自体冷血停跳液保护未成熟心肌的价值

目的研究自体冷血停跳液在婴幼儿心内直视手术中保护未成熟心肌的价值。方法婴幼儿（体重≤8k）非发绀型先天性心脏病30例,随机分为自体冷血（A组）、冷血（B组）和晶体（C组）停跳液组,每组10例。分别于术前,术毕,术后24、48h经桡动脉抽血检测心肌肌钙蛋白I（cTnI）及磷酸肌酸激酶同功酶（CK—MB）,术中记录复跳时间、室颤发生率和自动复跳率,术后监测心脏指数（CI）。结果术后cTnI和CK—MB明显升高,以后逐渐下降,同组手术前、后比较,cTnI术毕明显升高（P〈0．01）,CK—MB术后24h达到高峰（P〈0．05、P〈0．01）。A组与B组、C组比较,复跳时间、cTnI和CK—MB差异有统计学意义（P〈0．05、P〈0．01）;CIA组优于B和C组;室颤发生率和自动复跳率各组差异无统计学意义。B组与C组比较,复跳时间和cTnI差异有统计学意义（P〈0．05）;CIB组优于C组。结论自体冷血停跳液优于冷血和晶体停跳液,对婴幼儿心内直视手术保护未成熟心肌有重要价值。     

冷血停跳加温血诱导、复苏再灌注的心肌保护价值

目的；评价体外循环间断冷血停跳液加温血诱导复苏再灌注在心脏瓣膜置换术中心肌保护的价值。方法：在90例心脏瓣膜置换术中分别采用冷血停跳液加温血诱导复苏再灌注（Ⅰ组）和冷晶体灌注（Ⅱ组），每组各45例，比较其心肌保护疗效。Ⅰ组先用高钾温血停跳液（35℃）诱导心脏停跳。再用冷血低钾停跳液（4－8℃）每15－20分钟灌注1次，保持心肌低温（10℃－15℃），复跳前再用含低钾温血灌注。Ⅱ组应用4℃冷晶体停跳液灌注，每间隔20分钟灌注1次。结果：Ⅰ组心脏自动自动复跳率明显高于Ⅱ组（P＜0．001）；术后应用正性肌力药物剂量及时间明显于Ⅱ组（P＜0．05）；术后低心排症发生率明显低于Ⅱ组（P＜0．05）；在主动脉开放30分钟后Ⅰ组的cTnT,CK-MB及MDA水平升高明显低于Ⅱ组（P＜0．05）。结论：采用冷血停跳液加温血诱导、复苏再灌注技术，可明显减轻心肌再灌注损伤，使术后心功能恢复加快，具有良好的心肌保护作用。     

温血停跳液持续灌注与冷晶体停跳液间断灌注对心肌保护作用的比较

本文从临床效果、心肌酶代谢及细胞超微结构的变化方面，比较温血停跳液持续灌注与冷晶体停跳液间断灌注对心肌的保护作用。结果为，常温组术后自动复跳率为９２．３％，低温组仅２３．１％；常温组心肌酶释放减少，术后心脏功能恢复较快；心肌超微结构观察显示常温组细胞线粒体损伤较轻，心肌破坏较少。表明常温体外循环行温血停跳液持续灌注，对心肌的保护作用较以往的低温体外循环用冷晶体停跳液间断灌注为佳。     

体外循环中不同温度停跳液的心肌保护作用

详尽论述了不同温度心肌停跳液的发展 ,低温停跳液和常温含血停跳液各自的优势及不足之处 ,并介绍了近年来有关低温和常温含血停跳液联合应用的报道     

温血停跳液的心肌保护作用

近二十年来，低温停跳液一直被视作为心脏直视手术心肌保护的必要措施。温血停跳液灌注的倡用使人们对低温的某些不足，如冷收缩、微循环失调、血管内皮细胞损伤等引起了重视。然而常温心脏手术也存在一定的局限性。温血停跳液诱导使心肌对缺血缺氧的耐受增高，主动脉开放前温血灌注可改善再灌注损伤。     

