胸腔镜心包开窗术对恶性心包积液的治疗价值

目的　评价胸腔镜心包开窗术在恶性心包积液治疗中的效果。方法　对 2 2例恶性心包积液患者行胸腔镜心包开窗术。结果　平均手术时间 5 5min(4 5～ 110min) ,2 2例手术患者术中及术后均无手术并发症发生。术后 2 4～ 96h(平均 3 3 .5h)拔胸腔引流管。术后随访 ,无心包积液复发 ,也未发现缩窄性心包炎。结论　胸腔镜心包开窗手术是一个安全的手术方法 ,可以广泛切除心包 ,手术并发症少 ,可作为恶性心包积液的首选治疗方法。     

Thoracentesis in pericardial and pleural effusion caused by central venous catheterization: a less invasive neonatal approach

An 840 g infant developed a rapid onset of shock-like symptoms. Pericardial and pleural effusions from an indwelling central catheter were diagnosed via echocardiography. A thoracentesis was promptly performed with immediate clinical improvement. The fluid withdrawn from the pleural space was analysed as hyperalimentation. The infant survived because of early diagnosis and aggressive therapeutic intervention. A pericardial effusion should be drained if there is cardiovascular compromise and because pericardiocentesis represents a high risk technique, attempts should be made to rectify the extravasation via thoracentesis.     

Mediastinal mass obscured by a large pericardial effusion in a child: a potential cause of serious anaesthetic morbidity

Anaesthesia in the presence of a mediastinal mass is known to be hazardous. We report a case of a 5-year-old boy with a presumed postviral pericardial effusion presenting for pericardiocentesis under general anaesthesia. Cardiorespiratory collapse following induction of anaesthesia occurred due to an undiagnosed mediastinal tumour. The reasons for misdiagnosis, mechanisms for perioperative complications and optimal management are discussed. Mediastinal masses and underlying malignancy should always be considered in patients with large pericardial effusions.     

Spontaneous contained rupture of the nonaneurysmal ascending aorta: Diagnostic importance of pericardial effusion

A 58-year-old man with a history of hypertension, dyslipidemia, and an obtuse marginal branch coronary stent developed the sudden onset of chest pain. A contrast computed tomography demonstrated a penetrating ulcer of nondilating ascending aorta and a small pericardial effusion. Coronary angiography showed three-vessel disease. At emergency surgery, there was blood in the pericardial sac and the whole of the ascending aorta had hematoma with no evidence of tamponade. We performed a hemiarch replacement under circulatory arrest and concomitant coronary artery bypass grafting. The left side of the proximal arch had ruptured just beyond the pericardial reflection.     

The pericardium exerts constraint on the right ventricle during cardiac surgery

The right ventricle may be particularly susceptible to the effects of pericardial constraint. This study examined the effects of pericardiotomy on right ventricular function. Twenty-four anesthetized patients with coronary artery disease, but without evidence of pericardial pathology, were studied. Anesthesia consisted of fentanyl (100 micrograms.kg-1), diazepam, pancuronium, and 100% oxygen. The American Edwards REF-1 Cardiac Output Computer, rapid-response thermistor pulmonary arterial catheter, and a radial arterial catheter were used to measure hemodynamic variables. Baseline measurements were obtained with the sternum fully retracted. The measurements were then repeated following pericardiotomy by a midline incision. There were significant (P less than 0.05) changes in systolic arterial pressure (+4.5%), mean arterial pressure (+3.7%), systolic pulmonary arterial pressure (+11.8%), cardiac output (+9.1%), stroke volume (+6.9%), right ventricular end-diastolic volume (+7.6%), and right atrial pressure (-8.6%). In the current study, pericardiotomy augmented right ventricular diastolic filling and stroke volume, while the right atrial pressure decreased. These results support the concept of pericardial constraint.     

