孕羊低温体外循环对胎羊血流动力学以及碳水化合物代谢的影响

目的 探讨孕羊低温体外循环(CPB)对胎羊血流动力学以及碳水化合物代谢的影响.方法 孕羊20头,随机分成对照组,开胸不建立体外循环;常温CPB组(35～36℃)、浅低温组CPB(32～34℃)和中低温CPB组(28～31℃),建立常规体外循环,转流降温、复温30 min.分别监测孕羊和胎羊的心率、平均动脉压、胎羊脐动脉和颈内动脉的搏动指数(pulse index,PI),孕羊与胎羊血糖、乳酸含量和HCO-3值的变化.结果 母羊和胎羊平均动脉压差异无统计学意义(P＞0.05).浅低温组和中低温组颈内动脉PI值较对照组和常温组显著增高(P＜0.05),脐动脉PI值组间差异无统计学意义,但随体外循环时间的延长而增高.血糖水平胎羊各组间差异无统计学意义(P＞0.05),但中低温CPB组中胎羊显著低于孕羊(P＜0.05).中低温CPB组胎羊血乳酸随时间延长有上升趋势(P＜0.05),而且显著高于孕羊(P＜0.05),但各CPB组间血乳酸差异无统计学意义.结论 孕羊低温体外循环降温时,胎羊心率明显下降,复温后胎羊心率能回复正常,体外循环对胎羊平均动脉压无明显影响,但低温降低胎羊脑部和脐动脉的血流;低温体外循环导致胎羊血糖水平降低,而血乳酸浓度显著增高.

Abstract：

Objective To evaluate effects of maternal hypothermic cardiopulmonary bypass on fetal homodynamic and carbohydrate metabolism. Methods Twenty pregnant sheep were divided into four groups randomly: control group(n=5),normothermic group (35-36℃)(n=5), mild hypothermic group(32-34℃)(n=5) and moderate hypothermic group (28-31℃)(n=5).Thoracotomy was performed without CPB in the control group. Routine CPB was established with different temperature in other three groups. The temperature of normothermic group was kept normal; the left two groups were cooled down to the set point of temperature and then rewarmed back to normal level. Fetal and maternal temperatures, heart rate,mean blood pressure(BP), pulse index (PI) of fetal umbilical artery (UA) and internal carotid artery (CA) were evaluated at cooling and rewarming stages. Biochemical indicators including blood glucose and lactic acid were also measured at the same time. Results There are no differences in mesn BP of ewas and fetal lambs between the different groups (P＞0.05). CA PI value of mild hypothermic group and moderate hypothermic group were significantly higher than those of control group and normothermic group (P＜0.05). There was no difference of UA PI in the four groups, but PI increased following the prolonged duration of CPB. There was no difference change of blood glucose in the four group of fetus, which was significantly lower than the ewe groups. An upward trend of fetal blood lactic acid with time was observed in three CPB groups. The whole level of fetal blood lactic acid was much higher than that of maternal blood of lactic acid. Conclusion Cooling of maternal bypsss decreases fetal heart rate significantly,and fetal heart rate recovered to base line following rewarming phase. There was no signicant effect of CPB on fetal mean BP. However, CPB impacted on the blood flow of fetal brain and umbilical artey. Hypothermia CPB can increase fetal blood glucose and blood lactic acid dramatically.     

经心包斜窦行扩大吻合口心上型全肺静脉异位引流矫治术

目的 探讨经心包斜窦入路行心上型全肺静脉异位引流(TAPVC)矫治术,利用垂直静脉延长共同静脉切口,从而扩大共同静脉与左心房的吻合口.方法 2007年12月至2009年1月,我院共收治27例TAPVC患儿在体外循环下行畸形矫治手术,其中男17例,女10例;年龄2 d至13岁;体重2.3～21 kg,平均(5.16±3.49)kg;其中心上型TAPVC 11例,占40.7%;心下型1例,占3.7%;心内型12例,占44.4%;混合型3例,占11.1%.在全部接受手术的11例心上型TAPVC患儿中,10例采用经心包斜窦人路行扩大吻合口的矫治技术,其中7例同时采用无内膜接触缝合技术.此10例患儿中,男7例,女3例;年龄2 d至13岁;体重2.4～21 kg,中位数为6.0 kg.术后行心脏超声随访,随访时间为1～14个月,中位数为7个月,常规随访时间点分别设在出院前、术后3个月、术后半年及术后1年.手术选择心包斜窦入路,沿长轴横向剖开共同静脉,并将此切口上延至垂直静脉的心包返折处,使用7-0 PDS缝线将左心房后壁切口与共同静脉切口或其周边的心包组织吻合.结果 1例患儿因凝血功能障碍于术后第二天死亡;另1例患儿由于家庭原因于术后第五天放弃治疗死亡,其他8例患儿均存活.在8例存活患儿中,1例患儿因术前并发双侧肺实变,另1例患儿因合并重度肺动脉高压,术后机械辅助呼吸超过7 d,其他患儿均无并发症发生.至目前为止,心脏超声随访提示:全部存活患儿肺静脉回流通畅,血流速度介于0.65～1.2 m/s之间.结论 在治疗心上型TAPVC时,选择心包斜窦入路不仅可以获得良好的术野,还可以利用垂直静脉扩大吻合口内径,同时方便采用无内膜接触缝合技术,以预防术后肺静脉梗阻的发生.但本技术路线尚有待大宗病例的远期随访进行验证.     

