肥厚型心肌病患者非心脏手术的麻醉处理二例报道

肥厚型心肌病(hypertrophic eardiomyopthy)又称原发性肥厚型主动脉瓣下狭窄(IHSS)，麻醉处理有一定特殊性。本文报告我院2例肥厚型心肌病患者行胆囊切除术的麻醉处理体会。     

左肾上腺嗜铬细胞瘤切除合并肥厚型心肌病麻醉处理1例

患者,女,50岁,体重56kg,因“发现腹部肿块,CT示左上腹腹膜后肿块1周”于2013年1月10日收治入院。患者一般情况尚可,ASAⅣ级,T36．5C,BP191/104mmHg（1mmHg=0．133kPa）,P72次/分,RR18次／分。既往史：高血压8年,最高200／120mmHg;糖尿病7年;三年前有脑卒中史。术前血、尿常规及生化检查无异常。     

EF 10.4%的严重扩张型心肌病患者非心脏手术麻醉处理1例

患者, 男性, 年龄42岁, 体重53 kg, 身高164 cm, BMI 19.71 kg/m2。术前诊断:扩张型心肌病(DCM), 心功能Ⅳ级;双侧结石伴双肾积水, 右侧输尿管上段扩张, 泌尿系统感染;结石性胆囊炎。既往1年多前诊断DCM, 口服药物治疗。1年来反复出现胸闷、气促、乏力, 纳差, 活动耐力下降等症状。20 d前因上述症状加重并右侧腰痛就诊于本院心内科。6年多前诊断脑出血, 经药物治疗后自愈, 未遗留肢体活动、言语障碍。否认高血压、糖尿病、精神病等病史。入院查体:体温36.6 ℃, RR 20次/min, BP 120/70 mmHg(1 mmHg=0.133 kPa), 神志清楚, 颈静脉无怒张, 双肺呼吸音清, 心界向左下扩大。HR 91次/min, 律齐, 各瓣膜听诊区未闻及明显杂音。腹部平坦, 全腹无压痛, 右侧肾区叩击痛, 双下肢无水肿。心电图示:窦性心律, HR 85次/min, 电轴不偏, T波改变。心脏磁共振成像(CRMI)示:左室增大, EF 10.4%, 心指数1.28 L·min-1·m-2;二尖瓣重度关闭不全。肝肾功能异常, 心肌酶、肌...     

高原病患者平原手术麻醉处理体会

随着交通和经济条件的改善,高原患者常选择到内地手术。合并高原病的手术患者初到平原地区,其自身病理生理情况的改变及高原病本身的特殊性,为临床围麻醉期处理,提出了特殊的要求。本文就115例年龄50岁以上,同时合并较为严重高原病的患者手术麻醉处理总结如下。     

肥厚型心肌病合并冠状动脉夹层形成一例

患者女,55岁。阵发性心前区疼痛1年。既往有高血压、高脂血症病史。查体:血压(BP):170/110mmHg,胸骨左缘第3、4肋间可闻及3/6～4/6级收缩期杂音。心脏彩色超声心动图(UCG)提示:左心室壁非对称性肥厚,室间隔最宽处31mm,心尖部增厚(19mm),左室侧壁增厚(15mm),左心室流出道狭窄。临床诊断:肥厚型心肌病(HCG),高血压病3级(极高危组),冠心病(CHD),不稳定型心绞痛。于2005年4月18日行左心室测压 冠状动脉造影(CAG) 经皮腔内化学消融术(percutaneous transluminal septal myocardial ablation,PTSMA)。左心室造影显示:左心室腔狭小,左心室…     

妊娠合并艾森曼格综合征患者麻醉处理1例

患者,女性,31岁,孕35周,合并艾森曼格综合征(动脉导管未闭合并肺动脉高压),因活动后胸闷气短,BP升高10 d入院.术前检查:发绀,BP 155/120 mm Hg(1 mm Hg=0.133 kPa),HR 102次/min,杵状指趾,呼吸音粗,NYHA分级IV级,心脏听诊闻及左第2肋间3级双期杂音.     

300例肾移植手术麻醉处理体会

<正> 我院1991年至今,施行同种异体肾移植手术300例,取得良好的麻醉效果,现作回顾性分析,将处理体会总结如下。 1 临床资料 1.1 一般资料 本组300例,男203例,女97例。年龄16-68岁,平均39岁。合并高血压285例,占95％;贫血281例,占93.7％,其中极度贫血1例,Bb仅27g/L,重度贫血57例,中度贫血152例,轻度贫血50例;高血钾舛例,占31.3％,最高达     

胸腔镜手术麻醉处理体会

胸腔镜手术麻醉处理体会于忠元＊陈振毅＊我院自１９９６年６月以来开展电视胸腔镜手术４８例，效果满意。现将麻醉处理的体会总结如下。资料与方法４８例患者中男性３２例，女性１６例，年龄２４～７２岁，ＡＳＡ均为Ⅱ～Ⅲ级。手术时间２０ｍｉｎ～２２０ｍｉｎ不等。术...     