Sources of error in partial rebreathing pulmonary blood flow measurements in lungs with emphysema and pulmonary embolism

Background. Studies of the accuracy of partial rebreathing measurementsof pulmonary blood flow (PBF) in patients with abnormal lungshave not fully explained the sources of error. Methods. We used computer models of emphysema and pulmonaryembolism incorporating both ventilation-perfusion (     

Biventricular repair of double outlet right ventricle with non-committed ventricular septal defect (VSD) by VSD rerouting to the pulmonary artery and arterial switch

Objectives: Biventricular repair of double outlet right ventricle non-committed ventricular septal defect (DORVncVSD) is usually achieved by a VSD rerouting to the aorta. This technique can be limited by the presence of tricuspid chordae and by the pulmonary artery to tricuspid valve distance. Furthermore, there is an important risk of late subaortic obstruction related to the long patch required that creates a potential akinetic septal area. Presented here is another technique; by VSD rerouting to the pulmonary infundibulum and arterial switch. Methods: Ten patients, with DORVncVSD, underwent a VSD rerouting to the pulmonary infundibulum followed by arterial switch. Seven had a previous pulmonary artery banding and one a moderate infundibular stenosis. The median age at surgery was 16 months (range 3 weeks to 4.5 years). All patients had a bilateral infundibulum, with a large persistent subaortic conus, D malposition of the aorta, side-by-side vessels and double loop coronary patterns. The VSD was perimembranous with inlet or trabecular extension. Subaortic obstruction was constant. The VSD was severely distant from both the aortic and the pulmonary annulus. The operation was conducted through a combined approach. The VSD was constantly enlarged superiorly. The almost permanent subaortic obstruction was released. The VSD was always found quite close to the pulmonary infundibular ostium. The arterial switch technique was adapted to the complex coronary anatomy. Results: There was one non-cardiac death. At a mean follow-up of 20 months, all nine survivors are in NYHA class I, in sinus rhythm, and have no subaortic gradient greater than 15 mm. Conclusion: This technique of VSD rerouting to the pulmonary artery and arterial switch limits greatly the size of the rerouting patch, respects the tricuspid chordae and is independent of the pulmonary artery–tricuspid valve distance. In this early series of biventricular repair of DORVncVSD, the VSDs were always found close to the pulmonary artery, allowing this new type of repair.     

Thoracoscopic partial pericardiectomy in the diagnosis and management of pericardial effusion

Background: An effort was made to present our experience with thoracoscopy in the diagnosis and management of pericardial effusions. Methods: Twenty-two partial pericardiectomies were performed with the thoracoscopic approach in patients with pericardial effusions, the etiology of which was uremic (n= 7), neoplastic (n= 8), idiopathic (n= 5), septicemia (n= 1), and postpericardiotomy (n= 1). All cases had grade III-IV/IV radiological cardiomegaly and ultrasonographic confirmation of the effusion. We found hemodynamic compromise in 17 patients. The operation, requiring the insertion of three trocars, enabled us to remove a large part (approximately 6 × 10 cm) of the left anterolateral side of the pericardium and aspirate the effusion contents for diagnostic and therapeutic purposes. Results: In five cases we found coexisting pleural effusions. The pericardial effusion had a mean volume of 817 ml, which was serous in 11 cases, hematic in six, serohematic in four, and purulent in one. Cytology of the pericardial effusion was positive for neoplasia in four cases (one pulmonary neoplasia, two breast carcinomas, and one lymphoma). We observed conversion to grade I/IV cardiomegaly in 16 cases and a return to normality in the other six, with the absence of ultrasonographic effusion in all cases. There was no recurrence during the mean follow-up period of 20.5 months (range: 2–47). Conclusions: The thoracoscopic management of pericardial effusions is a simple and effective technique that allows us to create a large pericardial window that drains the effusion definitively, determines its etiology, and explores and treats coexisting pleural lesions, all without recurrences. Received: 30 May 1996/Accepted: 27 August 1996     

Non-invasive prediction of fluid responsiveness during major hepatic surgery

Background. The aim of this study was to evaluate potentialpredictors of fluid responsiveness obtained during major hepaticsurgery. The predictors studied were invasive monitoring ofintravascular pressures (radial and pulmonary artery catheter),including direct measurement of respiratory variation in arterialpulse pressure (PPVart), transoesophageal echocardiography (TOE),and non-invasive estimates of PPVart from the infrared photoplethysmographywaveform from the Finapres^® (PPVfina) and the pulse oximetrywaveform (PPVsat). Methods. We conducted a prospective study of 54 fluid challenges(250 ml colloid) given for haemodynamic instability in eightpatients undergoing hepatic resection. Fluid responsivenesswas defined as an increase in stroke volume index (SVI)     

