右前胸小切口治疗先天性心脏病65例

目的总结应用右前胸小切口进行心内直视手术的治疗体会.方法1999年3月-2003年6月,我们采用右前胸小切口行心内直视下修补先天性房、室间隔缺损65例,其中房间隔缺损37例,室间隔缺损28例.结果所有患者无手术死亡及手术并发症.结论经右前胸小切口进行心内直视手术是一种安全可靠的微创手术,对一些简单的先天性心脏病有良好的手术和美容效果,但不适合比较复杂的心脏病手术.     

右腋下直切口心内直视手术166例

目的:总结166例右腋下直切口心内直视手术的外科治疗经验。方法:选择性地对先天性心脏病(先心病)、房间隔缺损、室间隔缺损及肺动脉瓣狭窄等患者采用右腋下直切口心内直视手术。结果:全组患者无手术死亡病例。术后引流量明显减少,1例2次开胸止血,余均顺利出院。术后出院天数和住院费用均减少。结论:对先心病采用右腋下直切口,手术失血少、损伤轻、术后恢复快、切口隐蔽并美观。     

婴儿右腋下直小切口心内直视术694例临床分析

目的:探讨右腋下直小切口在婴儿常见先天性心脏病(先心病)心内直视手术中的应用效果。方法:回顾性分析我院2009年4月至2014年12月,采用右腋下直小切口对694例婴儿先心病行心脏直视手术的临床资料,其中男性349例,女性345例,年龄2~12个月,平均(8.0±3.2)个月,体质量4.0~11.2kg,平均7.5kg。行室间隔缺损(VSD)修补术535例,房间隔缺损(ASD)修补术36例,VSD+ASD修补术56例,VSD修补术+二尖瓣成形术(MVP)9例,VSD修补术+ASD修补术+二尖瓣成形术(MVP)3例,肺动脉瓣狭窄(PVS)交界切开术15例,ASD修补术+PVS交界切开术11例,VSD修补术+PVS交界切开术3例,部分肺静脉异位引流(PAPVC)矫治术9例,部分房室管畸形(PECD)矫治术12例,法洛四联症(TOF)根治术5例。结果:手术死亡10例(1.44%),术后发生右肺不张4例,右侧气胸2例,肺部感染21例,切口液化19例,Ⅲ°房室传导阻滞1例,脑气栓1例,二次开胸止血5例。术后6个月至1年门诊随访595例(85.7%),发现VSD残余漏7例,右下肺不张1例,二尖瓣轻度关闭不全4例,二尖瓣中度关闭不全1例。结论:在婴儿常见先心病直视手术中选用右腋下直小切口,只要把握好手术适应症,熟练掌握技术操作要点,均可取得满意临床效果。     

30例右外侧开胸体外循环心内直视手术(摘要)

３０例右外侧开胸体外循环心内直视手术（摘要）达嘎李勇李忠诚武建英杨永良唐振宇姚兵我院自１９９５年９月至１９９６年１２月期间，为３０例先天性心脏病病人行经右侧第４肋间进胸体外循环心内缺损修补手术，现报告如下：１临床资料一般资料：本组３０例病人中，男性１...     

小切口心脏不停跳心内直视手术治疗先天性心脏病

目的总结小切口心脏不停跳心内直视手术治疗先天性心脏病的优点。方法2001年1月至2005年2月共完成小切口心脏不停跳心内直视手术76例,包括房间隔缺损48例、室间隔缺损22例、肺动脉狭窄4例、单心房2例。合并畸形包括二尖瓣关闭不全、三尖瓣关闭不全、部分肺静脉异位引流等。结果本组患者体外循环时间(43.1±12.4)min,术后机械通气时间(3.0±1.1)h,术后引流量(3.2±1.5)ml/kg,术后住院(7.2±1.1)d。全组无1例死亡。所有患者随访14～65个月,无并发症。结论小切口剖胸矫治先天性心脏病具有创伤小、不破坏胸廓的完整性、切口隐蔽美观、恢复快等优点。     

