Descripción de un caso de hernia diafragmática de Morgagni con derrame pericárdico masivo resuelto mediante pericardiocentesis intrauterina

IntroductionMorgagni diaphragmatic hernia with prenatal diagnosis is a rare entity, with lower risk of pulmonary hypoplasia and respiratory problems than posterior diaphragmatic hernia. Our case highlights how in Morgagni diaphragmatic hernia cases lungs tend to develop properly, despite significant pericardial effusion or how greatly diminished they may seem.Main symptoms and/or clinical findingsMorgagni diaphragmatic hernia diagnosed at 14 weeks, with massive pericardial effusion and anterior thoracic herniation of the liver.Main diagnosis, therapeutic interventions, and resultsNo other malformations were identified, other causes of pericardial effusion were ruled out and foetal karyotype was normal. At 25 weeks, in-utero pericardiocentesis was performed, observing significant pulmonary distension and adequate vascularization. After delivery, the newborn required respiratory support due to severe hypoxaemia related to pulmonary hypertension. Six days later surgical diaphragm closure was performed. The newborn had no significant respiratory problems and progressed positively after surgery.ConclusionUltrasonographic detection of this rare anomaly is useful for optimal management, and pericardial drainage can provide prenatal resolution of pericardial effusion, enabling us to evaluate pulmonary hypoplasia risk.     

Anterior parasternal approach for creation of a pericardial window

IntroductionThe optimal method for creation of a pericardial window (PW) is still controversial and it remains a surgical challenge, mainly in obese patients. The aim of this study was to evaluate the efficacy and safety of a novel approach that has not been described previously, for creation of a PW in patients with symptomatic, chronic, large pericardial effusion.MethodsWe retrospectively analysed the records of 30 patients (14 men, 16 women) who underwent a PW procedure between 2001 and 2011. The mean age was 63 years (standard deviation [SD]: 17 years, median: 60 years, range: 27–90 years) and the mean body mass index was 34kg/m² (SD: 2kg/m²). The operation was performed through a curvilinear parasternal approach, 6–8cm in length, followed by a mini-thoracotomy between ribs 4 and 5. Discharged patients were followed up clinically.ResultsThe mean operative time was 73 minutes (SD: 21 minutes) and a median of 658ml (range: 300–1,500ml) of fluid was evacuated. The main aetiologies were idiopathic in 17 patients (57%) and malignant in 9 (30%). Seven patients (23%) died in hospital owing to underlying malignancy. Postoperative complications included mild renal failure (20%), respiratory failure (20%), pneumonia (13%), atrial fibrillation (10%) and atelectasis (6%). There were no wound infections. The median length of stay following the procedure was 8 days. In a median follow-up period of 3.8 years, 16 patients with non-malignant effusion were free of recurrence of pericardial effusion.ConclusionsThe anterior parasternal approach for creation of a PW is simple, safe and efficacious, and results in long-term symptomatic improvement, specifically in patients with non-malignant effusions. This approach may be more appealing in obese patients.     

心房颤动射频导管消融术并发急性心脏压塞九例临床分析

目的探讨心房颤动射频消融术发生急性心脏压塞的临床特点和治疗结果。方法 2006年1月—2010年6月我院2 094例心房颤动患者接受射频消融治疗,其中9例并发急性心脏压塞,回顾性分析9例患者的临床表现和治疗结果。结果急性心脏压塞发生率为0.43%(9/2 094)。9例患者早期均表现为胸闷、血压下降。9例患者经心包穿刺引流后症状均完全缓解,无继续出血。结论急性心脏压塞是心房颤动射频消融术的严重并发症,及时发现和有效救治是十分重要的。     

心包穿刺置管引流术治疗大量心包积液57例

目的：探讨心包穿刺引流术的方法、引流时间、引流体位、引流量的控制。方法：患者取半卧位,超声心动图定位穿刺点、穿刺深度及方向。根据探及情况选用心尖部或剑突下进针。采用Seldinger's法将中心静脉导管送人心包腔内,连接无菌引流袋引流积液。结果：57例患者心包穿刺均获成功,未出现并发症。引流导管留置时间1～25d,平均4.5±2d。引流积液量380～3500mL,平均1150±650mL。穿刺引流后患者胸闷、气促明显改善,颈静脉怒张消失。术后患者心率减慢(由106±28次／分钟降至92±30次／分钟,P＜0.05)。心功能亦获明显改善。结论：seldinger导管法用于心包穿刺安全,可避免损伤心肌,引流彻底,疗效可靠。     

急性心包填塞25例临床分析

本文对２５例急性心包填塞的病因、诊断、临床表现、抢救措施及死因进行探讨，认为心包转移性肿瘤是本病最常见的原因。如肿瘤患者在病程中突然出现呼吸困难等类似心力衰竭症状，或感染性疾病突然出现休克综合征，应考虑为急性心包填塞。鉴别的最可靠方法是超声心动图检查。及时、可靠的心包穿刺引流是缓解急性心包填塞最有效的方法。     