Implantation of the Total Artificial Heart by Lateral Thoracotomy

Progress in the techniques for surgical implantation of the artificial heart has progressed in parallel with the technology and design of the prosthesis. In the author's first experience with total artificial heart (TAH) implantation (1968) a trans-sternal split was used opening the sixth intercostal space on the right side across the sternum to the left space. This obviously was not the optimum approach but the complexity, design and size of the prosthesis required maximum exposure of the atria and great vessels. Subsequently the mid-sternal split incision was used. The Dacron fibril coated silicone rubber 8 cm Kwan-Gett ventricles implanted by the mid-sternal split sustained a calf for 14 days in 1972. A calf with the improved Jarvik 3 ventricles fabricated with the same material and implanted via mid-sternal split survived 19 days in early 1973. The surgical techniques for lateral (right) thoracotomy were adopted in this laboratory in 1973. These techniques were applicable only when the prosthesis fit better in the chest. This procedure has been adopted by other laboratories replacing the natural heart of the calf with a TAH. This report describes in detail the stepwise procedure for implantation of the total artificial heart by a lateral thoracotomy in the calf.     

Volumetric preload measurement by thermodilution: a comparison with transoesophageal echocardiography

Background. End-diastolic volume indices determined by transpulmonarythermodilution and pulmonary artery thermodilution may givea better estimate of left ventricular preload than pulmonarycapillary wedge pressure monitoring. The aim of this study wasto compare volume preload monitoring using the two differentthermodilution techniques with left ventricular preload assessmentby transoesophageal echocardiography (TOE). Methods. Twenty patients undergoing elective cardiac surgerywith preserved left–right ventricular function were studiedafter induction of anaesthesia. Conventional haemodynamic variables,global end-diastolic volume index using the pulse contour cardiacoutput (PiCCO) system (GEDVI_PiCCO), continuous end-diastolicvolume index (CEDVI_PAC) measured by a modified pulmonary arterycatheter (PAC), left ventricular end-diastolic area index (LVEDAI)using TOE and stroke volume indices (SVI) were recorded beforeand 20 and 40 min after fluid replacement therapy. Analysisof variance (Bonferroni–Dunn), Bland–Altman analysisand linear regression were performed. Results. GEDVI_PiCCO, CEDVI_PAC, LVEDAI and SVI_PiCCO/PAC increasedsignificantly after fluid load (P<0.05). An increase >10%for GEDVI_PiCCO and LVEDAI was observed in 85% and 90% of thepatients compared with 45% for CEDVI_PAC. Mean bias (2 SD) betweenpercentage changes (     

Comparison of stroke volume (SV) and stroke volume respiratory variation (SVV) measured by the axillary artery pulse-contour method and by aortic Doppler echocardiography in patients undergoing aortic surgery

Background. The goal of the study was to compare stroke volume(SV) and respiratory stroke volume variation (SVV) measuredby pulse-contour analysis and aortic Doppler. Methods. These were measured by pulse-contour analysis and thermodilution(PiCCO) and by aortic pulsed wave Doppler with transoesophagealechocardiography in patients undergoing abdominal aortic surgery.Simultaneous measurements were done at different times of surgery.All data were recorded on PiCCOwin software and videotape andanalysed off-line by a blinded investigator. Results. A total of 114 measurements were achieved in 20 patients.There was a good correlation and small bias between the PiCCOand the echo-Doppler values of the mean SV [r=0.885; bias=0.2(8) ml], and between the minimum [r=0.842; bias=1 (9) ml] andmaximum SV [r=0.840; bias=2 (10) ml] values. Conclusions. There is a fair correlation between pulse-contouranalysis and aortic Doppler for beat-by-beat measurement ofSV but not for calculation of SV respiratory ventilation.     