左心发育不全综合征Ⅰ期Norwood手术的围术期处理

目的 总结Ⅰ期Norwood手术围术期处理的经验。方法 2004年7月～2006年3月，应用Ⅰ期Norwood手术治疗3例患左心发育不全综合征（hypoplastic left heart syndrome，HLHS）及单心室合并左心流出道梗阻的患婴。第1例行升主动脉与主肺动脉侧侧吻合，体-肺分流重建肺循环血流;第2例利用主肺动脉重建升主动脉以及弓部，Core-Tex人造血管连接右心室和肺动脉（Sano Shunt术式）重建肺循环血流;第3例同样应用Sano Shunt术式重建肺循环血流。结果 前2例手术取得成功，随访24～34个月，两例均已成功进行Ⅱ期Norwood手术，心功能Ⅰ～Ⅱ级;第3例术后早期死亡，死因是重度低心输出量综合征。结论 Norwood手术是治疗左心发育不全综合征和单心室合并左心流出道梗阻疾病的有效治疗方法之一，选择适当的手术方式和术前、术后维持体-肺循环动态平衡是取得良好手术疗效的关键。     

产前诊断双主动脉弓并结局随访10例报道

目的探讨胎儿双主动脉弓(double aortic arch,DAA)产前诊断及生后结局随访。方法收集广东省人民医院心脏母胎科2016年8月至2019年8月经胎儿超声心动图诊断并生后确诊为DAA的10例胎儿的超声心动图及生后结局随访资料。结果 10例胎儿诊断时孕周22~33周;超声心动图在三血管-气管切面、左心室长轴切面显示升主动脉发出左侧及右侧主动脉弓,形成"O"形血管环,包绕气管和食管。10例经产前咨询后足月出生,其中右弓优势型9例,均衡型1例。1例患儿生后出现气促、喘鸣等临床症状,心脏计算机断层扫描(CT)及纤维支气管镜提示气管受压明显。其余9例无明显临床症状,其中4例行纤维支气管镜检查,3例存在轻度气管狭窄。共3例行手术治疗,术后恢复良好。结论 DAA可产前明确诊断,并进一步分型,通过心血管专业产前咨询,制定临床治疗策略。生后有症状患儿需尽早手术,效果良好。无气道、食道压迫症状患儿可长期随访。     

胎羊心脏转流对胎羊心功能的影响

目的探讨胎羊心脏转流对不停跳下胎羊心功能的影响。方法孕120-140d母羊8只，共孕9只胎羊，随机分为对照组（n=4）和胎羊体外循环组（CPB组，n=5）。对照组胎羊开胸，不建立体外循环。CPB组建立胎羊心脏转流模型，转流30min。分别于转流前、转流30min、转流结束后1h、2h测胎羊平均动脉压、心率和动脉血气值。观察血肌钙蛋白（TnI）含量的变化，B超检测左、右心室Tei指数和脐动脉搏动指数（PI），观察心肌超微结构变化。结果两组胎羊平均动脉压、心率无显著变化。CPB组胎羊脱离体外循环后出现高碳酸血症和酸中毒，血氧分压无显著变化。对照组胎羊血气值无明显变化。CPB组胎羊左右心室Tei指数、脐动脉PI、血TnI含量均显著大于对照组（P〈0．05）。CPB组胎羊心肌细胞糖原明显减少。结论胎羊心脏转流对胎羊心功能造成损害，心功能不良与胎盘功能不良存在相互影响。     

儿童先天性心脏病术后静脉-动脉体外膜肺氧合治疗期间营养干预策略探讨

目的 探讨不同营养干预策略对先天性心脏病术后行静脉-动脉体外膜肺氧合(VA-ECMO)治疗患儿临床结局的影响。方法 回顾性分析2015年1月至2021年1月在广东省人民医院行先天性心脏病手术并接受VA-ECMO治疗的58例患儿的临床资料。根据营养干预策略将患儿分为肠内营养(EN)组15例,肠外营养(PN)组33例和混合营养(EN+PN)组10例;根据EN干预时机分为早期EN组9例和晚期EN组16例。主要结局为住院死亡率,次要结局为住ICU时间、总住院时间、新发感染及消化道并发症发生率。比较不同营养干预策略及EN干预时机的临床结局。结果 EN组、EN+PN组和PN组的住院死亡率、住ICU时间、总住院时间、新发感染率比较差异均无统计学意义(P>0.05),三组消化道并发症发生率比较差异有统计学意义(P<0.05)。早期EN组和晚期EN组的住院死亡率、住ICU时间、总住院时间、新发感染率以及消化道并发症发生率比较差异均无统计学意义(P>0.05)。结论 EN或EN+PN增加消化道并发症,不增加住院死亡率、住ICU时间、总住院时间及新发感染率。EN启动时机对临床结局无影响。     

