右胸前外侧小切口修补室间隔缺损

1998年 12月至 2 0 0 0年 10月 ,我们采用右胸前外侧小切口治疗先天性心脏病室间隔缺损患者 2 0例 ,收到良好效果 ,现报告如下。临床资料 :本组男 12例 ,女 8例 ;年龄 2～ 17岁 ,平均 6岁。因查体发现心脏杂音或存在不同程度的活动后心慌气短就诊。体格检查示胸骨左缘第三、四肋间可闻及 3～ 4级收缩期杂音 ,P2 亢进。心电图示正常 9例 ,左心室肥厚 6例 ,双室肥厚 5例。胸部 X线片示肺血流量增加 ,左或右心室增大。彩色多普勒超声检查均明确诊断为先天性心脏病室间隔缺损。2 0例患者均于中度低温体外循环下施行手术。患者在手术台上的位置…     

112例经右外侧小切口下行房间隔缺损修补术的体会

目的:通过分析右外侧小切口行房间隔缺损修补术的病例,探讨右外侧小切口在房间隔缺损修补术的应用与推广。方法:2011年1月至2011年9月,112例房间隔缺损修补术在右外侧小切口下完成。其中男性44例,女性68例。年龄平均58.7个月(6～489个月),体质量平均16.6kg(4.8～69kg)。20例合并心脏畸形如三尖瓣关闭不全,部分肺静脉异位引流,永存左上腔静脉。结果:术后2例出现早期血痰,1例出现神经系统并发症,1例引流偏多。均获得定期随访,随访时间3～12个月,无死亡,超声心动图示无残余分流,无胸廓畸形。结论:房间隔缺损修补术可以在右外侧小切口下完成,该入路安全可靠,创伤小,暴露好,恢复快及美观效果强。     

2～6个月婴儿右侧开胸室间隔缺损修补手术的体会

目的:总结2～6个月婴儿经右侧开胸室间隔缺损(VSD)修补手术的结果,探讨小切口手术在婴儿手术应用的适应证、禁忌证及技术关键点。方法:2011年1月至9月完成2～6个月小婴儿经右侧开胸VSD修补手术108例,男性67例,女性41例。平均年龄4.56个月(2～6个月),平均体质量6.37 kg(3.8～9 kg)。VSD分型,膜周部81例,嵴下型8例,干下型19例,心内膜垫型1例,多发VSD 1例。与同期同年龄段经正中开胸40例,7～12个月右侧开胸78例室缺修补手术过程及效果进行比较。结果:本组手术无死亡,术后并发症较少。结论:右侧开胸可以在多数2～6个月婴儿室缺修补术中应用。少数具有一定特殊性的病例,可以选择传统的正中开胸方式。     

右外侧小切口剖胸矫治合并心底部畸形的室间隔缺损体会

目的:总结经右外侧小切口剖胸矫治合并心底部畸形的室间隔缺损(VSD)手术方法及临床疗效。方法:总结经右侧剖胸入路矫治合并简单心底部畸形(动脉导管未闭和/或永存左上腔静脉)的VSD 16例(R组),同期经右侧剖胸入路矫治不合并心底部畸形的VSD 144例(C组),R组在矫治心内畸形的同时,游离结扎动脉导管或游离阻断左上腔静脉。通过对比体外循环时间、主动脉阻断时间、术后机械通气时间、术后引流量、监护室时间以及术后住院时间,观察处理简单心底部畸形对手术的影响和治疗效果。结果:与C组相比较R组体外循环时间[(65.31±17.10)vs.(55.02±15.97)min P<0.05]明显延长,但主动脉阻断时间[(33.44±8.02)vs.(31.40±10.12)min]、术后机械通气时间4.25 hvs.13.08 h、术后引流量88.44 mL vs.89.83 mL、监护室时间2.38 d vs.1.95 d、术后住院时间[(7.88±1.82)vs.(7.88±2.30)d],差异无统计学意义。2组均无死亡及严重并发症,C组有8例患儿术后血痰,1例肺部感染;R组2例血痰。结论:经右外侧小切口剖胸入路矫治合并简单心底部畸形的VSD安全可行。     

右腋下小切口剖胸矫治5公斤以下婴儿室间隔缺损

目的:探讨右腋下小切口剖胸心内直视手术矫治5 kg以下婴儿室间隔缺损的安全性和手术效果。方法:与正中切口手术的病例(正中组,n=113)比较,分析右腋下小切口剖胸(右侧组,n=85)矫治婴儿室间隔缺损的效果,评价指标包括:术前资料、围术期指标、术后病死率及并发症。结果:两组病例大多术前指标差异无统计学意义(P0.05),仅正中组体质量[(4.61±0.41)vs.(4.95±1.18)kg,P0.05]、体表面积[(0.27±0.02)vs.(0.28±0.01)m2,P0.05]、术前有肺炎史的病例所占比例(44.2%vs.64.7%,P0.05)低于右侧组。右侧组手术切口小于正中组[(6.01±0.85)vs.(9.13±1.04)cm,P0.05],手术时间[(143.64±22.41)vs.(152.12±22.80)min,P0.05]、术后住院时间较正中组短[(7.13±2.60)vs.(8.86±3.67)d,P0.05],引流量[14.6(12,16)vs.16.4(13,20)mL/kg,P0.05]和输血量[10(0,20)vs.11.1(0,20)mL/kg,P0.05]也较正中组少,两组其他围术期指标类似(P0.05)。结论:右腋下小切口剖胸心内直视手术矫治婴儿室间隔缺损病例的效果确切、可靠。     