Evaluation of serial haemodynamic changes during coronary artery anastomoses in patients undergoing off-pump coronary artery bypass graft surgery: initial experiences using two deep pericardial stay sutures and octopus tissue stabilizer

Objective: This study was designed to evaluate the serial haemodynamic changes during coronary artery anastomoses using two deep pericardial stay sutures and octopus tissue stabilizer in patients undergoing initial experiences of off-pump coronary artery bypass graft surgery (OPCAB) using continuous cardiac output and mixed venous oxygen saturation (SvO₂) monitoring. Methods: With IRB approval, thirty patients undergoing OPCAB were studied. Pulmonary artery catheter (PAC) for continuous cardiac output and SvO₂ monitoring was inserted before anaesthesia. Haemodynamic measurements were recorded after pericardiotomy for baseline value. During each coronary artery anastomosis, haemodynamic variables were measured at 1,3,5,10, and 15 min after the application of tissue stabilizer and after the removal. Vasopressors were used to maintain mean arterial pressure (MAP) higher than 60 mmHg. Results: MAP and heart rate (HR) were maintained without significant change during the anastomoses of all three arteries. Cardiac index (CI), and SvO₂ decreased significantly after stabilizer application in all three arteries. CI was below 2.5 l/min/m² and SvO₂ was under 70% during left circumflex artery (LCX) anastomosis. The decrease in CI and SvO₂ were significantly greater during LCX anastomosis. The increase in mean pulmonary artery pressure (MPAP) and pulmonary capillary wedge pressure (PCWP) was significant only in left anterior descending artery (LAD). Central venous pressure (CVP) increased significantly during the anastomosis of all three coronary arteries. The differences in MPAP, PCWP and CVP among the three coronary arteries were not statistically significant. The highest dose of vasoconstrictor was used during LCX anastomosis. Conclusions: When the coronary anastomoses were performed with two deep pericardial stay sutures and octopus tissue stabilizer on the beating heart, CI and SvO₂ decreased significantly during all coronary artery anastomoses immediately after the stabilizer application and the degree of reduction in CI and SvO₂ increased with time, though MAP was maintained constantly. CI and SvO₂ during LCX anastomosis were consistently below normal values. Therefore close monitoring and proper managements are needed during graft anastomoses.     

右室双出口的外科治疗

目的：总结手术纠治右室双出口６７ 例的经验。资料与结果：手术年龄４ 个月～１２ 岁,平均（４ ．９８ ±２ ．９６） 岁;体重４ ．１ ～３６ ．０ｋｇ,平均（１５ ．１３ ±５ ．５４）ｋｇ 。其中伴右室流出道梗阻４８ 例,肺动脉高压１８例,肺动脉瓣闭锁１ 例。１３ 例行姑息手术者无死亡。５４ 例行根治术,其中４ 例又行ＩＩ期根治,６ 例行Ｆｏｎｔａｎ 纠治术;根治手术死亡５ 例,病死率８ ．６２ ％ 。本组总病死率７ ．４６ ％ 。结论：右室双出口伴肺动脉高压者,必须早期手术,防止肺血管病变发生。对肺动脉瓣下型室缺的手术纠治较困难,死亡率高。心内隧道补片方法,术后需定期随访,及时发现左室流出道梗阻,必要时需再次手术解除。     

Haemodynamic changes associated with thermodilution cardiac output determination during myocardial ischaemia or pulmonary oedema in dogs

Since the technique of thermodilution (TD) cardiac output measurements per se causes haemodynamic alterations, the authors examined whether the alterations elicited by iced injectate are augmented in the presence of myocardial ischaemia (MI) or pulmonary oedema (PE), compromised conditions frequently associated with critically ill patients. MI (N = 7) or PE (N = 7) was induced by clamping the anterior descending coronary artery or by a slow infusion of oleic acid into the right atrium, respectively, in anaesthetized dogs. Injection of iced injectate, 3 ml, caused similar changes in heart rate, mean systemic and pulmonary arterial pressures, pulmonary blood flow, right ventricular dP/dt, and right atrial pressure in dogs with and without MI or PE. Cardiac output estimated by TD correlated closely with pulmonary blood flow measured by electromagnetic flowmeter in both MI and PE (r > 0.9). No profound alterations in haemodynamics were observed at any injection during TD cardiac output measurements under MI or PE. These results indicate that TD cardiac output determination does not cause serious haemodynamic alterations, and can estimate right ventricular output accurately under MI and PE.     