右腋下剖胸小儿心内直视术

目的 :探讨右侧剖胸小切口的手术要点及手术指征。　　方法 :本组 10 2例患者经右腋下小切口剖胸及体外循环下行小儿心内直视术 ,其中房间隔缺损 2 4例 ,室间隔缺损 6 8例 ,法乐四联症 5例 ,室间隔缺损合并房间隔缺损 3例 ,右心室双出口、Ebstein畸形各 1例。合并畸形 :左上腔静脉 4例 ,右心室双腔及动脉导管未闭各 1例。　　结果 :全组患者无死亡。　　结论 :切口的正确选择是术野良好显露的前提 ,主动脉插管是手术成功的关键。该切口适用于大部分常见先天性心脏病的矫治。     

胸骨下段小切口心内直视手术40例

目的介绍胸骨下段小切口心内直视手术体会。方法选择10岁以下房间隔缺损3例、室间隔缺损20例,纵劈胸骨上至第二肋间;10岁以上房间隔缺损5例、室间隔缺损3例、风湿性二尖瓣狭窄9例,纵劈胸骨上至第二肋间并向右侧横断。常规体外循环,胸正中小切口第三胸肋关节水平至剑突根部,完成心内直视手术。结果无手术死亡,平均主动脉阻断时间、体外循环时间、术后24h胸液量与对照组无明显差异。切口长度约为常规胸骨正中切口的60%。结论胸骨下段小切口可以顺利完成部分心内直视手术,美观且保留了胸廓的连续性,无胸骨前凸畸形。     

先天性心脏病右腋下小切口心内直视术的围术期护理

目的对先天性心脏病右腋下小切口心内直视术的围术期护理措施进行分析。方法选取我院2014年1月~2015年1月收治的先天性心脏病患儿90例作为研究对象,将其随机分为对照组与观察组,各45例。所有患儿均行右腋下小切口心内直视术。对照组患儿行常规护理干预,观察组患儿行综合性护理干预。观察患儿的手术效果,对比两组患儿的胸液引流量、呼吸机辅助时间及住院时间。结果患儿均顺利完成手术治疗,切口愈合良好。观察组患儿的胸腔引流量明显少于对照组,且呼吸及辅助时间、住院时间均短于对照组,差异有统计学意义(P0.05)。结论对先天性心脏病右腋下小切口心内直视术患儿加强围术期护理干预,能够确保手术顺利开展,提高手术效果,值得临床推广与应用。     

右外侧小切口剖胸矫治小儿先天性心脏病1972例

目的:总结右外侧小切口剖胸矫治先天性心脏病(先心病)的经验,探讨右外侧切口在先心病的应用与推广。方法 :2002年1月至2011年10月,本手术组经右外侧剖胸小切口完成1 972例小儿先天性心脏畸形矫治。其中男性1 143例,女性829例。年龄平均38.7个月(3～489个月),体质量平均11.6 kg(4.8～69 kg)。主要病种:室间隔缺损、房间隔缺损及法洛四联症等。结果 :术后并发症81例(4.1%):低心排出量综合征(低心排)26例(死亡3例)、严重肺部感染22例(死亡2例)、二次开胸止血8例(死亡1例)、多脏器功能衰竭4例(死亡1例)、一过性脑功能障碍5例、术后残余分流6例(经原切口再次手术1例)、右膈神经麻痹5例(1例膈肌折叠)、术后房室传导阻滞4例(1例置永久起搏器)、乳糜胸2例。随访3～108个月,3例法洛四联症存在残余梗阻26～50 mmHg(1 mmHg=0.133 kPa)观察中,1例二尖瓣成型术后大量反流行二尖瓣置换。结论:先心病可以在右外侧剖胸小切口下完成,该入路安全可靠、创伤小、暴露好并恢复快。     

