儿童瓣膜成形术30例临床分析

目的探讨儿童瓣膜病变行瓣膜成形术的治疗效果。方法分析儿童瓣膜成形术30例患儿的临床资料。根据不同瓣膜的具体病理改变,行二尖瓣成形术包括瓣叶裂缺行修补术12例;瓣环扩大行改良DeVega环缩5例,交界环缩2例;腱索、乳头肌劈开延长1例;外伤性二尖瓣前乳头肌断裂转移至心室壁1例。三尖瓣病变主要包括瓣叶裂缺行瓣叶修补13例,交界环缩3例。主动脉瓣膜穿孔行瓣叶修补1例;共同房室瓣单片法修补4例。合并心脏畸形予以同期矫治。结果术后无死亡病例,无严重室性心律失常病例,早期发生低心排综合征2例,呼吸道感染12例、血红蛋白尿6例、胸腔及心包积液5例、30例病例均门诊复查随访,时间2-48个月,平均16．6个月。超声心动图提示二尖瓣轻度关闭不全4例,中重度1例,后在外院再次手术;三尖瓣轻度关闭不全3例,中度1例;主动脉瓣关闭良好。结论儿童心脏瓣膜病采取瓣膜成形术能取得良好的术后效果。术中依据不同瓣膜病变,采用适合的手术方法以及确实有效的围手术期处理,是儿童瓣膜成形术取得满意效果的关键。     

78天婴儿卵巢囊肿蒂扭转坏死一例

患儿,女,78 d,主因反复呕吐伴体检B超发现腹部肿快8小时入院.患儿入院当天上午因哺乳后即出现呕吐,反复四次,在当地医院就诊,考虑急性肠套叠,行腹部B超发现非肠套叠同心圆征象,而是一右肾上极囊性均质回声.     

非胸腔镜辅助下Nuss手术治疗儿童漏斗胸的临床研究

目的探讨非胸腔镜辅助下Nuss手术治疗儿童漏斗胸的疗效与经验。方法 2011年3月至2016年3月本院共收治42例漏斗胸患儿,其中男性36例,女性6例;年龄3岁至15岁2个月。所有患儿术前CT评估Haller指数均≥3.4(4.36±0.63)。胸廓对称30例,不对称12例。心电图异常14例。术中采用两侧切口,均经右胸入路,放置1条钢板。25例右侧固定片固定,7例双侧固定。所有病例均用可吸收线将钢板和固定器缝合于肋骨外膜上。结果 42例均顺利完成手术,平均手术时间(70.98±12.1)min,术后平均住院时间(7.24±0.85)d,39例效果良好,2例效果不显著,1例钢板移位,2例对钢板产生过敏反应。结论 Nuss手术治疗漏斗胸创伤小,安全性好,术后恢复快,效果良好。     

阿魏酸钠对婴幼儿体外循环血管内皮功能的保护作用

目的 观察婴幼儿先天性心脏病心肺转流术(CPB)围手术期一氧化氮(NO)、内皮素(ET-1)和循环内皮细胞(CEC)水平的变化,初步探讨阿魏酸钠对血管内皮功能的保护作用.方法 60例先天性心脏病病儿随机分为阿魏酸钠组(S组)和对照组(C组)各30例.S组于体外循环前静脉滴注阿魏酸钠注射液8 mg/kg,C组予等量平衡盐溶液,检测CPB前(TO)、30 min(T1)、结束时(T2)、手术后2h(T3)、6 h(T4)5个时间点血浆NO和ET浓度,以及T0和T2两个时间点的CEC变化.结果 两组间T0比较差异不明显,12与T0比较CEC浓度均升高明显;T2时与C组比较,S组CEC升高幅度明显被抑制,差异有统计学意义(P<0.05).两组血浆N0浓度T1均降低,差异有统计学意义,组间比较无统计学意义(P>0.05),T2、T3、T4时间点两组NO浓度均有所上升,但均低于T0,差异明显,S组NO降低程度比C组小(P<0.05).两组T1时ET-1稍有降低,随后ET-1升高明显(P<0.01);S组T1、T2、T3、T4时间点均低于C组,差异有统计学意义(P<0.05或P<0.01).结论 体外循环手术可造成NO/ET失平衡状态,CEC数明显增加,证实CPB后存在着血管内皮功能的损伤.阿魏酸钠组术后NO下降幅度,ET、CEC升高的幅度,明显较对照组小,阿魏酸钠可有效拮抗ET的分泌,促进NO的生成,对婴幼儿体外循环手术有较好的血管内皮功能保护作用.

