延迟关胸在儿童心脏移植中的应用

目的探讨延迟关胸技术在儿童心脏移植中的应用价值。 方法回顾性分析华中科技大学同济医学院附属协和医院2018年1月1日至2021年8月31日73例儿童心脏移植受者临床资料，根据术后一期胸骨闭合情况分为延迟关胸组(10例)和非延迟关胸组(63例)，分析延迟关胸对于受者心功能恢复、手术切口感染、肺部感染、术后30 d和住院期间死亡情况的影响。 结果延迟关胸组原发病以复杂先天性心脏病心力衰竭为主，非延迟关胸组以心肌病心力衰竭为主。延迟关胸组延迟关胸时间中位数4 d，采用一次或分次关胸技术均成功关胸。延迟关胸组平均年龄(6.4±5.3)岁，平均体质量(16.3±11.4)Kg，均小于非延迟关胸组(9.7±4.7)岁和(29.5±15.6)Kg]；供受者体质量比为(3.1±1.4)，高于非延迟关胸组(1.9±0.7)]，差异均有统计学意义(t＝2.0、3.2和-4.5，P均<0.05)。延迟关胸组术前和术后使用VA-ECMO辅助、术后肾脏替代治疗的受者比例以及发生肺部感染和住院期间死亡的受者比例均高于非延迟关胸组，差异均有统计学意义(P均<0.05)。延迟关胸组受者术后2周右室面积变化分数为(37.0±5.8)%，低于非延迟关胸组(43.1±7.8)%]，差异有统计学意义(t＝2.4，P<0.05)。2组受者性别、术前血清总胆红素和肌酐、术后2周左室射血分数、手术切口感染及术后30 d内死亡发生率差异均无统计学意义(P均>0.05)。 结论延迟关胸是儿童心脏移植供受者体质量不匹配时一种安全且有效的治疗策略。

Application of delayed sternal closure in pediatric heart transplantation

ObjectiveTo explore the value of delayed sternal closure in pediatric heart transplantation. MethodsThe clinical data of 73 children with heart transplantation in the Union Hospital, Tongji Medical College, Huazhong University of Science and Technology from January 1, 2018 to August 31, 2021 were analyzed retrospectively. According to the primary sternal closure after operation, they were divided into delayed sternal closure group (n=10) and non-delayed sternal closure group (n=63). The effects of delayed sternal closure on the recovery of graft function, surgical incision infection, pulmonary infection, 30 days mortality after operation and mortality during hospitalization were analyzed. ResultsThe protopathy of recipients in the delayed sternal closure group consisted largely of complex congenital heart disease heart failure, and the non-delayed sternal closure group was mainly cardiomyopathy heart failure. The median delayed sternal closure time in the delayed sternal closure group was 4 d, all recipients used the sternal closure technique once or several times, and the sternum were all successfully closed. The mean age and weight of recipients in the delayed sternal closure group were (6.4±5.3) years and (16.3±11.4) kg, both lower than those in the non-delayed sternal closure group (9.7±4.7) years and (29.5±15.6) kg]; the donor recipient weight ratio of the delayed sternal closure group was (3.1±1.4), which was higher than that in the non-delayed sternal closure group (1.9±0.7). The differences were statistically significant (t=2.0, 3.2 and -4.5, all P<0.05). The preoperative and postoperative usage rate of VA-ECMO assistance, postoperative renal replacement treatment usage rate, pulmonary infection rate and mortality during hospitalization in the delayed sternal closure group were all higher than those in the non-delayed sternal closure group, and the differences were statistically significant (all P<0.05). The right ventricular volume change fraction in the delayed sternal closure group (37.0±5.8)% at 2 weeks after operation was lower than those (43.1±7.8)% in the non-delayed sternal closure group, and the difference was statistically significant (t=2.4, P<0.05). There was no significant difference in sex, preoperative serum total bilirubin and creatinine, left ventricular ejection fraction 2 weeks after operation, incision infection rate and mortality within 30 days after operation between the two groups (all P>0.05). ConclusionDelayed sternal closure is a safe and effective treatment strategy in pediatric heart transplantation when the donor recipient weight is mismatched.