St.Thomas NO.2停跳液与含血心肌停跳液对未成熟兔心肌的保护作用

比较观察St.ThomasNO .2停跳液与含血心肌停跳液对未成熟兔心肌的保护作用 ,以期为未成熟心肌保护的临床应用找到一种更有效的方法。选用生后 14～ 2 1天新西兰兔 12只 ,在改良的Langendorff模型上 ,对St.ThomasNO .2停跳液及含血心肌停跳液分别进行低温缺血再灌注离体心脏实验。观察缺血前后心功能变化 (左心室最大压力变化速率、左心室搏出功、左心室搏出功指数及心输出量等指标 )、心肌含水率及心肌酶学的变化。结果发现 ,离体心脏缺血再灌后 ,含血心肌停跳液组左心室最大压力变化速率、左心室搏出功、左心室搏出功指数和心输出量等心功能指标恢复明显好于St.ThomasNO .2停跳液组 (P <0 .0 5 ) ;含血心肌停跳液组心肌肌酸激酶及乳酸脱氢酶漏出率与St.ThomasNO .2停跳液组相比明显降低 (P <0 .0 5 ) ;但两组心肌含水率无明显差异。结果提示 ,初步证实含血心肌停跳液对未成熟心肌的心肌保护效果比St.ThomasNO .2停跳液效果好     

心脏瓣膜手术中冷氧合血与冷晶体停跳液保护心肌作用的比较(附20例报告)

将20例行心脏瓣膜置换术的患者随机分为两组，分别在体外循环期间采用冷氧合血停跳液及冷晶体停跳液。通过监测围术期，术后24h的血流动力学变化，心脏自动复跳率及复跳时间，开放主动脉后6h心肌肌钙蛋白T（cTnT)的变化，术后标准Ⅱ导联心电图变化和临床强心药物使用及患者在危重监测病房（ICU）停留时间等，对比观察两组的心肌保护效果。结果：冷氧合血停跳液组（氧合血组）的心脏自动复跳率及自动复跳时间优于冷晶体停跳液组（冷晶体组）；开放主动脉后6h cTnT含量少于冷晶体组，两组术中及术后24h内血流动力学变化无差异。认为冷氧合血停跳液的心肌保护效果优于冷晶体停跳液。     

常温体外循环间断4：1温血停跳液灌注的心肌保护

良好的心肌保护方法不仅要提供有效的心肌保护 ,同时亦为了提供良好的操作环境。不同的心肌保护方法各有特点 ,不能相互取代。当今心肌保护在于综合利用各种心肌保护方法 ,相互弥补[1] 。1997年至 1998年对 10 6例冠脉搭桥患者采取不同的综合心肌保护方法取得较好的效果 ,现将结果报告如下。资料与方法选 1997年至 1998年ＣＡＢＧ术 10 6例随机分为 2组 ,温血组 (Ｗ组 ) 74例 ,冷血组 (Ｃ组 ) 32例。 2组病人术前临床资料无明显区别 (表 1)。常规建立体外循环 ,右心房二级静脉插管 ,升主动脉根部动脉插管及顺行停跳液灌注管并接多头灌注管 ,…     

复跳前控制性温血停跳液灌注的心肌保护作用

目的探讨复跳前自体氧合温血停跳液控制性灌注在体外循环手术中对心肌缺血再灌注损伤的保护作用.方法选择256例复杂或重症患者,随机分为对照组128例,实验组128例.常规在体外循环下进行各种手术,均采用4℃ThomasⅡ号液间断顺灌行心肌保护.实验组在主动脉开放前约5min,用4:1自体氧合温血停跳液控制性灌注(压力:50mmHg,量:10ml/kg,流量:100～200ml/min,温度:35℃).分别在阻断主动脉前和开放主动脉后0,1,6,24h测定心肌酶,比较二组自动复跳率、复跳后血流动力学、围术期升压药应用、心律失常发生率、病死率、术后心功能等指标.结果实验组心肌酶含量低于对照组(P＜0.05),其余各指标优于对照组(P＜0.05).结论复跳前控制性温血灌注对心肌缺血有良好保护作用,方法简单、可行,值得临床应用.     

