anaesthesia, 2 h after onset of surgery, at the end of surgery, 2 h after surgery, and on the morning of the first postoperative day. Results: Cardiac index (CI) increased significantly in the dopexamine group (from 2.61±0.41 to 4.57±0.78 1 · min^?1 · m^?2) and remained elevated until the morning of the first postoperative day. Oxygen delivery index (DO₂I) and oxygen consumption index (VO₂I) were also significantly increased in the dopexamine group (DO₂I: from 416±91 to 717±110 ml/m² · m²; VO₂I: from 98±25 to 157±22 ml/m² · m²), being significantly higher than in the control group. pHi remained stable only in the dopexamine patients, indicating adequate splanchnic perfusion. Vasopressive regulators of circulation increased significantly only in the untreated control patients (vasopressin: from 4.37±1.1 to 35.9±12.1 pg/ml; ET-1: from 2.88±0.91 to 6.91±1.20 pg/ml). Conclusion: Patients undergoing major abdominal surgery may profit from prophylactic perioperative administration of dopexamine hydrochloride in the form of improved haemodynamics and oxygenation as well as beneficial influence on important regulators of organ blood flow.     

Immunomodulation in Transplantation with Photopheresis

Abstract: Photopheresis is a technique in which peripheral blood mononuclear cells, in the presence of a photoacti-vatable compound, are exposed extracorporeally to ultraviolet A light and reinfused, inducing a host autoregula-tory immune response. Experimental work and ongoing clinical studies are helping to define the role of this novel, safe, and non-toxic immunomodulating technology in the field of transplantation.