右胸外侧小切口小儿先天性心脏畸形矫治术793例体会

目的 :介绍经右胸外侧小切口体外循环下小儿心脏直视手术的经验。　　方法 :经右外侧第 4或第 3肋间入胸 ,体外循环下先天性心脏畸形矫治术 793例。修补房间隔缺损 180例 ,室间隔缺损 45 2例 ,室间隔缺损合并房间隔缺损 32例 ,法乐四联症 95例 ,部分心内膜垫缺损 17例 ,二尖瓣关闭不全 7例及其他畸形 10例 ;合并畸形包括 :动脉导管未闭 ,左上腔静脉 ,肺静脉畸形引流 ,右心室流出道狭窄 ,单冠状动脉畸形等。　　结果 :本组患儿手术死亡 3例 (死亡率 0 .38% ) ,1例因术后低心输出量综合征 ,1例因严重肺部感染 ,1例因气管插管故障导致器官功能衰竭 ;其它患儿术后并发症少。　　结论 :这种切口可安全有效地替代正中剖胸矫治某些小儿常见的心脏畸形 ,它具有损伤小 ,瘢痕隐蔽 ,不破坏胸廓完整性 ,防止术后鸡胸等优点 ,符合微创外科的原则。     

Open-heart surgery in 48 patients via a small right anterolateral thoracotomy.

To limit the trauma to the chest and to achieve a pleasing cosmetic result, we used 2 types of right anterolateral thoracotomy in 48 patients who required open-heart surgery: 1 was a curved incision along the lower edge of the right breast in women with developed breasts; the other was a slanted incision for men and children. These surgical procedures took place between July 1996 and November 1997. Intraoperatively, a right atriotomy was used to repair 11 atrial septal defects and 11 ventricular septal defects, 2 combined atrial and ventricular septal defects, 1 case of a single atrium, and 1 partial atrioventricular canal. A right ventricular outflow tract incision was used to repair 7 ventricular septal defects and 7 ruptured aortic sinus aneurysm. A combination of a right atriotomy and right ventricular outflow tract incision was used for 2 repairs of combined atrial and ventricular septal defects, 3 radical corrections of tetralogy of Fallot, and 2 radical corrections of trilogy of Fallot. A combined right and interatrial septal incision was used for 6 mitral valve replacements and 1 mitral valvuloplasty. Smooth bypass cannulation and satisfactory intracardiac exposure were achieved with the right anterolateral thoracotomy. There was no complication or mortality directly related to the incision. We believe that the right anterolateral thoracotomy is safer and more effective than the median sternotomy for many common congenital and acquired heart diseases. The thoracotomy causes less trauma and results in a cosmetic appearance that is more acceptable to the patient.     

Comparison of clinical outcomes and postoperative recovery between two open heart surgeries:minimally invasive right subaxillary vertical thoracomy and traditional median sternotomy

Objective:To compare the clinical outcomes of minimally invasive right subaxillary vertical thoracotomy and traditional median sternotomy through right atrium in treatment of common congenital heart diseases.Methods:Clinical data of 59 cases of common congenital heart diseases treated with minimally invasive right axillary vertical thoracotomv from May,2011 to February,2013 and 77 cases of same diseases with traditional median sternotomy in the past three years were retrospectively analyzed,including atrial septal defect,membranous ventricular septal defect and partial endocardial cushion defect.The results were compared from the two groups,including the time for operation and cardiopulmonary bypass,amount of blood transfusion,postoperative drainage,ventilation time,hospital stay,and prognosis.Results:No severe complications happened in both groups,like deaths or secondery surgery caused by bleeding.No significant differences were in CPB time and postoperative ventilator time between groups(P0.05),while for all of the operative time,the length of incision,postoperative drainage and hospital stay,minimally invasive right axillary vertical thoracotomy was superior to median sternotomy,with statistically significant differences(P0.05).In six-month lollowup after operation,no complications of residual deformity and pericardial effusion were found in both groups bv doing echocardiography,but mild pectus carinatum was found in X patients in the traditional median sternotomy group(traditional groupi.whereas patients in another group were well recovered.Conclusions:Minimally invasive right subaxillary vertical thoracotomv for common congenital heart diseases is as safe as traditional median sternotomy,without the increasing incidence of postoperative complications.Additionally,compared with traditional median sternotomy,minimally invasive right subaxillary vertical thoracotomv is better in the aspects of hidden incision,appearance,and postoperative recovery.     