加锌停跳液心肌保护的动物实验研究

本实验显示锌在心肌缺血、再灌注中,既能阻止氧自由基产生,加强清除自由基能力,稳定心肌细胞膜,又可作为Ca~(11)拮抗剂和抗氧化物质,最终减少了心肌摄Ca~(11)并降低心肌张力,加强对ATP的保护,有利于心功能的恢复。本实验结果初步显示,冷钾停跳液加锌可有效地预防或减轻长时间心脏缺血及再灌注损伤,是心肌保护课题中值得进一步研究较为理想的物质。     

Effect of dexmedetomidine on perioperative hemodynamics and organ protection in children with congenital heart disease: A randomized controlled trial

Background:This study aimed to investigate the effects of dexmedetomidine (Dex) on hemodynamics and organ protection in congenital heart disease (CHD) children who underwent open-heart surgery under cryogenic cardiopulmonary bypass.Methods:Ninety children were randomly allocated to group C (0.9% saline 0.2 μg/kg/hour), group D1 (Dex 0.2 μg/kg/hour), and group D2 (Dex 0.4 μg/kg/hour) (n = 30 per group). All participants received fentanyl, propofol and 1% sevoflurane for anesthesia induction. Hemodynamic data were measured from T0 (before the induction) to T7 (30 minutes after extubation). The difference of arterial internal jugular vein bulbar oxygen difference and cerebral oxygen extraction ratio were calculated according to Fick formula. Enzyme-linked immunosorbent assay was performed to detect the serum myocardial, brain and kidney injury markers. The incidence of acute kidney injury (AKI) was calculated by serum creatinine level. Tracheal extubation time, postoperative pain score and emergence agitation score were also recorded.Results:Compared with group C, group D1, and D2 exhibited reduction in hemodynamic parameters, myocardial and brain injury indicators, and tracheal extubation time. There were no significant differences in blood urea nitrogen and neutrophil gelatinase-associated lipocalin or incidence of AKI among the 3 groups. Besides, the incidence of tachycardia, nausea, vomiting and moderate agitation, and the FLACC scale in group D1 and D2 were lower than those in group C. Moreover, Dex 0.4 g/kg/hour could further reduce the dosage of fentanyl and dopamine compared with Dex 0.2 g/kg/hour.Conclusions:Dex anesthesia can effectively maintain hemodynamic stability and diminish organ injuries in CHD children.     

常温体外循环心脏跳动中矫治婴幼儿先心病35例

目的 :观察常温体外循环心脏跳动中矫治婴幼儿先天性心脏病的疗效。方法 :4月～ 3岁婴幼儿先天性心脏病患儿 35例 ,采用常温体外循环在心脏跳动中进行心内直视修补手术。结果 :全组无 1例早期死亡 , °房室传导阻滞 2例 ,无低心排、肺动脉高压危象、呼吸衰竭需气管切开病例 ,痊愈出院 35例。结论 :在婴幼儿先天性心脏病心内直视修补手术中采用常温体外循环心脏不停跳方法是可行、可靠的。     