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。     

389例先天性心脏病右外侧小切口剖胸心内直视手术

目的:总结经右胸外侧小切口体外循环下行先天性心脏病心内直视手术经验。方法:1996年11月至2011年12月,我科室应用右胸小切口完成各类先天性心脏病(先心病)的心内直视手术389例。年龄1.5～57岁,平均13.5岁。体质量7.6～68 kg,平均24.5 kg。手术切口后缘自右腋中线第3肋间处,向前下斜行达锁骨中线第6肋间处做8～12 cm弧形切口,第4肋间入胸。手术方式:房间隔缺损修补157例,室间隔缺损修补150例,部分房室隔缺损矫治8例;右心室流出道疏通术24例;法洛三联症矫治32例,法洛四联症矫治5例以及其他畸形矫治13例。随机选择同期常规手术(胸正中切口)患者100例作为对照。结果:研究组切口长度、手术时间及术后引流量都显著低于对照组;研究组术后呼吸机辅助时间明显低于对照组;术后监护时间各组间差异无统计学意义。研究组手术死亡4例(1.03%),2例死于术后脑栓塞,另外2例死于低心排出量综合征(低心排)。结论:右胸小切口手术入路,可安全有效地行常见先心病的矫治。该技术创伤小、恢复快、美观,并提高了患者的生活质量,值得进一步推广应用。     

经右外侧小切口矫治室间隔缺损合并复杂畸形技术的应用

目的:分析经右外侧小切口剖胸矫治合并需行心底部操作的室间隔缺损(VSD)手术方法及临床疗效。方法:比较经右外侧小切口剖胸矫治需行心底部复杂操作(干下型VSD或右心室流出道狭窄或主动脉瓣下狭窄)的VSD 84例(A组),和经右外侧小切口剖胸矫治不合并心底部畸形的VSD450例(B组),A组在矫治心内畸形的同时需切开主动脉、肺动脉或者右心室流出道。通过对比体外循环时间、主动脉阻断时间、术后机械通气时间、术后引流量、监护室时间以及术后住院时间,观察在心底部进行复杂操作对手术的影响和治疗效果。结果:尽管A组比B组需要更长的体外循环时间[(60.68±16.12)vs.(47.07±16.55)分,P<0.05]和主动脉阻断时间[(37.68±12.84)vs.(25.16±12.60)分,P<0.05],但在术后评价指标,机械通气时间9.18vs.8.51小时、术后引流量(96.98 vs.92.30m L)、监护室停留时间(1.44 vs.1.40)天、术后住院时间[(7.00±1.76)vs.(7.06±2.23)天,P<0.05]。两组均无死亡及严重并发症。A组有3例血痰、肺部感染1例,室上性心动过速1例。B组有9例患儿术后血痰,2例肺部感染,临时起搏器4例。结论:经右外侧小切口剖胸矫治VSD的同时行心底部复杂操作安全可行。     

右位心伴室间隔缺损1例

1 一般资料 患者,女,24岁,已婚。妊娠7个月。因呼吸困难伴咯血,于1999年5月到医院急诊,抢救无效死亡。其家属同意尸检。 尸检中发现:肺瘀血,右位心,全心肥大,以右     

右外侧小切口行法洛四联症根治术346例临床分析

目的:总结右外侧小切口剖胸行法洛四联症根治的经验及技术关键。方法:1997年1月至2013年10月,本手术组经右外侧小切口根治法洛四联症346例。其中男性159例,女性187例。年龄4个月~5岁;体质量6~15kg,平均体质量(9.7±2.4)kg。合并卵圆孔未闭43例、房间隔缺损22例、动脉导管未闭10例、永存左上腔静脉10例、主动脉瓣下隔膜7例、二尖瓣关闭不全1例。跨环补片205例,右心室流出道补片141例。结果:术中体外循环时间(90±24)min;主动脉阻断时间(64±17)min,术后机械通气时间4~165 h,监护室停留时间(3.2±1.7)d,术后当日胸腔引流量(138±91)mL,平均带胸管(2.5±0.9)d。术后并发症36例(1.04%):低心排出量综合征(低心排)17例(死亡5例),严重肺部感染2例(死亡1例),灌注肺5例(死亡1例),右肺损伤7例,膈神经损伤4例,室间隔缺损残余分流2例,乳糜胸2例。死亡共计7例,病死率2.02%。结论:经右外侧小切口行法洛四联症根治安全可靠。     

Repair of postinfarction ventricular septal defect through the right atrium

Repair of post infarction posterior ventricular septal defect has generally been performed with a ventriculotomy through the infarcted zone. This approach has a significant mortality and morbidity due to haemorrhage, extension of infarction or further compromise of ventricular function secondary to suture placement. We present a case with delayed repair of a post infarction posterior septal defect using a right atrial approach, where no discrete infarct or other abnormality of the free ventricular wall was found.     