The correction of congenital heart defects with less invasive approaches

BACKGROUND: The minimally and less invasive approaches for the surgical treatment of different heart diseases are rapidly increasing because of their cosmetic and recovery-related advantages. Presented here are the results of less invasive surgery in 51 patients with congenital heart defects. METHODS: From June 1996 to January 1999, we used less invasive techniques for the correction of congenital heart defects in 51 patients. In 32 patients, we performed right anterolateral thoracotomy (6-13 cm), and on the other 19 patients, we used the partial inferior sternotomy (4-7 cm). The ascending aorta and the caval veins were cannulated in all patients. RESULTS: The following congenital heart defects were corrected: ostium secundum atrial septal defect (n = 35), sinus venosus atrial septal defect with partial anomalous pulmonary venous connection (n = 7), ventricular septal defect (n = 7), tetralogy of Fallot (n = 1), and cor triatriatum sinistrum (n = 1). The average age of the patients was 15 years old ranging from 2 months to 48 years and the average weight 39.6 kg (range 3.8-86 kg). The patients were removed from artificial respiratory support on average 8 hours (range 1-48 hours) after surgery and left the hospital after 7 days (range 2-10 days). In 16 patients, blood transfusions were required, an average 5.7 ml/kg BW (range 1.45-19.75 ml/kg BW). The postoperative course was uneventful in all patients. Follow-up (range 3-33 months, mean 17.5 months) was complete with no late deaths or residual defects. CONCLUSION: The right anterolateral thoracotomy and the partial inferior sternotomy provide a safe approach for the correction of certain congenital heart defects. These techniques enable operative correction without any additional risks being incurred and can be performed with standard instruments and cannulation. Additional approaches for extracorporeal circulation are unnecessary.     

Anterolateral Minithoracotomies for the Radical Correction of Congenital Heart Diseases

During the past 10 years, minimally invasive surgical techniques have been applied more and more widely in both adult and pediatric populations, especially in female patients. Right anterolateral minithoracotomy is an alternative to median sternotomy that yields a better cosmetic outcome.From May 1997 through September 2008, 132 patients (107 females, 25 males) underwent open-heart surgery through right anterolateral minithoracotomy. Ages ranged from 1 to 49 years (mean, 10.12 yr). Mean body weight was 21.3 kg (range, 9.4–78 kg). Corrected defects included atrial septal defect, partial anomalous pulmonary venous connection, partial atrioventricular canal defect, ventricular septal defect alone or with pulmonary valve stenosis, tetralogy of Fallot, cor triatriatum, mitral valve defect, and pericardial cyst. The anterolateral skin incision was 5 to 7 cm.Our control group—which in the same period underwent the same interventional procedures through median sternotomy—consisted of 415 patients, 245 of whom were female (59%).There was no early or late death or major illness as a sequela. No patient required conversion to full sternotomy. All patients had gratifying cosmetic results at longer follow-up. Indeed the mortality and morbidity rates obtained through our approach were almost the same as those obtained through median sternotomy, and there were no significant differences in cardiopulmonary bypass time, aortic cross-clamp time, ventilation time, or postoperative hospital stay.We conclude that the right anterolateral minithoracotomy for correction of congenital heart defects offers superior cosmetic results without increasing morbidity or mortality rates and confers upon patients psychological and social satisfaction.Key words: Adolescent, adult, breast/growth & development, cardiac surgical procedures/methods, child, child, preschool, esthetics, heart defects, congenital/surgery, patient satisfaction, pectoralis muscle/growth & development, retrospective studies, surgical procedures, minimally invasive/methods, thoracic surgery/adverse effects/methods, thoracotomy/methods, treatment outcomeMedian sternotomy has been the conventional approach for the correction of cardiac defects for many years. However, during the past 10 years, minimally invasive surgical techniques have been applied more and more widely in both adult and pediatric populations, especially in female patients.^1–5 Potential advantages include improved cosmetic results and comfort for the patient, as well as shorter hospital stays that reduce total costs.⁶ Nevertheless, whether minimally invasive approaches actually reduce postoperative pain and bleeding and improve respiratory function is still a matter of controversy.^2–5 This retrospective study reviews our experience with the use of right anterolateral minithoracotomies (RAMTs) for radical correction of congenital heart diseases.     

