右胸小切口行心内直视手术16例

目的介绍右胸小切口行心内直视手术的体会。方法选择一般先天性心脏病１６例，其中房间隔缺损９例，室间隔缺损７例，室间隔缺损合并右心室流出道狭窄２例，室间隔缺损合并左上腔静脉１例，均采用右胸小切口经右第４肋间进胸行心内直视手术。结果无手术并发症和手术死亡。结论右胸小切口行心内直视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，但不适合较复杂的心脏手术。     

右腋下小切口体外循环心内直视手术270例

目的总结右腋下小切口在常见先天性心脏病手术中的应用经验。方法回顾性分析济宁医学院附属医院2009年10月至2011年6月采用右腋下小切口经第4肋间进胸,在体外循环下施行心内畸形矫治手术270例患者的临床资料,其中男132例,女138例;年龄3个月～9岁(3.0±1.6)岁,行室间隔缺损(VSD)修补术132例,房间隔缺损(ASD)修补术50例,ASD修补术+部分型肺静脉异位引流(PAPVC)矫治术12例,部分型房室管畸形(PECD)矫治术15例,VSD+ASD修补术26例,法洛四联症根治术35例。结果全组无手术死亡,无二次开胸止血,平均住院时间9 d,平均住ICU 1.6 d。发生右肺不张3例,右侧气胸2例,阵发性室上性心动过速1例,Ⅱ°房室传导阻滞1例。术后全部患者均获得随访,随访时间1～16个月,随访期间3例VSD术后发生小于2 mm的残余漏,其余患者恢复良好。结论对具有该术式适应证的患者经右腋下小切口行心内直视手术,有安全可靠、创伤小、美观等优点。     

右胸前外侧小切口心内直视术102例

目的　总结选择性应用右胸前外侧小切口在体外循环 (CPB)下行心内直视手术的临床经验。　方法　对10 2例先天性心脏病及风湿性二尖瓣病变患者均采用右胸前外侧小切口进行心内直视手术。　结果　全组无手术死亡 ,术后 6例发生少量胸腔积液 ,出院时自然吸收 ,无其它并发症发生。术后胸腔引流量 4 0～ 32 0 ml,平均 14 0 .0±2 1.5 ml,较同期同类手术患者胸腔引流量少。　结论　右胸前外侧小切口行心内直视手术是一种安全可靠的微创手术 ,易掌握 ,但不适用于复杂的心内直视手术。     

右腋下小切口心内直视手术224例

目的总结右腋下小切口径路手术治疗先天性心脏病的经验,并探讨其相关的问题。方法224例先天性心脏病患者采用右腋下小切口径路经第3或第4肋间进胸,在体外循环下行心内直视术,其中室间隔缺损(VSD)修补术168例,房间隔缺损(ASD)修补术48例,法洛四联症(TOF)根治术6例,右心室双出口(DORV)和埃布斯坦综合征(Ebsteinsyndrome)矫治术各1例。结果全组术后死亡1例(0.45%),死于急性肺水肿。发生并发症13例(5.8%)。右腋下小切口径路手术患者的体外循环时间、主动脉阻断时间、呼吸机辅助呼吸时间和术后住院天数与同期胸骨正中切口径路手术患者比较差别无统计学意义(P>0.05),但术中出血量和术后胸腔引流量较胸骨正中切口径路少(P<0.01)。术后随访214例,随访时间2个月~7年,除3例患者术后早期心功能稍差(射血分数<0.50)和2例VSD患者术后发生轻度残余漏外,其余患者均恢复良好。结论对具有该术式适应证的患者经右腋下小切口径路行心内直视手术,有安全可靠、术中出血少和美观等优点,但对TOF以及复杂先心病患者慎用本术式。     