新生儿心包积气诊治分析并文献复习

目的探讨新生儿心包积气的临床特征及治疗经过，并进行文献复习。 方法选择2018年4月21日，于四川省妇幼保健院经剖宫产术分娩后约10 min时，出现气促、呻吟、面色青紫，立即在吸氧下转入四川省妇幼保健院新生儿科治疗的1例生后1 h＋22 min心包积气新生儿为研究对象。采用回顾性分析方法，收集该例新生儿的临床病例资料，对其临床特征和诊治经过进行总结。本研究对新生儿心包积气文献进行复习时，设定的文献检索策略为：以"新生儿""心包积气""neonate"及"pneumopericardium"为中、英文关键词，在PubMed数据库、Wily Online Library、万方数据知识服务平台、维普中文科技期刊数据库中，检索新生儿心包积气相关文献，检索时间设定为2008年1月1日至2018年6月30日。总结心包积气新生儿的临床特点及诊治方法。本研究遵循的程序符合2013年修订的《世界医学协会赫尔辛基宣言》要求。 结果对本例心包积气新生儿的研究结果如下。①病史采集：本例新生儿为男性，出生胎龄为36周，无胎膜早破、宫内窘迫及羊水粪染病史，出生体重为2 750 g，生后1、5、10 min Apgar评分分别为9、10、10分。②入院相关检查结果：胸部X射线摄片检查结果提示湿肺合并感染可能，新生儿呼吸窘迫综合征(NRDS)待排查；动脉血气分析结果提示呼吸性酸中毒；心脏彩色多普勒超声检查及血常规、C反应蛋白、电解质检查结果，以及肝、肾功能，均未见明显异常。③治疗与转归：本例新生儿经呼吸机辅助机械通气治疗后，出现大量心包积气，合并气胸、纵隔气肿、间质性气肿、皮下气肿等其他气漏综合征症状，并且合并心包填塞、心排血量低症状。临床对该例新生儿并未立即进行常规心包穿刺术，而是采取胸腔穿刺术＋高频振荡通气(HFOV)治疗，新生儿接受此方法治疗后，心包积气于24 h内被完全吸收。新生儿住院治疗30 d后，治愈出院。文献复习结果如下，共计检索14篇新生儿心包积气相关文献，涉及15例心包积气新生儿。其中，8例新生儿未合并心包填塞，除1例因为大量心包积气采取心包穿刺术治疗外，其余7例均采取吸氧处理，8例均治愈出院。另外7例合并心包填塞新生儿均进行心包穿刺术，其中6例进行穿刺术后持续引流，4例联合胸腔穿刺术，2例因放弃治疗后死亡，其余5例均治愈出院。这5例治愈出院新生儿中，2例心包穿刺术失败，失败后，其中1例采取HFOV＋胸腔穿刺术及术后引流治疗，1例采取胸腔穿刺术及术后引流＋间歇指令通气(IMV)治疗，均获得良好治疗效果。 结论对于生命体征、心脏血液动力学稳定的心包积气新生儿，甚至合并心包填塞时，建议首先采取保守治疗策略。胸腔穿刺术＋HFOV治疗，可能对改善新生儿心包积气有效，同时又可避免心包穿刺术可能导致的风险。     

Pericardial decompression syndrome: A comprehensive review

Pericardial decompression syndrome(PDS) is an infrequent, life-threatening complication following pericardial drainage for cardiac tamponade physiology.PDS usually develops after initial clinical improvement following pericardiocentesis and is significantly underreported and may be overlooked in the clinical practice. Although the precise mechanisms resulting in PDS are not well understood, this seems to be highly associated with patients who have some underlying ventricular dysfunction. Physicians performing pericardial drainage should be mindful of the risk factors associated with the procedure including the rare potential for the development of PDS.     

经皮冠状动脉介入治疗并发急性心脏压塞的临床分析

目的:分析8例经皮冠状动脉介入治疗(PCI)并发的急性心脏压塞原因、临床表现和治疗结果。方法:2005年1月至2008年12月对5 241例冠心病患者进行了PCI术,8例患者并发急性心脏压塞。采用心包穿刺引流术处理,无效时采用外科手术。结果:急性心脏压塞的发生率为0.15%。8例患者早期均表现为胸闷、血压下降。7例患者行紧急心包穿刺引流,其中2例因引流后仍继续出血而行外科修补手术。1例患者未行心包穿刺引流死亡。结论:急性心脏压塞是PCI术的严重并发症,及时发现和有效救治是十分重要的。     

心脏介入性治疗术并发急性心脏压塞的临床表现和处理

目的 探讨心脏介入手术并发急性心脏压塞的临床特征和防治要点。方法 回顾性分析在心脏介入治疗中并发急性心脏压塞的患者4例，并重点分析导致心脏压塞的原因。结果 4例中，经皮冠状动脉腔内成形术(PTCA)及支架置人术1例，二尖瓣球囊扩张术2例，射频消融术1例。原因是导引钢丝损伤冠状动脉分支；房间隔穿刺位置过高损伤右心房；电极导管损伤冠状静脉窦。全部病例均因及早发现心脏压塞症状并经床旁超声心动图和X线透视所证实，及时采取抢救措施，包括心包穿刺和引流，输血，输液及用升压药等，全部病例均抢救成功。结论 心脏压塞是介入性治疗中少见并发症，抢救中最重要的是及时发现，立即行心包穿刺引流等急救措施。