外科治疗肥厚型梗阻性心肌病合并冠心病的处理策略及早中期结果

目的总结肥厚型梗阻性心肌病(HOCM)合并冠状动脉粥样硬化性心脏病(冠心病)的患者行改良扩大Morrow术时同期冠状动脉旁路移植术(CABG)的围术期处理策略及早期结果。方法回顾性分析2012年1月至2017年12月阜外医院住院二部实施手术治疗的HOCM合并冠心病32例患者的临床资料,男20例、女12例,年龄37～67(53.7±8.7)岁;术前出现胸闷症状者24例,胸痛症状者14例,晕厥史6例。手术前后及随访期常规行心脏超声心动图、心电图及胸部X线片、核磁共振检查,评价心功能、左室流出道及二尖瓣的结构和功能变化。结果全部患者均接受改良扩大Morrow术联合CABG,术前左室流出道峰值压差(LVOTG)为40～152(79.6±28.7)mm Hg,同期行心肌桥松解术4例,二尖瓣置换术2例,二尖瓣成形术3例,三尖瓣成形术3例,改良迷宫手术2例。全组无术中死亡及术后30 d内死亡。患者合并行CABG的分支包括前降支26例,对角支16例,回旋支8例,右冠状动脉11例。合并行CABG搭桥1支的患者15例,合并行CABG搭桥2支的患者5例,合并行CABG搭桥3支的患者12例,平均CABG支数(1.9±0.6)支。术后住ICU时间1～13(4.1±2.8)d,术后住院时间6～30(12.6±5.5)d,术后未见严重并发症,术后切口愈合不良1例,术后新发左束支传导阻滞6例。术后左室流出道峰值压差[(79.6±28.7) mm Hg vs.(10.8±5.9)mm Hg,P0.001],室间隔厚度[(1.9±0.4)cm vs.(1.3±0.5)cm,P0.001]与术前比较均明显降低。术后二尖瓣反流程度较术前明显减轻(P0.001),二尖瓣前向运动(SAM征)基本消失。本组术后随访6～68 (38.8±20.6)个月,随访患者症状均消失,心功能(NYHA)分级级别较术前降低Ⅰ～Ⅱ级,无远期死亡、并发症或再次手术。结论对于HOCM合并冠心病的患者行改良扩大Morrow术时同时行CABG是安全的。可明显改善患者的生存率及症状,起到协同作用,不增加患者的手术并发症。     

Anesthetic management of adrenalectomy in a patient with aldosteronism complicated with hypertrophic cardiomyopathy

We had a rare patient for adrenalectomy who had aldosteronism complicated with hypertrophic cardiomyopathy (HCM). It has been suggested that aldosteronism could be the cause of HCM. The association is not clear in this case, but there is a possibility that myocardial hypertrophy was deteriorated with hypertension caused by aldosteronism. Two important points of the anesthetic management of a patient with HCM are (1) to prevent direct or reflex increases in contractility, and (2) to maintain adequate preload and afterload. In a case complicated with aldosteronism, there is a risk that a significant increase in peripheral vascular resistance following the manipulation of the adrenal gland would aggravate left ventricular pressure load, resulting in a marked decrease in cardiac output. Therefore, in such a case, vasodilators which are said to be poorly tolerated in a patient with HCM might be considered to facilitate the anesthetic management, provided that the vascular system is kept appropriately full. In this case, we employed enflurane-oxygen-nitrous oxide with fentanyl to keep deep levels of general anesthesia. Nitroglycerin (NTG) was used when arterial pressure increased suddenly with the manipulation of the adrenal gland. The effect of NTG is not definitely convincing since blood pressure returned to normal after adrenal excision. But the fact that pulmonary capillary wedge pressure decreased with infusion of NTG suggests improvement of hemodynamic function.     

Anesthetic management of a patient with mid-ventricular obstructive hypertrophic cardiomyopathy treated with dual-chamber pacing

A 64-year-old man complicated with mid-ventricular obstructive hypertrophic cardiomyopathy (MVO) was scheduled for resection of rectum cancer under general anesthesia with epidural block. Because of unexpected circulatory collapse at the induction of anesthesia, the operation was canceled. Therefore three weeks later, we inserted a temporary dual-chamber (DDD) pacing device before induction of general anesthesia, and we could maintain stable hemodynamics during general anesthesia. In the patients with MVO, blood outflow from the left ventricle to the aorta is decreased by the abnormal blood flow produced by hypertrophy of the mid left ventricle when inotropic stimulation is applied. Even in an asymptomatic patient with MVO, the hemodynamic catastrophe could occur during the operative period. In patients with hypertrophic obstructive cardiomyopathy (HOCM), DDD pacing appears to be effective to reduce the pressure gradient between the left ventricle and the aorta. Similarly, in our case, DDD pacing was effective to maintain the hemodynamic state during general anesthesia in a patient with MVO.     