Abstract：

Objective Cardiopulmonary bypass (CPB) and its related ischemia reperfusion injury may cause endothelial cell injury.To study the protective effects of sodium ferulate in vascular endothelial function during CPB by testing the changes of vascular endothelial cell( CEC),nitric oxide( NO) and endothelin-1 ( ET-1 ) in children with congenital heart disease.Methods Sixty patients with congenital heart disease,including 28 males and 32 females were studied.The mean age was (19.7 ±10.4) months and body weight (10.5 ±6.1) kg.There were 37 VSD,8 ASD,7 TOF,5 TAPVC and 3 CAVC,among them 26 patients had pulmonary hypertension.They were randomly divided in to two groups:sodium ferulate group ( group S,n = 30),and control group ( group C,n =30) .Sodium ferulate (8 mg/kg) was given intravenously before CPB.Blood samples were taken from the arterial line at following time points:before CPB (TO),bypass 30 min(Tl ),the termination of CPB (T2 ),2h after operation ( T3 ) and 6h after operation ( T4 ),respectively for determination the concentration of vascular endothelial cell (CEC) in the blood,the concentration of nitric oxide (NO) and endothelin-1 ( ET-1) in the plasma.Results There were no significant difference for the two groups regarding above parameters at TO ( P > 0.05).The level of CEC was significantly elevated after CPB in both groups ( P < 0.05 ) .CEC were lower at T2 in group S than in group C ( P < 0.05 ) .NO was decreased in both groups,but was higher in group S at T2,T3 and T4 ( P < 0.05 ) .The concentration of plasma ET-1 was not significantly different before CPB,but there was a slight decrease at T1,and then it was significantly increased in both groups (P<0.05).But it was lower in group S than in group C at T1,T2,T3 and T4(P<0.05 orP<0.01).Conclusion There was severe endothelial cell damage during CPB.Sodium Ferulate can effectively antagonize the secretion of ET-1 to promote the formation of NO.Therefore,it reduces CPB-induced endothelial cell damage and protects vascular endothelial function during CPB.     

PBL联合MDT教学模式在小儿心胸外科规培医师教学中的应用

目的：探讨以问题为基础的学习（problem-based learning,PBL）+多学科协作（multidisciplinary team,MDT）教学模式在小儿心胸外科规培医师教学中的应用效果。方法：以30名在苏州大学附属儿童医院心胸外科进行临床规培的医师为研究对象,分为试验组（PBL联合MDT教学模式）15名和对照组（PBL教学模式）15名,对比分析2组规培学员出科时的基础理论、病例分析和操作考试成绩,以及问卷调查教学满意度。结果：试验组的病例分析及操作考试成绩分别为（77.90±2.583）分和（79.40±2.862）分,显著高于对照组的（64.60±1.875）分和（68.30±1.328）分（P < 0.05）。试验组对教学效果的满意度也明显优于对照组（P < 0.05）。结论：PBL联合MDT教学模式应用于小儿心胸外科教学中,较单纯PBL教学模式可以显著提升临床规培医师的教学成绩及临床素养,值得在小儿心胸外科进行推广应用,以便更好地培养优秀的临床医师。     

两种心肌保护液对儿童心脏手术心肌保护的前瞻性研究

目的 研究对比HTK心肌保护液(赫特金)和del Nido心肌保护液在儿童心脏手术中的心肌保护作用。方法 将本院88例体外循环支持下室间隔缺损和房间隔缺损患儿随机入组,采取单盲随机对照试验,将所有患儿分为HTK组和del Nido组,分别使用HTK心肌保护液和del Nido心肌保护液,每组44例患儿。两组通过收集分析术前、术中和术后2 h、术后12 h、术后24 h和术后48 h的临床观察指标和血液样本化验指标数据得出结论。结果 心脏复跳时间、机械通气时间、术中至术后4 h的血管活性药物评分、术后2 h和术后24 h的白介素-6、术后24 h的肌钙蛋白I、术后48 h的肌酸激酶同工酶、术后2 h、12 h和48 h的脑钠肽和术后2 h至48 h的肌红蛋白HTK组均低于del Nido组(P<0.05),其余指标均无显著差异(P>0.05)。结论 HTK与del Nido心肌保护液在儿童简单先天性心脏病心内直视手术中心肌保护作用的总体效果相仿。在部分临床指标方面,HTK心肌保护液的心肌保护作用表现稍优于del Nido心肌保护液。     