右腋下小切口心内直视手术治疗婴幼儿先天性心脏病

目的探讨右腋下小切口手术应用于婴幼儿先天性心脏病（先心病）的可行性。方法2010年7月～2012年3月,采用右腋下小切口心内直视手术治疗68例年龄6—15个月婴幼儿先心病。体重6．5～12kg。房间隔缺损27例（其中合并部分型肺静脉异位引流3例,合并肺动脉瓣狭窄1例,合并永存左上腔1例）,室间隔缺损37例,（其中合并永存左上腔3例,右室流出道狭窄1例）,部分性房室管畸形4例。均在全麻体外循环下经右腋下4—6cm小切口手术修补。结果全组无围术期死亡。体外循环时间（21．6±10．7）min,主动脉阻断时间（16．8±7．5）min;术后渗出胸液量（21．9±9．3）m1,术后呼吸机辅助时间（8．5±2．5）h,术后住院时间（5．4±0．7）d。术后1个月复查无残余分流。结论小切口手术对婴幼儿简单先心病效果确切,术后出血少,美观,隐蔽,不影响胸骨发育,值得推广。     

右腋下垂直小切口心脏不停跳心内直视手术135例

目的 探讨右腋下垂直小切口心脏不停跳手术治疗先天性心脏病的方法.方法 2003年11月～2006年6月,采用右腋下小切口在心脏不停跳下施行心脏手术135例;其中室间隔缺损(VSD)68例,房间隔缺损(ASD)61例(ASD合并左上腔静脉4例),VSD+ASD 5例,冠状动静脉瘘1例.结果 全组无手术死亡.平均住院时间8 d.术后发生右肺不张2例,右侧气胸1例,切口液化2例.术后随访122例,随访时间1个月～2年,除2例VSD患者术后发生残余漏外,其余患者均恢复良好.结论 对单纯ASD、VSD患者选择右腋下垂直小切口,在心脏不停跳下施行心内直视手术,安全可靠、手术时间短、创伤轻、恢复快、切口美观.     

右胸小切口心内直视术52例的临床应用

目的 总结右胸小切口心内直视手术临床应用体会。方法 对1997.10～1998.12本院经右胸小切口施行的心内直视手术52例进行总结分析。结果 术中心肌阻断时间、术后辅助呼吸时间以及ICU停留时间等与常规正中开胸无显著差异;但术后疼痛时间及其程度都明显缩短及减轻,无手术并发症及手术死亡。结论 右胸小切口心内直视术具有创伤小、恢复快和伤口隐蔽、美观等特点,易为患者接受。但必须选择适当的病例和相应的手术器械,才能保证手术顺利实施。     

右胸单一切口手术治疗胸段食管癌32例体会

目的探讨右胸单一切口手术治疗胸段食管癌的方法和效果。方法 2012-01—2017-01间,嵩县人民医院采用右胸单一切口手术治疗食管癌32例,回顾性分析患者的临床资料。结果本组均顺利完成手术,手术时间160~220 min,平均180 min。清扫淋巴结12~20枚,平均16枚。阳性23枚,其中隆突下19枚,胃左血管旁2枚。食管切缘均无癌残留。术后发生右下肺不张1例,经对症处理后痊愈。未发生吻合口瘘等其他并发症,均安全出院。结论右胸单一切口手术治疗食管癌,具有创伤较小、并发症较少、手术后恢复较快、术后生活质量较高等优点,但需严格掌握手术适应证。     

右腋下小切口在先天性心脏病手术中的应用

目的介绍右腋下小切口在先天性心脏病手术中的应用体会。方法１９９５年３月～１９９７年５月，经右腋下小切口在常温体外循环心脏不停跳下修补心脏间隔缺损２０例。房间隔缺损１３例，室间隔缺损７例。结果体外循环时间２０．０９±６．４分钟，无死亡及并发症，术后住院时间８．０±２．２天。随访２～２０个月，均能参加正常活动。结论右腋下小切口常温心脏不停跳修补小儿心脏间隔缺损创伤小、恢复快、简便、安全、美容效果好。     

剑突下小切口婴幼儿心内直视手术

2001年3月至2004年10月,我们在原有右侧切口及胸骨下段切口纠治儿童先天性心脏病基础上,采用剑突下小切口对86例病儿实施了较复杂的先天性心脏病（先心病）手术治疗,现总结报道如下.     