Anesthetic management of a patient with a history of Batista procedure for dilated cardiomyopathy undergoing gastric surgery

We experienced anesthetic management for an operation to remove a hemorrhagic gastric submucosal tumor in a patient who had undergone left ventricular volume reduction (the Batista procedure) for dilated cardiomyopathy (DCM) 2 years previously. Preoperative evaluations indicated the relapse of severe DCM. Intravenous and epidural anesthesia was employed with the aid of an intraaortic balloon pump (IABP). Safe anesthetic management was achieved under the guidance of a Swan-Ganz catheter without inducing overreduction of afterload or excessive preload.     

Anesthetic management for pericardial fenestration in a hypertrophic cardiomyopathy (HCM) patient with massive pericardial effusion

A 65 year-old male with HCM had progressively increased pericardial effusion. He also had atrial fibrillation (af), cardiac systolic dysfunction and chronic renal failure needing hemofiltration. Pericardial fenestration was carried out to improve diastolic function. Anesthetic management with fentanyl plus low-dose propofol infusion and postoperative analgesia with epidural morphine were effective for hemodynamic stability to prevent myocardial depression and to control ventricular response to atrial fibrillation. Intraoperative trans-esophageal echocardiography (TEE) monitoring was very useful for fluid therapy, inotropic support and estimation of systolic and diastolic function.     

Anesthetic management of a child with Noonan syndrome and hypertrophic obstructive cardiomyopathy

Noonan syndrome is characterized by facial, skeletal and cardiovascular anomalies. We describe the anesthetic management of a one-year-old boy with Noonan syndrome and hypertrophic obstructive cardiomyopathy scheduled for tonsillectomy and adenoidectomy under general anesthesia. He had a history of congestive heart failure at 5 months of age. Preoperative echocardiogram revealed a hypertrophied septum (12.8 mm) with concentric hypertrophy of the left ventricle. Mild mitral regurgitation was also noted. Our anesthetic goal was set to maintaining adequate preload and afterload as well as adequate anesthesia depth to avoid LV outflow tract obstruction. Intravenous fluid was started the day before surgery. Anesthesia was induced with fentanyl 30 microg and midazolam 2 mg and maintained with propofol 8 mg x kg(-1) x hr(-1), fentanyl 30 microg, ketamine 4 mg, and sevoflurane 1-2%. Intraoperative monitoring included 12-lead electrocardiogram and direct measurement of arterial pressure. Intra- and post-operative course was uneventful.     

Anesthetic management of a patient with Bardet-Biedl syndrome and dilated cardiomyopathy

Bardet-Biedl syndrome is a rare autosomal recessive disease characterized by renal abnormalities, obesity, dysmorphic extremities, retinal dystrophy, and hypogenitalism, as well as cardiac abnormalities, diabetes mellitus, hypertension and mental retardation. Renal failure is the leading cause of death and survival is substantially reduced. We describe the anesthetic management of a patient with Bardet-Biedl syndrome, dilated cardiomyopathy and fractured right femur and tibia requiring open reduction and internal fixation. A combined spinal-epidural (CSE) block was performed; 7.5 mg of bupivacaine and 20 microg of fentanyl were administered into the subarachnoid space. Postoperative analgesia was obtained with an epidural infusion mixture of bupivacaine (0.125%) and fentanyl (1 microg/mL). Hemodynamic status was monitored by direct measurement of intra-arterial blood pressure and central venous pressure. The perioperative course was uneventful.     

Anesthetic management in a patient previously diagnosed with takotsubo cardiomyopathy

Takotsubo cardiomyopathy (transient apical ballooning of the left ventricle) is a recently described and often underdiagnosed entity. The syndrome is observed predominately in postmenopausal women and the clinical signs are similar to those of an acute anterior myocardial infarction. In most of the reported cases an emotional or physical stress event has been identified as a trigger, and perioperative stress has been suggested as the trigger in some of these cases. Outcome is favorable with the right treatment, though recurrences are possible. We report the anesthetic management of a 79-year-old woman with a previously diagnosed episode of Takotsubo cardiomyopathy, who was admitted to our hospital for total hip replacement. Care was taken to provide proper preoperative sedation before provision of hyperbaric spinal anesthesia, followed by sedation with intravenous propofol. Surgery and the early postoperative period were uneventful. We believe that minimizing perioperative anxiety should be a priority in these patients due to the possibility that a catecholamine discharge might trigger an episode of Takotsubo cardiomyopathy.     

Subvalvular procedure for functional mitral regurgitation in a patient with dilated-phase hypertrophic cardiomyopathy

Surgical correction of the subvalvular apparatus to reduce tethering, along with mitral annuloplasty, has recently been highlighted in the treatment of functional mitral regurgitation. However, because of anatomical differences in the subvalvular apparatus between cases of progressive cardiomyopathy, a uniform procedure to reduce tethering has not been established. We report a case-specific reconstructive method consisting of procedures mainly on papillary muscles for a rare case of dilated-phase hypertrophic cardiomyopathy with moderately severe mitral regurgitation.