小儿体外心肺复苏临床结果的回顾性研究

目的 本文总结单中心小儿体外心肺复苏(ECPR)的临床结果,探讨死亡与并发症的高危因素,以指导临床治疗.方法 回顾性分析2015年1月至2018年12月单中心开展小儿ECPR患者(<14岁)的临床资料,一般特征包括性别、年龄、体重、身长、体外膜氧合(ECMO)前血压,以及心肺转流时间、主动脉阻断时间等.比较死亡患儿和存...     

肺动脉与下腔静脉直接连接TCPC术后凝血功能变化

目的 探讨肺动脉与下腔静脉直接连接TCPC术(DCPC)后凝血功能变化及意义.方法 收集行DCPC术患者的术前、术后及随访时的临床资料及实验室检查结果,进行回顾性研究.结果 共19例入组,男11例、女8例,中位手术年龄6.6(5.2～9.2)岁;与术前相比,患者出院时的凝血酶原时间、活化部分凝血活酶时间和血纤维蛋白原差异无统计学意义(P＞0.05),而凝血国际标准比值和凝血酶原活动度较术前相比差异有统计学意义(P＜0.05);随访时的凝血指标基本恢复正常,仅纤维蛋白原较术前稍高(P＜0.05).结论 DCPC术后的凝血功能变化不明显,非长期抗凝治疗的条件下无血栓等并发症发生,远期临床效果满意.     

Early variation of left ventricular dimension and mitral regurgitation after correction for anomalous origin of the left coronary artery from the pulmonary artery

Background Anomalous origin of the left coronary artery from the pulmonary artery is a rare congenital cardiac lesion resulting in myocardial ischemia even infarction,morphological impairment and dysfunction of left ventricle,together with mitral regurgitation.Here we will introduce our experience in the surgical repair of this kind of congenital lesion and the retrospective analysis about the improvement of left ventricular dimension and mitral regurgitation in early postoperative term.Method From May 1998 to July 2012,38 consecutive patients with anomalous coronary artery from the pulmonary artery underwent surgical correction(33 received left coronary artery re-implantation,4 left coronary artery ligation or primary closure,1 Takeuchi procedure,and 10 simultaneous mitral valve plasty).Left ventricular dimension,mitral regurgitation,and ejection fraction,were measured by color Doppler echocardiography preoperatively,and 1 month after discharge.Results Hospital survival was 94.7%(2 in-hospital deaths).Ten paptients with more than moderate mitral regurgitation received simultaneous mitral plasty,one of whom was converted to mechanical prosthetic valve replacement.Mitral valve annuloplasty was applied in 9 cases of coronary re-implantation correction,3 of whom also received additional mitral leaflet cleft repair.Meanwhile 8 patients underwent other different concomitant operations.Echocardiographic results for the survivals 1 month after discharge showed that left ventricular end-diastolic,endsystolic dimension decreased from 40.05 ± 5.56 mm and 28.94 ± 6.21 mm to 33.07 ± 6.82 mm(P < 0.01) and 23.04 ± 5.87 mm(P < 0.01) respectively.The average mitral regurgitation grade was also reduced from 2.36 ± 1.08 to 1.64 ± 93(P < 0.05) in the group.All survival patients improved clinically and NYHA functional class decreased significantly from 2.37 ± 1.08 to 2.10 ± 0.54(P < 0.05).Conclusions The surgical repair of anomalous origin of the left coronary artery from the pulmonary artery is safe and effective,and can get satisfactory dimensional and functional improvement of the left ventricle in early term.Although controversial,concomitant mitral valve plasty can be helpful for critical patients with severe mitral regurgitation.     

左心发育不全综合征Ⅰ期Norwood手术的围术期处理

目的 总结Ⅰ期Norwood手术围术期处理的经验.方法 2004年7月～2006年3月,应用Ⅰ期Norwood手术治疗3例患左心发育不全综合征(hypoplastic left heart syndrome,HLHS)及单心室合并左心流出道梗阻的患婴.第1例行升主动脉与主肺动脉侧侧吻合,体一肺分流重建肺循环血流;第2例利用主肺动脉重建升主动脉以及弓部,Core-Tex人造血管连接右心室和肺动脉(Sano Shunt术式)重建肺循环血流;第3例同样应用Sano Shunt术式重建肺循环血流.结果 前2例手术取得成功,随访24～34个月,两例均已成功进行Ⅱ期Norwood手术,心功能Ⅰ～Ⅱ级;第3例术后早期死亡,死因是重度低心输出量综合征.结论 Norwood手术是治疗左心发育不全综合征和单心室合并左心流出道梗阻疾病的有效治疗方法之一,选择适当的手术方式和术前、术后维持体一肺循环动态平衡是取得良好手术疗效的关键.