Mitral valve replacement through right thoracotomy after previous coronary artery bypass grafting

The Usefulness of Brachial Artery Cannulation, Perfused Ventricular Fibrillation with Moderate Hypothermia, and Minimal Dissection Techniques It has been reported by several authors that a right thoracotomy for mitral valve surgery can be useful after previous coronary aortery bypass grafting (CABG). A 76-year-old man with mitral valve regurgitation after previous CABG underwent mitral valve replacement with some modified techniques. Cardiopulmonary bypass was established with right brachial artery cannulation and right femoral venous cannulation with the aid of vacuum-assisted venous drainage. Ventricular fibrillation (VF) was induced by rapid pacing of the ventricle, and mitral valve replacement was performed under perfused VF with moderate hypothermia. The patient’s postoperative course was uneventful. This method appears to be a safe and easy alternative mitral valve surgery for complicated cases of this type.     

右外侧小切口剖胸小儿先天性心脏畸形矫治术319例体会

目的介绍经右外侧小切口剖胸体外循环下小儿心脏直视手术的经验。方法１９９４年１０月至１９９７年４月，共完成经右外侧第４或第３肋间进胸，体外循环下先天性心脏畸形矫治术３１９例。患儿年龄３．４４±１．５９岁（５个月～８岁），体重１３．６６±３．９８（６～２６）ｋｇ。修补房间隔缺损８７例（合并左上腔静脉１例，肺动脉瓣狭窄６例，部分肺静脉畸形引流５例），室间隔缺损２００例（合并动脉导管未闭７例，二尖瓣关闭不全７例，左上腔静脉３例，右室流出道狭窄１１例），法乐氏四联症１９例（合并左上腔静脉３例，单冠状动脉畸形１例），部分心内膜垫缺损２例及其他畸形１１例。体外循环时间平均５６．０７±２４．９０（２０～１７６）分，心肌循环阻断３２．９７±２０．３８（６～１４０）分。术后机械通气平均１８．７５±２４．５７（２～１４０．７２）小时，平均住院７．０８±０．６９（７～１７）天。结果全组患儿无手术死亡。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，不破坏胸廓连续性，防止术后鸡胸等优点，其美观效果优于胸部正中或双乳腺下皮肤切口。     

不同年龄发绀型先心病患儿围体外循环期凝血功能的比较

Objective To investigate the changes in blood coagulation during cardiopulmonary bypass (CPB) in children of different ages undergoing open heart surgery for cyanotic congenital heart disease.Methods Sixty children with cyanotic congenital heart disease undergoing open heart surgery under CPB were divided into 3 age groups: Group A(age≤12 mort, n=25), Group B (12mon＜age≤24 mon, n= 17) and Group C (24 mon＜ age＜4 yr, n=18). Venous blood samples were taken immediately after induction of anesthesia(T1) and at 10 min after protamine administration (T2)for determination of activated coagulation time (SonACT), clot rate and platelet function (PF) using Sonoclot coagulation and platelet function analyzer-type DP2951 (Sieuco Co., USA).Results There was significant difference in SonACT, clot rate and PF at T1 among the 3 groups: the SonACT was significantly shorter in Groups B and C than in Group A, the clot rate was significantly higher in Group B than in Group C, and the PF was significantly lower in Group C than in Group A. At T2 , the SonACT was significantly prolonged in all 3 groups, the clot rate was significantly decreased in Groups A and B, and the PF was significantly decreased in Group A.Conclusion There are significant differences in blood coagulation and PF among the 3 different age groups of children with cyanotic congenital heart disease after induction of anesthesia and CPB has different effects on their blood coagulation and PF.     

