电视胸腔镜心脏手术微创体外循环中并发症的预防及处理方法

目的 :探讨电视胸腔镜微创体外循环心内直视术治疗先天性心脏病手术过程中并发症的预防及处理方法。方法 :2 0例房间隔缺损和 4例室间隔缺损的先心病患者应用双腔气管插管机械辅助呼吸 ,采用股动脉、股静脉和上腔静脉插管建立体外循环 ,通过胸壁打孔借助电视胸腔镜进行房间隔缺损和室间隔缺损修补。结果 :2 4例患者中第 1例患者因血氧饱和度低而延长切口进行探查 ,1例患者因主动脉壁损伤而被迫再次建立体外循环进行修补 ,2例患者体外循环转流中出现血红蛋白尿 ,3例患者在单肺通气时因血氧饱和度低而应用高频通气进行辅助 ,1例室间隔隔瓣下缺损患者心脏复跳后发现有残余漏。结论 :电视胸腔镜微创体外循环下心内直视术中以单肺通气时血氧饱和度低、转流中血红蛋白尿最为常见 ;以操作不慎引起大血管损伤最为严重。创伤小 ,恢复快 ,安全可行。只要熟练电视胸腔镜下手术器械的操作方法和技巧可以减少或避免并发症的发生。     

全电视胸腔镜下房室间隔缺损修补术的探讨

目的探讨全电视胸腔镜下房室间隔缺损修补的体外循环手术方法和经验。方法9例房室间隔缺损患者采用股动脉、股静脉和上腔静脉插管建立体外循环,经第7肋间置入胸腔镜,另选第4肋间打2个手术操作孔,在电视胸腔镜下行房室间隔缺损修补。结果患者均手术顺利,术后无并发症。结论电视胸腔镜体外循环下行房室间隔缺损修补术安全可靠。     

116例微创心脏外科手术的体外循环管理

［］：目的 探讨微创心脏外科手术体外循环管理方法和经验。方法：自2013年7月至2014年12月间,我院心胸外科共开展116例右胸前外侧小切口微创心脏手术,其中男性71例,女性45例,年龄13-72岁,平均(40.6±14.2)岁,体重35-85Kg,平均(50.5±10.8)Kg。手术方式包括房间隔缺损修补术,室间隔缺损修补术,二尖瓣成形/置换术,主动脉瓣置换术,三尖瓣成形术,左房/右房粘液瘤摘除术。所有患者均为右胸前外侧小切口进行手术,采用股动脉插管灌注,食道超声引导下的二极股静脉进行插管引流,如有必要可加用上腔静脉插管。其他病例则采用同侧股动脉,股静脉,上腔静脉或右侧颈内静脉插管建立体外循环。除心脏不停跳的术式外,升主动脉顺行灌注4:1冷含血停搏液进行心肌保护。浅低温,中高流量灌注。全组病例都应用负压辅助静脉引流装置(vacuum-assist venous drainage, VAVD)和常规超滤。体外循环结束后,股动脉插管处重建,颈内经脉压迫止血。结果：全组病例均顺利完成手术,体外循环转流时间31-158(82.3±31.7)min,主动脉阻断时间16-96(48.1±19.8)min,超滤量1100-3500ml。除47例不停跳手术外,其余病人中56例心脏自动复跳,自动复跳率81.2%。术后呼吸机辅助时间3-16(4.5±1.4)h,胸腔引流量90-550(160±65)ml,术后住院时间6-21(9.1±2.7)d。88例病人(75.9%)住院期间未输血。115例痊愈出院,1例死于术后感染引起的多脏器功能衰竭,死亡率0.86%。结论：各种外周插管建立的体外循环;VAVD技术的应用;适宜的灌注流量和灌注压力;良好的心肌保护;综合全面的体外循环管理为微创心脏手术提供了坚实的保障,实用性强,值得临床上推广和应用。     

微创心脏手术中周围体外循环120例总结

目的 :总结分析不开胸的体外循环及心肌保护 12 0例。方法 :对 12 0例胸腔镜心脏手术所采用的不开胸体外循环及心肌保护技术进行回顾分析。全组均采用股动、静脉或加上腔静脉插管建立体外循环 ,右侧胸壁打孔胸腔镜下长阻闭钳阻闭升主动脉 ,冷晶体停跳液顺行灌注保护心肌。结果 :全组无手术死亡病例。术中泵压偏高 8例 ,灌注流量不足 3例 ,术后血红蛋白尿 13例 ,肝功能损害 7例 ,术后右下肢轻度肿胀 3例 ,右下肢局部麻木、疼痛 4例 ,右股动脉处可闻及杂音 3例。结论 :周围体外循环及心肌保护安全、可行。并发症以血红蛋白尿 ,肝功能损害 ,股动、静脉损伤为常见。     