双心房输注在并发肺动脉高压的复杂性先天性心脏病患儿手术中的应用评价

目的：评估双心房输注对并发肺动脉高压的复杂性先天性心脏病患儿（复杂先心病）术后血流动力学的影响。方法：择期行复杂先心病矫治术的患儿46例,年龄6月一5岁,体质量5～19kg,心功能分级Ⅱ或Ⅲ级,随机分为两组（每组n=23）：双心房输注组（经左房泵入具有血管收缩作用的正性肌力药,从右房或肺动脉泵入血管扩张药物）和右心房输注组（直接经右房泵入具有血管收缩作用的正性肌力药和血管扩张药物）。腔静脉开放后常规给予血管活性药物,双心房输注组经中心静脉输注米力农0．5～0．75μg／（kg·min）,经左心房输注多巴胺5～lOμg/（kg·min）、肾上腺素0．03～0．1μg／（kg·min）。右心房输注组经中心静脉输注米力农0．5-0．75μg／（kg·rain）、多巴胺5-10μg/（kg·min）、肾上腺素0．03～0．1μg／（kg·min）。分别于给药前5min（TO）、给药后5min（T1）、10min（T2）、30rain（耶）和60min（T4）时记录平均动脉压（MAP）、HR、平均肺动脉压（MPAP）、左心房压（LAP）、中心静脉压（CVP）和心排出量（CO）,计算肺血管阻力指数（PVRI）、体循环血管阻力指数（SVRI）和心指数（cI）。结果：与11D时比较,双心房输注组T1一T4时MAP、CI和SVRI升高,HR、MPAP、T｜AP、CVP和PVRI降低（均P〈0．05）;右心房输注组T1～T4时MAP、MPAP、LAP和PVRI降低,cI升高（均P〈0．05）,HR、CVP和SVRI差异无统计学意义。与右心房输注组比较,双心房输注组MAP、CI和SVRI升高,HR、MPAP、LAP、PVRI和CVP降低（均P〈0．05）。结论：双心房输注可改善复杂先心病患者矫治术后左心排血功能,降低肺动脉压和肺循环血管阻力。     

Transesophageal echocardiography for congenital heart disease

Surface echocardiographic imaging of small children is routinely successful in defining anatomical details and Doppler flow patterns with even the most complex congenital cardiac malformations. However, in larger children or adults, imaging is frequently limited. A recent expansion of the role of echocardiography is intraoperative epicardial imaging. Epicardial and postoperative imaging, however, have significant limitations. To avoid some of these limitations, transesophageal echocardiography has increasingly been used in the arena of congenital heart disease. The more recent development of small sized gastroscopic probes has allowed transesophageal echocardiographic assessment of congenital heart disease in children down to newborn size. As detailed studies of individual lesions are reported, it has become clear that the mere presence of a congenital heart defect is not an indication for transesophageal echocardiography in most children if imaging can be accomplished by surface examination. However, transesophageal echocardiography may be indicated for the intraoperative or postoperative assessment of that defect, particularly when repair has been difficult or is known to be associated with significant residual abnormalities. Cardiac structures encountered with horizontal and vertical imaging plane transducers have been described and should be completely familiar to the examining echocardiographer.     

Interventional therapy for neonates with critical congenital heart disease

Transcatheter interventional therapies for children continue to evolve at a remarkable rate. Perhaps no where are these procedures more important than in the critically ill newborn. In this core curriculum review article several of the most commonly performed interventions performed in critically ill newborns are discussed with regards to technique and outcomes. © 2008 Wiley‐Liss, Inc.     

The prevalence and risk factors for cholelithiasis and asymptomatic gallstones in adults with congenital heart disease

Purpose

Cyanosis is considered to be a risk factor for cholelithiasis which is an important complication of cyanotic congenital heart disease (CCHD) in adults. In this study, the prevalence of cholelithiasis and asymptomatic calcium bilirubinate gallstones was evaluated in adults with congenital heart disease (CHD). Furthermore, risk factors for this potentially high risk complication were assessed.

Materials and methods

Subjects were derived from 114 consecutive congenital patients who visited our center from May 2008 to January 2009. For analyses of risk factors, we divided them into 4 groups: group A, 15 CCHD patients without reparative surgery (7 men, 31.8 ± 7.0 years old); group B, 41 CCHD patients rendered acyanotic by reparative surgery (21 men, 32.5 ± 11.8 years old); group C, 23 unoperated acyanotic CHD patients (11 men, 42.4 ± 16.4 years old); and group D, 35 patients who were acyanotic before and after operation (18 men, 36.3 ± 14.8 years old). Gallstones were identified by abdominal ultrasound and risk factors were analyzed by a multivariate logistic regression model.