Repair of double outlet right ventricle with doubly-committed ventricular septal defect

OBJECTIVE: To investigate our surgical results of intraventricular rerouting in patients having double outlet right ventricle with doubly-committed ventricular septal defect. METHODS: We undertook repair in 8 patients with this particular feature. Of these, 2 patients had pulmonary stenosis, and another had interruption of the aortic arch. The subarterial defect was unequivocally related to both the aortic and the-pulmonary orifices in all, albeit slightly deviated towards the aortic orifice in one, and towards the pulmonary orifice in another. Intraventricular rerouting was carried out via incisions to the right atrium and the pulmonary trunk. To ensure reconstruction of an unobstructed pulmonary pathway, a limited right ventriculotomy was made in 5. RESULTS: All patients survived the procedure, and are currently doing well, with follow-up of 25 to 194 months, with a mean of 117+/-68 months. Catheterization carried out 16+/-6 months after repair demonstrated excellent ventricular parameters. Mean pulmonary arterial pressure was 16+/-7 mmHg, being higher than 20 mmHg in 2 patients. No significant obstruction was found between the right ventricle and the pulmonary arteries. A pressure gradient across the left ventricular outflow tract became significant in one patient in whom a small outlet septum was present, and a heart-shaped baffle had been used for intraventricular rerouting. Reoperation was eventually needed in this patient for treatment of the obstruction, which proved to be progressive. CONCLUSION: Precise recognition of the morphologic features is of paramount importance when choosing the optimal options for biventricular repair in patients with double outlet right ventricle and doubly-committed interventricular communication.     

Apical muscular ventricular septal defect closure via hybrid approach using a right ventricular stay suture

Transcatheter closure of large apical muscular ventricular septal defects (VSDs) can be performed via transfemoral or hybrid approach. A very large apical muscular VSD was closed via a hybrid approach. A strategy for deployment of a right ventricular stay suture was utilized to minimize the risk of device embolization without the use of bypass and without externalization of a portion of the device.     

右后外侧小切口剖胸治疗冠状动脉右心室和/或右心房瘘

目的:总结经右外侧腋下小切口入胸体外循环辅助直视下治疗冠状动脉右心室右心房瘘的手术经验及效果。方法:选取本院2002年1月至2018年12月,行冠状动脉右心室和/或右心房瘘矫治术患儿31例,其中经胸骨正中开胸完成手术矫治的患儿16例(正中组),男性9例,女性7例,中位年龄11.8个月(6～32)个月,中位体质量12.7 kg(7.5～29 kg)。其中右冠状动脉右心室瘘9例,左冠状动脉右心室瘘5例,右冠状动脉右心房瘘2例;经右外侧小切口剖胸(右侧组)行手术矫治的患儿15例,男性9例,女性6例。中位年龄10.8个月(5～28个月),中位体质量11.6 kg(5.6～18)kg。右冠状动脉右心室瘘9例,左冠状动脉右心室瘘4例,右冠状动脉右心房瘘2例。均在全身麻醉体外循环辅助下完成冠状动脉右心室和/或右心房瘘矫治术。结果:右侧组术后无死亡。术后残余瘘2例。正中死亡1例,死于低心排出量综合征(低心排);术后残余瘘2例。右侧组手术时间、切口长度、ICU停留时间、术后引流量、术后输血量、术后呼吸机辅助时间以及住院时间都显著低于正中组;主动脉阻断时间差异无统计学意义。随访3～38个月,心脏功能恢复良好。结论:经右侧腋下小切口直视下行冠状动脉右心室右心房瘘矫治手术,手术安全可靠,术野清晰,创伤小,术后恢复良好。     

Electrocardiographic aspects of right ventricular repolarization in interauricular septal defect

In order to know the value of a peculiar right ventricular repolarization in the diagnosis of atrial septal defect. We studied-one hundred patients with main right bundle branch block and atrial septal defect confirmed by cardiac catheterization. The peculiar right ventricular repolarization consist in a straight and long S-T segment (longer than 160 msc) that form a 60 degrees or greater angle with the ascendent branch of the T wave. This electrocardiographic sign was found in 82 patients (sensitivity 82%). There were no differences between the age groups or the pulmonary pressure levels. In sixty five patients with main right bundle branch block without atrial septal defect, this peculiar right ventricular repolarization was investigated. It was found in fourteen cases (specificity 78.4%). Positive predictive value was 85.4%, negative predictive value 73.9% and diagnostic efficiency 80.6%. When the atrial septal defect was repaired (76 patients), the peculiar right ventricular repolarization disappeared in 87.7% of the cases (p less than 0.0001). It can be concluded that the peculiar right ventricular repolarization, in presence of main bundle branch block supports the diagnosis of atrial septal defect.