经皮体外循环微创心脏直视手术

本文介绍经皮导管血管内体外循环、血管内升主动脉阻断、血管内灌注心脏冷停跳液、经胸壁开窗（Port—Access技术）在胸腔镜下行微创冠状动脉旁路移植（CABG）和心脏瓣膜替换动物实验模型［1－5］。一、手术方法1．手术准备：选20～30kg狗，全麻气管内插双腔管作单肺通气。心电连续监测。经颈动脉和颈静脉穿刺测动脉压、中心静脉及肺动脉压。2．导管放置技术：肝素化后，用17F导管作左股静脉穿刺插管，经引导钢丝将导管置于右心房（上腔静脉入口处）。左股动脉穿刺插入14F导管。动静脉管分别与体外循环机连接。由颈外静脉穿刺插入导管至…     

右腋下微创小切口经左心房入路行成人复杂房间隔缺损修补术的临床应用

目的 探讨右腋下微创小切口经左心房入路行成人复杂房间隔缺损修补术的临床应用.方法 选取2019年12月至2021年10月浙江省人民医院心脏大血管外科收治的33例房间隔缺损患者的临床资料,年龄40～60岁.患者均接受胸腔镜辅助下无可见瘢痕右腋下微创手术,股动静脉插管建立体外循环,经左心房路径行房间隔缺损修补.结果 全组患...     

经右胸壁3孔完全胸腔镜心脏手术46例分析

目的　总结经右胸壁3孔完全胸腔镜下心脏手术的经验。 方法　2014 年 3 月至 2019年4 月 46例全胸腔镜经右胸壁3孔心脏手术,其中房间隔缺损 26 例,部分性肺静脉异位引流 1 例,室间隔缺损 1例,二尖瓣病变置换8 例,三尖瓣环成形8例,左房黏液瘤 2 例。体外循环（Extracorporeal circulation ECC）采用浅、中低温,46 例行股动、静脉插管。 12例患者 ＥＣＣ 中予以负压辅助静脉引流。 16 例手术采用含血停搏液灌注法心肌保护,心脏不停跳 30 例。结果　 46例患者无死亡且全部痊愈出院。ECC 时间 (38-110)min 平均(53.4±28.6) )min。 升主动脉阻断时间(28～94)min平均 (44.2±13.8) min。术后 5-12 ｄ 痊愈出院。 出院患者随访时间1～36mon,结果满意。 结论　 完全胸腔镜ECC下心脏手术是微创、安全、可行的,围术期间需加强监护及防治各种并发症。     

胸腔镜下心脏外科手术并发症的分析及预防

目的 分析胸腔镜心脏手术围手术期的并发症及意外情况.方法 采用经股动、静脉插管,体外循环下全电视胸腔镜心脏手术对心脏病患者进行治疗,对治疗过程中出现的意外情况及并发症进行详细记录、观察、分析,并讨论相应预防及处理措施.结果 105例患者中出现了以下并发症：低氧高碳酸血症2例,周围体外循环泵压高、灌注流量不足2例,升主动脉夹层1例,主动脉出血1例,乳内动静脉损伤1例,血气胸2例,股动脉狭窄2例,股神经卡压、损伤1例.经术中相应补救措施、术后妥善治疗后并发症得以缓解或痊愈,均得到了有效控制.结论 经股动、静脉插管,体外循环下全电视胸腔镜心脏手术是安全有效的,其术中、术后可能出现的并发症及意外情况是完全可防可治的.     

胸腔镜下体外循环心脏手术的麻醉管理

目的 总结胸腔镜下体外循环心脏手术的麻醉管理经验。方法回顾性分析2011年1月至12月在广东省人民医院行胸腔镜下体外循环心脏手术患者的麻醉及围术期处理的相关资料。结果2011年我院共行胸腔镜辅助小切口或全胸腔镜下体外循环心脏手术85例,其中男30例,女55例,年龄（42．5±15．2）岁。手术类型包括：房间隔缺损修补术20例,同期三尖瓣成形术15例;左心房黏液瘤摘除术7例;二尖瓣成形术8例：二尖瓣置换术50例,同期三尖瓣成形术19例、心房颤动射频消融术5例、房间隔缺损修补术2例及左心房血栓清除术1例。麻醉均采用静吸复合全身麻醉,左侧双腔气管插管单肺通气,经皮上腔静脉插管、股动静脉插管建立外周体外循环,体外循环时间（151．8±63．6）min,心肌血运阻断时间（92．1±43．7）min。全组患者术后并发症8例（9．4％）,死亡1例。结论良好的单肺隔离通气、充分的静脉引流以及完善的术中监测有利于手术的顺利进行,维持血流动力学平稳和避免缺血、缺氧可以减少围术期并发症,是胸腔镜下体外循环心脏手术麻醉管理的重点。     