Continuous cardiac output during off-pump coronary artery bypass surgery: pulse-contour analyses vs pulmonary artery thermodilution

Background: No gold standard method exists for monitoring continuous cardiacoutput (CO). In this study, the agreement between the two mostfrequently used methods, PiCCO pulse-contour analysis (PCCO)and STAT pulmonary artery thermodilution (STAT-CO), was assessedduring multiple-vessel off-pump coronary artery bypass (OPCAB)surgery. Methods: Thirty patients were enrolled in the study. Two time periodswere defined during surgery; Period 1 included positioning ofthe heart and stabilizer device and Period 2 included the coronaryocclusion. Measurements were obtained every minute during bothperiods. The agreement for the continuous CO and the changein CO (CO) was estimated using the Bland–Altman method. Results: Significant changes in mean arterial pressure (MAP), centralvenous saturation, PCCO and STAT-CO were seen only during Period1. MAP correlated only with changes in PCCO, (P < 0.001,r = 0.60). The mean difference (2SD) between PCCO and STAT-COranged from – 0.29 (1.82) to – 0.71 (2.57) litremin^–1, and the percentage error varied from 32 to 50%.For the CO measurements, the limits of agreements did not differbetween Period 1 and Period 2. In contrast, for the CO measurements,the limits of agreements were wider in Period 1 than in themore haemodynamically stable Period 2. Conclusions: PCCO and STAT-CO show large discrepancies in CO during OPCABsurgery. Clinically acceptable agreement was seen only for trendsin CO during haemodynamically stable periods.     

The two-compartment recirculatory pharmacokinetic model--an introduction to recirculatory pharmacokinetic concepts

Background. Some limitations of traditional (‘mamillary’)compartmental pharmacokinetic models of anaesthetic relateddrugs arise from representing the blood as a central compartment.Recirculatory pharmacokinetic models overcome these limitations.It is proposed that the simplest recirculatory model has onlytwo compartments, and that understanding the properties of thismodel is a useful introduction to recirculatory pharmacokineticconcepts. Methods. The compartments of the model are the lungs and theremainder of the body. The traditional rate constants (e.g.k₁₂ and k₂₁) are replaced by terms that include cardiac output.Drug infusion is into the lung compartment, and drug clearanceis from the ‘body’ compartment. The ‘total’drug concentrations can be thought of as the sum of the first-passand recirculated drug concentrations at any time. Equationsfor both first-pass and total drug concentrations in arterialand mixed venous blood are presented. The effects of cardiacoutput and injection time on these concentrations were analysed. Results. The first-pass arterial concentrations were shown tomake a significant contribution to the total concentrationsfor high-clearance drugs and/or bolus drug administration. Therewas an inverse relationship between these first-pass concentrationsand cardiac output, and a direct relationship with bolus injectionrate. Thus, the total arterial concentrations are affected bythese factors in these circumstances. Conclusions. The two-compartment recirculatory model is thesimplest tool available for elaborating recirculatory pharmacokineticconcepts. The recirculatory approach may provide a conceptualframework of drug disposition that better matches the clinicalexperience of anaesthetists. Br J Anaesth 2004; 92: 475–84     

Hemodynamic effect of sustained pulmonary hyperinflation in patients after cardiac surgery: open vs. closed chest

BACKGROUND: In a previous study, we showed that sustained pulmonary hyperinflation, i.e. a lung recruitment maneuver, after closure of the chest in patients undergoing cardiac surgery had significantly negative effects on the central hemodynamics. As elevated pleural pressure is believed to be a major cause of this cardiovascular impairment, we hypothesized that performing the sustained pulmonary hyperinflation under open chest conditions would affect the circulation less. METHODS: Patients undergoing cardiac by-pass surgery were included and sustained pulmonary hyperinflations (40 cmH(2)O airway pressure for 15 s) were performed immediately before and after closure of the sternum. Pulse contour cardiac output, heart rate, mean arterial pressure and pulse pressure variation were measured before, during and 1 min after the hyperinflations. Left ventricular dimensions were measured using trans-esophageal echocardiography. RESULTS: Cardiac output (CO) and mean arterial blood pressure (MAP) decreased significantly during the sustained pulmonary hyperinflation both with an open and closed chest (in parenthesis): CO by 50 (45)% and MAP by 19 (24)%. The left ventricular end-diastolic area was significantly reduced by 24 (33)%. One minute after the hyperinflation, all measured variables had returned to baseline values. No significant differences in the measured variables were found between the two conditions before, during or 1 min after the hyperinflation. CONCLUSION: Contrary to our hypothesis, sustained pulmonary hyperinflations with the chest open, i.e. before sternal closure, had similar negative effects on central hemodynamics as those performed with the chest closed, i.e. after sternal closure.