阿魏酸钠对婴幼儿体外循环血管内皮功能的保护作用

Objective Cardiopulmonary bypass (CPB) and its related ischemia reperfusion injury may cause endothelial cell injury.To study the protective effects of sodium ferulate in vascular endothelial function during CPB by testing the changes of vascular endothelial cell( CEC),nitric oxide( NO) and endothelin-1 ( ET-1 ) in children with congenital heart disease.Methods Sixty patients with congenital heart disease,including 28 males and 32 females were studied.The mean age was (19.7 ±10.4) months and body weight (10.5 ±6.1) kg.There were 37 VSD,8 ASD,7 TOF,5 TAPVC and 3 CAVC,among them 26 patients had pulmonary hypertension.They were randomly divided in to two groups:sodium ferulate group ( group S,n = 30),and control group ( group C,n =30) .Sodium ferulate (8 mg/kg) was given intravenously before CPB.Blood samples were taken from the arterial line at following time points:before CPB (TO),bypass 30 min(Tl ),the termination of CPB (T2 ),2h after operation ( T3 ) and 6h after operation ( T4 ),respectively for determination the concentration of vascular endothelial cell (CEC) in the blood,the concentration of nitric oxide (NO) and endothelin-1 ( ET-1) in the plasma.Results There were no significant difference for the two groups regarding above parameters at TO ( P > 0.05).The level of CEC was significantly elevated after CPB in both groups ( P < 0.05 ) .CEC were lower at T2 in group S than in group C ( P < 0.05 ) .NO was decreased in both groups,but was higher in group S at T2,T3 and T4 ( P < 0.05 ) .The concentration of plasma ET-1 was not significantly different before CPB,but there was a slight decrease at T1,and then it was significantly increased in both groups (P<0.05).But it was lower in group S than in group C at T1,T2,T3 and T4(P<0.05 orP<0.01).Conclusion There was severe endothelial cell damage during CPB.Sodium Ferulate can effectively antagonize the secretion of ET-1 to promote the formation of NO.Therefore,it reduces CPB-induced endothelial cell damage and protects vascular endothelial function during CPB.     

阿魏酸钠预处理对免肺缺血再灌注损伤的保护作用

目的 通过检测血清中一氧化氮(NO)和肺组织核转录因子-κB p65(NF-κB p65)的变化,探讨阿魏酸钠(sodium ferulate,SF)对兔肺缺血再灌注损伤(I/R)的保护作用和机制.方法 采用复制Sekido模式再造兔肺缺血再灌注损伤模型,将实验动物(新西兰大白兔,1.8-2.5 kg)分为3组,每组6只:假手术组(S组,只开胸分离左肺韧带而不结扎肺门),SF处理组(SF组,在行左肺I/R前10min耳缘静脉注射ST,100 mg/kg)和缺血再灌注损伤组(I/R组,开胸分离左肺韧带并结扎肺门).分别在缺血前、缺血60min、再灌注30、120 min时抽取颈动脉血液离心测定血清NO,实验结束时取肺组织行NF-κB p65免疫组化灰度值测定.结果 SF预处理保护和提高了再灌注30 min(28.650±6.185)以及再灌注120 min(33.748±6.157)内源性NO活性,与I/R组(15.070±8.560;20.500±4.619)差异有统计学意义(P<0.01);抑制了NF-κB p65(78.852±4.875)在再灌注损伤肺组织中的激活,与I/R组(63.390±1.190)差异有统计学意义(P<0.01),减轻肺组织的再灌注损伤.结论 SF预处理能够降低肺组织的缺血再灌注损伤,其机制可能是通过减低内皮舒张因子NO产生源的破坏和抑制NF-κB p65的活化,进而减轻炎症损害作用.     

先天性膈疝的临床表现和诊治分析

目的探讨先天性膈疝的临床表现和诊治。方法对11例先天性膈疝的患儿的临床表现和围手术期进行回顾分析。结果全部病例进行胸腹联合X线拍片和诊断,无一误诊。11例患儿9例经过手术治疗恢复良好,1例因为术后并发症(新生儿硬肿症)自动出院,1例患儿术后死亡。结论对患有先天性膈疝的新生儿和婴幼儿必须早期诊断和手术治疗。