直视微创心脏外科手术体外循环建立的经验

目的：讨论直视微创心脏外科手术体外循环建立方法及建立量化学习曲线并减少学习所需例数。方法：选取我院2010年4月至2012年12月,行直视微创心脏外科患者217例,其中包括瓣膜病145例（66.8%）,先天性心脏病（先心病）71例（32.7%）,外伤1例（0.5%）。体外循环建立方法均为经股动静脉及右侧颈静脉插管,食道超声术中引导并调整插管位置至上下腔静脉开口处。双腔气管插管。经右侧胸骨第3或4肋间经胸腔入路,左侧肺单侧呼吸情况下,以Chitwood钳经胸阻断升主动脉的情况下,升主动脉根部灌注晶体或HTK停跳液,心脏停跳行心脏手术,或者不灌注停跳液行体外循环下不停跳心脏手术。体外循环结束后,拔除股动静脉置管,6-0prolene线缝合股动脉重建通路,股静脉荷包打结止血,颈静脉压迫止血。结果：此种体外循环建立方式较之常规体外循环的建立方法有很大不同,有操作例数经验的学习曲线,体外循环建立和撤销时间在经过50例左右的操作经验后,可以安全快速的完成。结论：在跨越学习曲线后,直视微创心脏外科手术体外循环是安全、有效、易于操作的手术技术。     

Port-access approach for cardiac surgical procedures: our experience in 776 patients

BACKGROUND: Recent advances in minimally invasive technology has expanded the application of the right thoracotomy approach for mitral valve surgery and atrial septal defect closure. The present study examines the feasibility, safety and efficacy of this technique. METHODS AND RESULTS: Between September 1997 and December 2004, 430 patients underwent mitral valve surgery through right anterolateral thoracotomy. The mitral valve was repaired in 62 patients, and 368 patients underwent mitral valve replacement. During same period, 336 patients underwent surgical closure of atrial septal defect. In all cases femoral artery and femoral venous cannulation was used for cardiopulmonary bypass. There was no approach-related limitation to surgical exposure, nor complication in cannulation of femoral vessels through the groin. Mean duration of cardiopulmonary bypass and cross-clamp time was 90 +/- 48 min and 51 +/- 29 min, respectively. Mean intubation time was 14.8 hours (range: 8-28 hours). Mean duration of intensive care andhospital stay was 26 hours (range: 18-38 hours) and 7 days (range: 5-17 days), respectively. In the atrial septal defect group, the mean cardiopulmonary bypass time and aortic cross-clamp time was 29 +/- 14 min and 19 +/- 8 min, respectively. Mean intensive care unit stay and mean hospital stay was 9.8 +/- 2.6 hours and 4.0 +/- 1.9 days, respectively. Hospital mortality was 0.46% (2/430) in the mitral valve group while there was no hospital mortality in atrial septal defect group. At a mean follow-up of 38.0 +/- 6.2 months there was one late death and two re-operations in the patients who underwent mitral valve surgery. CONCLUSIONS: Port-access approach is safe, offers faster recovery, cosmetic advantage, more patient satisfaction: it obviates the complications due to re-entry in redo cases and offers same efficacy as conventional operation. Furthermore, it is an excellent approach for mitral valve surgery in patients who had previous cardiac procedures. It has become our standard approach for repair of atrial septal defect and isolated mitral valve procedures.     

静脉窦房间隔缺损的外科治疗

目的:总结我科1999年7月至2004年4月26例静脉窦房间隔缺损手术病例的临床资料,探讨静脉窦房间隔缺损的外科手术方式和经验。方法:采用浅低温体外循环心脏不停跳技术行静脉窦房间隔缺损及合并畸形的手术治疗。其中男性11例,女性15例,年龄6个月～27岁,平均(12.1±5.7)岁。合并部分肺静脉异位引流19例,其中引流入上腔静脉8例,引流入右心房11例;合并动脉导管未闭1例、左上腔静脉引流入冠状静脉窦2例。合并室间隔缺损1例,三尖瓣返流3例,二尖瓣重度返流1例。体外循环转流时间25～98min,平均(56.4±6.2)min,全组均用自体心包补片修补,术中8例用右心房外侧切口避开窦房结延长至上腔静脉,3例用另外心包加宽上腔静脉与右心房结合部;5例术中扩大房间隔缺损利于异位引流的肺静脉回流,1例同期行二尖瓣置换。结果:术后平均重症监护时间(4.2±2.1)d,平均住院时间(15±6.5)d。全组无死亡病例。1例术后早期窦房结功能失调,经使用临时起搏器辅助3d后恢复,术后1例转为心房颤动心律,余均为窦性心律。1例出现上腔静脉梗阻,二次手术加宽上腔静脉后好转。结论:运用经食道超声心动图较易诊断静脉窦房间隔缺损和确定有无肺静脉异位引流,外科手术治疗静脉窦房间隔缺损的效果满意,选择适当的手术方式可以降低上腔静脉梗阻、窦房结功能失调等并发症。     