Results

Cholecystectomy was performed in 5/114 (4.3%), asymptomatic gallstones were seen in 16/114 (14%), and symptomatic gallstones except for patients after cholecystectomy were seen in 7/114 (6.1%). In group A, 4 (27%) with gallstones underwent cholecystectomy (p < 0.01). Non-cholesterol gallstones were observed in 5 patients (33%) in group A, 12 patients (29%) in group B, nobody in group C, and 3 patients (8.6%) in group D. By a multivariate logistic regression model, CCHD by nature regardless of repair, prolonged cyanosis periods, higher frequency of cardiopulmonary bypass (CPB), and lower platelet counts were significant factors predicting gallstones (odds ratio 4.48, 1.08, 3.96, and 0.87, 95% CI, 1.14-17.5, 1.00-1.18, 1.65-9.54, and 0.75-0.99, respectively).

Conclusions

The prevalence of cholelithiasis and asymptomatic gallstones is significantly high in CCHD patients regardless of cardiac repairs. CCHD by nature, prolonged cyanosis durations, high frequency of CPB and low platelet counts have influences on gallstone formation in adults with CHD.     

The whole adult congenital heart disease patient

Adults with congenital heart disease (CHD) have unique medical and psychosocial needs. They require lifelong cardiac surveillance from medical providers with training and expertise in the care of adults with CHD. Patients with CHD must recognize the importance of ongoing surveillance and must not be lost to care in childhood, adolescence, or adulthood. This can be accomplished with the implementation of a comprehensive transition program with the collaboration of patients, parents, and both pediatric and adult health care providers. Finally, consideration of the “whole” patient demands recognition of the unique medical and psychosocial challenges of adults with CHD.     

Magnetic resonance imaging of complex congenital heart disease

Current MR techniques enable both anatomical and functional evaluations of the heart. Although it is rarely used as a primary diagnostic tool in pediatric cardiology, it can be used as a valuable adjunct to echocardiography and angiography. MRI is particularly useful in clarification of morphology of complex congenital heart diseases. It is the most accurate method of determination of visceral and atrial situs. It is easy to evaluate the systemic and pulmonary venous connections that are very important for the Fontan type of operation, especially in patients with visceral heterotaxy. It facilitates demonstration of diminutive pulmonary arteries in patients with pulmonary atresia. It clearly demonstrates juxtaposition of the atrial appendages that is often missed by echocardiography. The anatomy of the twisted atrioventricular connections is much more clear in MRI than in echocardiography. It enables en face imaging of ventricular septal defect that provides a surgical view. We find en face imaging particularly helpful in patients with double inlet left ventricle and transposition of the great arteries where the size of the ventricular septal defect governs the blood flow into the aorta. It is often advantageous to echocardiography in defining the type of univentricular atrioventricular connections by demonstrating the position and topology of the rudimentary chamber in difficult cases. In double outlet right ventricle, the spatial relationship of the ventricular septal defect to the great arterial valves can be clearly defined by visualizing the ventricular septal defect and the outlet septum in the same imaging plane.     

保护性肺通气在婴儿先天性心脏病术中的应用

【】 目的 探讨体外循环下行先心纠治术的婴儿进行保护性肺通气的临床可行性及效应。方法 20例选择性体外循环下主动脉阻断行先天性心脏病根治术的婴儿(≤1岁),术中行小潮气量通气,体外循环停机后行肺复张,并监测压力-容量环和肺动态顺应性确定最佳PEEP值通气至术毕。监测保护性肺通气过程中基本生命体征及不良反应情况,并比较体外循环停机超滤后(T1)、肺复张后(T2)及出手术室前(T3)患儿氧合指数(PaO2/FiO2)、气道峰压( Ppeak) 、肺动态顺应性(Cdyn)、肺泡动脉血氧分压差(A-aDO2)、Pa-ETCO2、肺内分流率(Fshunt)。结果 所有患儿基本生命体征指标均处于正常稳定范围,无严重不良反应。T2较T1时,PaO2/FiO2、Cdyn增加(P<0.01),A-aDO2及Fshunt减小(P<0.01),Ppeak降低、Pa-ETCO2减小P<0.05)。其中,PaO2/FiO2、C、A-aDO2及Fshunt的改变效应可维持至T3。 结论 保护性肺通气策略可安全地应用于婴儿体外循环下先天性心脏病手术中,并可改善患儿体外循环后氧合、肺顺应性,弥散功能、及通气血流比,降低气道阻力,减小肺内分流。