Hemodynamic effects of dobutamine and dopexamine after cardiopulmonary bypass in pediatric cardiac surgery*

Background: After surgical repair of congenital heart disease, inotropic support is sometimes necessary to wean from cardiopulmonary bypass. In pediatric cardiac surgery, dobutamine and dopamine are often used as inotropic support. Dopexamine is a synthetic catecholamine, which has positive inotropic and vasodilating properties. Because the hemodynamic effects of catecholamines are modified after cardiopulmonary bypass, the aim of this study was to investigate the effects of dobutamine and dopexamine on cardiac index and systemic vascular resistance index after cardiopulmonary bypass in pediatric cardiac surgery. Methods: The study was performed in a prospective, randomized, and double‐blinded cross‐over design. The investigation included 11 children for elective, noncomplex congenital heart surgery. After weaning from cardiopulmonary bypass and a 20‐min period of steady state, children received either 2.5 μg·kg^?1·min^?1 dobutamine or 1 μg·kg^?1·min^?1 dopexamine for 20 min. Cardiac index (transpulmonary thermodilution), mean arterial pressure, central venous pressure, stroke volume, systemic vascular resistance, and central venous oxygen saturation were determined. The primary outcome variable was cardiac index. Results: No difference in cardiac index was observed between the two groups (P = 0.594). Both drugs increased cardiac index, dopexamine from 3.9 ± 0.6 to 4.7 ± 0.8 l·min^?1·m^?2 (P = 0.003) and dobutamine from 4.1 ± 0.7 to 4.8 ± 0.7 l·min^?1·m^?2 (P = 0.004). During treatment with dobutamine, children presented with significantly higher mean arterial pressure (P = 0.003) and systemic vascular resistance index (P = 0.026). Conclusions: This trial demonstrates that low‐dose dobutamine and dopexamine both increase cardiac index during pediatric cardiac surgery but with different hemodynamic effects.     

不同年龄发绀型先心病患儿围体外循环期凝血功能的比较

目的比较不同年龄发绀型先心病患儿围体外循环期的凝血功能。方法择期在CPB下行心脏直视手术的发绀型先心病患儿60例,心功能Ⅰ级或Ⅱ级,按年龄分为3组：A组（年龄≤12月,n=25）、B组（12月〈年龄≤24月,n=17）和C组（24月〈年龄〈4岁,n=18）。分别于麻醉诱导后即刻（T1）和鱼精蛋白中和肝素后10min（T2）时抽取中心静脉血,采用Sonoclot凝血与血小板功能分析仪检测激活凝血时间（SonACT）、凝集速率和血小板功能（PF）。结果与,T1时相比,T2时各组SonACT延长,A组和B组凝集速率,A组PF降低（P〈0.05）;与A组相比,T1时B组和C组SonACT缩短,T1时C组PF降低（P〈0.05）;与B组相比,T1时C组凝集速率降低（P〈0.05）。结论不同年龄发绀型先心病患儿围体外循环期的凝血功能有一定程度的差别。     

Anaesthesia considerations for cardiac MRI in infants and small children

BACKGROUND: General anaesthesia is frequently necessary in infants and small children undergoing cardiac magnetic resonance imaging (MRI), because of the imaging techniques, MRI environment and potential need for breath-holding to facilitate imaging. Anaesthetizing paediatric patients with congenital heart disease (CHD) for cardiac MRI poses many challenges for the anaesthetist and this report reviews our experience. METHODS: We retrospectively reviewed the anaesthesia and MRI records of all patients who had undergone cardiac MRI between January 2000 and October 2002. RESULTS: A total of 250 children with cardiac disease underwent general anaesthesia for cardiac MRI. ASA classification included class I, 2%; class II; 26%; class III, 60% and class IV, 12%. A total of 168 patients (67%) had undergone previous cardiac surgery, 182 patients (94%) were discharged the same day and 48 patients (19.2%) had cyanotic cardiac defects (SpO2 between 55 and 85%). No scans were interrupted because of low oxygen saturation during breath-hold or haemodynamic instability. No patient was admitted to the hospital from complications related to general anaesthesia, but one inhouse patient from the cardiology ward was admitted to the cardiac intensive care unit (CICU) after the MRI because of cyanosis and low cardiac output. Seven patients from the CICU were on inotropic infusions when they underwent the MRI procedure and two others needed inotropic support after induction of anaesthesia. Five patients had a brief episode of hypotension during the MRI and responded quickly to interventions. CONCLUSION: Our experience demonstrates that general anaesthesia for cardiac MRI can be provided safely in infants and small children with CHD, despite the complexity and pathophysiology of many defects, the frequent breath-holding for image acquisitions and the MRI environment.