Outcome following repair of sinus venosus atrial septal defects in children

The outcome of surgical repair of sinus venosus atrial septal defect was reviewed retrospectively. The operation was performed on 44 children aged 8 to 163 months, between April 1985 and November 1998. Median cardiopulmonary bypass and aortic crossclamp times were 58 minutes (range, 29 to 141 minutes) and 29 minutes (range, 4 to 67 minutes), respectively. Use of blood products decreased from 4.5 units per patient in the first period (1985 to 1989) to 0.6 units in the last period (1995 to 1998). Median intensive care and hospital stays were 2 days (range, 1 to 12 days) and 6 days (range, 4 to 16 days), respectively. There was 1 early death (2.3%). Complications included reexploration for bleeding in 2 patients (4.5%) and for superior vena cava obstruction in 1 (2.3%), and arrhythmias in 3 (6.8%), which required a pacemaker in one. During follow-up of 15 to 176 months, 83.8% of patients were in sinus rhythm. One required angioplasty for superior vena cava stenosis, hemodynamically insignificant residual shunt was found in 3, and mild superior vena cava stenosis in 3. Repair of sinus venosus atrial septal defect carries a low mortality and morbidity, but long-term follow-up is needed to monitor potential sinus node dysfunction and superior vena cava stenosis.     

部分房室隔缺损的外科治疗

目的 :总结部分房室隔缺损外科治疗的经验及效果。方法 :部分房室隔缺损病人 2 75例 ,年龄 9个月～ 6 0岁 ,平均 ( 14 4± 11 1)岁。男性 117例 ,女性 15 8例。术中见均有较大的原发孔缺损呈半圆形 ,二尖瓣裂隙为完全性的 179例 ,部分的为 81例 ,有二尖瓣双开口 1例。合并畸形有卵圆孔未闭4例 ,继发孔房间隔缺损 (房缺 ) 2 5例 ,左上腔静脉 4例 ,主动脉瓣下膜样狭窄 2例 ,动脉导管未闭 1例 ,单心房 2例 ,三房心 1例。所有病人均修复二尖瓣裂隙 ,以心包修补原发孔房缺。结果 :早期死亡 11例 ,4 %。晚期死亡 5例。其余病人经 6个月到 2 5年随诊 ,其中心功能已达Ⅰ级 2 0 6例 ,Ⅱ级 5 2例。晚期重度二尖瓣关闭不全 2例 ,行二尖瓣替换。Ⅲ度房室传导阻滞 6例 ,Ⅱ度房室传导阻滞 3例。结论 :对于部分房室隔缺损的病人一经发现需尽早手术治疗 ,妥善修复二尖瓣裂隙 ,严密闭合原发孔房缺 ,防止传导阻滞的发生 ,尽量修复三尖瓣关闭不全是取得良好远期效果的关键。     

Stroke after surgical treatment of sinus venosus type atrial septal defect: percutaneous treatment

Background and purposeSinus venosus-type atrial septal defect can be associated with anomalous drainage of the upper right pulmonary vein into the superior vena cava. Surgical correction provides reconstruction of superior vena cava and rerouting of the pulmonary vein into the left atrium.Summary of caseWe report the case of a young woman who experienced 2 strokes 11 years after surgical repair of sinus venosus-type atrial septal defect.ConclusionsInterventional treatment resolved the superior vena cava stenosis, rerouted the pulmonary vein into the left atrium and abolished the right to left shunt.     

Unusual venacaval anomalies in a patient with atrial septal defect

An unusual systemic venous drainage pattern was found in a 30-year-old man with ostium secundum atrial septal defect and pulmonary stenosis. He had the rare association of absent right superior vena cava, persistent left superior vena cava draining into the coronary sinus, and a left-sided inferior vena cava draining into a left superior vena cava through the hemiazygous vein.     

Occlusion of azygos vein via direct percutaneous puncture of innominate vein following cavopulmonary anastomosis

A 2-year-10-month-old boy was diagnosed with a complex congenital heart disease: right atrial isomerism, left superior vena cava (LSVC), complete atrioventricular septal defect, secundum type atrial septal defect, transposition of the great arteries with pulmonary atresia, patent ductus arteriosus, absence of a right superior vena cava (RSVC), and dextrocardia. He had received a left Blalock-Taussig (BT) shunt at the age of 3 months and a left bidirectional Glenn shunt one year after BT shunt. Progressive cyanosis was noted after the second operation and cardiac catheterization showed a functional Glenn shunt with an engorged azygos vein, which was inadvertently skipped for ligation. Because of the absence of RSVC, transcatheter occlusion of the azygos vein was performed successfully via direct puncture of the innominate vein.