提高先天性心脏病并发肺动脉高压外科治疗效果的综合方案

目的:探讨先天性心脏病并发肺动脉高压的手术适应证，包括术前综合评价病情、充分降肺动脉压、术中综合处理、术后重症监护，以提高其外科治疗成功率。方法: 对我院2009年1月～2010年12月在全麻低温体外循环下手术治疗室间隔缺损（VSD）并发肺动脉高压（pulmonary hypertension,PH）患者280 例进行回顾性分析。术前综合评价有无手术适应证及充分降肺动脉压准备:所有患者均接受氧疗，经静脉微泵静脉注射扩血管药［硝普纳和（或）前列地尔注射液］，必要时行心导管检查。术中综合处理:术中加强体外循环心肺保护及降肺动脉压的药物应用，精细操作，对部分极重度肺动脉高压的患者留单向活瓣，术中特别注意探查三尖瓣的处理同时矫正其他并发畸形。术后处理:术后呼吸机辅助呼吸时间适当延长，用呼气末正压（PEEP）、过度通气、一氧化氮治疗等。结果: 本组术后死亡5例，病死率1.8%，发生并发症者18 例（发生率9%）。入院后经术前降肺动脉压力及氧疗后，平均肺动脉压力由(71±14) mmHg降至手术开始前的(58±11) mmHg（P<0.05），手术后肺动脉压力进一步下降至出院前的平均肺动脉压力 (38±5) mmHg（P<0.05）。术后1年复查超声心动图265例，缺损处残余分流2例，三尖瓣中度反流2例、重度返流1例。结论: 我院术前正确评估、积极降压准备、术中综合处理、术后重症监护的综合外科治疗措施，明显提高了先天性心脏病并发肺动脉高压的治疗效果。

Surgical treatment for pulmonary artery hypertension secondary to congenital heart disease

AIM: To analyze the comprehensive preoperative evaluation,refined operative procedure,and postoperative intensive care to improve the healing rate of patients with congenital heart disease(CHD) with severe pulmonary hypertension(PH).METHODS: A retrospective analysis was conducted in 280 patients with ventricular septal defect(VSD) complicated by severe pulmonary hypertension(PH) who underwent surgical treatment with extracorporeal circulation from January 2009 to December 2010.Preoperative measures included oxygen therapy and depressurization of PH with hypotensive drugs such as sodium nitroprusside or PGE1.During surgery,special attention was given to myocardial and pneumopreservation with refined surgical technique,rectification of complicated abnormality and routine repair of the tricuspid valve.Adequate postoperative intensive care included proper prolonged intubation time under 4-6 PEEP,NO-inhalation and proper sedation.RESULTS: Of the 280 patients,five patients died due to circulatory failure,low-cardiac output,and lung infection(1.78%).Length of hospitalization after operation was(13.10±5.24) days and average pulmonary pressure significantly decreased from(71±14) mmHg to(58±11) mmHg(P<0.05) postoperation and to(38±5) mmHg(P<0.05) on discharge.There were only two cases of residual shunt.Two cases with moderate regurgitation and one patient with severe regurgitation of the tricuspid valve were observed in the 265 patients who were followed for 1 year postoperatively.CONCLUSION: Good preoperative evaluation,comprehensive surgical treatment and proper postoperative intensive care may effectively improve the healing rate and quality of life of patients with CHD with PH.