右外侧小切口剖胸先天性心脏病矫治术近远期疗效观察

目的:调查右外侧小切口先天性心脏病(先心病)矫治术近、远期疗效。方法:1994年10月至2004年4月,所完成的1 386例右外侧小切口先心病矫治术患者为完全组,其中单纯室间隔缺损矫治术患者共488例为处理组,随机抽取同期185例相同年龄正中开胸室间隔缺损修补术患者为对照组。调查以上患者近、远期疗效。近期疗效包括体外循环时间、心肌阻断时间、术后机械通气时间、术后引流液量、术后住院时间、院内死亡情况及并发症发生情况等。远期疗效包括与心脏有关的症状、异常体征及收到随访信1个月以内的超声心动图、胸片及心电图等检查结果。结果:完全组病种包括房间隔缺损、室间隔缺损、法乐氏四联症及部分心内膜垫缺损;共死亡9例(0.65%),并发症发生37例(2.67%)。与对照组相比,处理组在引流液量(106.71 mL vs.146.70 mL)、鸡胸(零例vs.3例)发生等方面具明显优势。结论:右外侧小切口先心病矫治术近、远期疗效不落后于甚至优于正中开胸手术。     

微创右前外小切口房间隔缺损修补术38例分析

目的:正中开胸行房间隔缺损(atrial septal defects,ASD)修补术是一项低风险和高效的手术方式,而右前外小切口微创手术由于其创口小,效果好而成为一种更好的选择。本文总结38例右前外小切口修补成人ASD的临床经验。方法:从2010年4月至2012年10月,共完成各类微创ASD患者38例,其中男性10例,女性28例,年龄平均(33.3±13.0)岁。手术操作特别关注以下几点:右前外小切口,长约4～6 cm,女性患者注意保护乳腺组织,预防膈神经损伤,均采用股动静脉插管,经胸阻断升主动脉。结果:患者中有21例为不停跳手术,体外循环时间平均(61.3±19.3)min;心脏停跳患者17例,体外循环时间平均(78.6±28.6)min,主动脉阻断时间平均(45.0±26.1)min。术后住院时间平均(5.7±2.2)d,未输血率81.6%。无手术死亡,无围术期并发症,无膈神经损伤。术后1例患者由于肝素诱发的血小板减少而导致大量渗血。出院超声检查无残余漏,对小切口美观效果感到非常满意的达73.68%,感到满意的有26.32%,无胸廓畸形和膈神经损伤。结论:右前外小切口微创手术方法治疗ASD,是安全可靠的,具有良好的美观效果。因此,推荐作为ASD修补的标准方法,尤其是女性患者。     

胸骨下段小切口心脏不停跳心内直视手术

目的评价胸骨下段小切口心脏不停跳心内直视手术的价值.方法2004年7月至2005年6月采用胸骨下段正中小切口、体外循环下心脏不停跳心内直视手术共25例,其中房间隔缺损10例,室间隔缺损13例,肺动脉瓣狭窄1例,法乐三联症1例.结果25例均治愈,无术后并发症,术后住院时间6～8 d.随访1～11个月,心功能恢复良好,无残余畸形.结论胸骨下段小切口心脏不停跳心内直视手术是一种安全、有效且创伤小的技术.     

Minimal access via lower partial sternotomy for congenital heart defects

To evaluate the invasiveness of a minimal access approach for simple congenital heart defects, and determine whether it can be regarded as a standard operation, 83 patients with an atrial septal defect and 73 with a ventricular septal defect underwent repair through a minimal skin incision and lower partial median sternotomy. There were no operative deaths, severe intraoperative complications, or conversion to full sternotomy. The clinical course of 106 patients was compared with that of 21 treated using a full sternotomy by the same surgeon; there were no significant differences, except in the operative time for ASD patients. The clinical courses of 2 minimal access subgroups (50 patients operated on by residents and 106 treated by the staff surgeon were compared; operative time, bypass time, ventricular fibrillation time (ASD repair), and cardiac arrest time (VSD repair) were significantly shorter in those operated on by the staff surgeon, but there was no difference in clinical course. The minimal access approach produced good cosmetic results, its invasiveness was similar to that of a full sternotomy, and it may be considered a standard operation for pediatric patients with septal defects.     

Intraoperative Device Closure of Atrial Septal Defects with Minimal Transthoracic Invasion: A Single-Center Experience

Atrial septal defect is one of the most common congenital heart defects. Open-heart repair via midline sternotomy or right thoracotomy and cardiopulmonary bypass has been considered the standard treatment for the closure of atrial septal defects, but transcatheter closure with the Amplatzer septal occluder has recently become a viable option. We have adopted a 3rd alternative: intraoperative device closure with minimal transthoracic invasion.From May 2007 through June 2011, 250 patients with secundum atrial septal defect underwent cardiac surgery at our institution. Open-heart repair with cardiopulmonary bypass was performed in 72 patients, and intraoperative device closure was performed in 178 patients. This minimally invasive approach, which required a full evaluation of the atrial septal defect by transthoracic echocardiography, was performed by deploying the device through the delivery sheath to occlude the atrial septal defect. The approach was successful in 175 of the 178 patients. The size of the implanted occluder ranged from 12 to 46 mm in diameter. Minor complications included transient arrhythmias (n=7) and pleural effusion (n=25). After complete release, the intraoperative occluder device dislodged in the right atrium in 3 patients, who then underwent immediate surgical repair with cardiopulmonary bypass. All discharged patients were monitored for 2.3 years to 5 years.As monotherapy, intraoperative device closure of atrial septal defect with minimal transthoracic invasion is a safe and feasible technique. It is particularly beneficial for elderly patients or patients with pulmonary hypertension and is associated with better cosmetic results and less trauma than is surgical closure.Key words: Heart defects, congenital; heart septal defects, atrial/therapy; prosthesis implantation; retrospective studies; septal occluder device; surgery, minimally invasive; treatment outcome; ultrasonography, interventionalAtrial septal defect (ASD), one of the most common congenital cardiac defects, accounts for approximately 6% to 10% of all congenital heart disease.¹ Most pediatric patients with ASD are asymptomatic and could await elective surgical or catheter-based closure until reaching school age. Open-heart repair via a midline sternotomy or right thoracotomy and with the aid of cardiopulmonary bypass (CPB) has been considered the standard treatment for closure of ASDs. In recent years, transcatheter closure with the AMPLATZER septal occluder (St. Jude Medical, Inc.; St. Paul, Minn) has become another standard treatment for most ostium secundum ASDs.² Although the safety and feasibility of both methods have been demonstrated, the use of CPB is still necessary in association with surgical secundum ASD closure, and the midline incisions cause physical and psychological trauma. Catheter-based closure requires “selective and suitable” patients, and the exposure to radiation is contraindicated for small children.^3–5 Our approach is to use an intraoperative device and minimally invasive surgery for ASD closure, which improves the cosmetic results compared with open-heart surgery. The aim of the present retrospective study was to evaluate the safety and feasibility of intraoperative device closure of secundum ASDs via minimal transthoracic invasion.     

介入技术和外科手术同期"复合"治疗先天性心脏病的临床研究

目的结合介入器械和外科手术,实施“复合（Hybrid）”技术对先天性心脏病实施治疗。方法2005年3-10月,20例先天性心脏病患者接受了术中Hybrid技术治疗。球囊扩张组包括3例室间隔完整型肺动脉闭锁的新生儿和4例婴儿重度肺动脉瓣狭窄。缺损封堵组13例,包括10例房间隔缺损和3例多发室间隔缺损。正中或右侧腋下小切口进胸,在超声引导下经右室流出道置入球囊扩张管扩张肺动脉瓣或经右心房置入封堵器。2例多发室间隔缺损于体外循环下经三尖瓣置入封堵器。合并的其他心脏病变同期常规外科矫正,术式包括部分性肺静脉异位引流矫正、动脉导管结扎、冠状动脉旁路移植术等。术后心脏超声随访。结果患者全部顺利出院。1例婴儿重度肺动脉瓣狭窄术后2个月接受常规右室流出道成形术,1例多发肌部室间隔缺损因无法置入封堵器而转为常规术式。其余患者均顺利实施Hybrid术式。随访期内未发现介入器材相关的并发症。结论“复合”Hybrid技术可以避免体外循环,减少手术创伤,对于提高先天性心脏病的疗效具有重要的意受．