肺动脉高压致双向分流性先天性心脏病的手术指征

目的:研究重度肺动脉高压致双向分流性先天性心脏畸形患者血流动力学特点及其治疗方法选择。方法:漂浮导管动态监测肺动脉压,评估血流动力学、急性肺血管反应试验和药物敏感试验,分析双向分流量;采用单向活瓣补片修补室间隔缺损、房间隔缺损或未闭动脉导管,改良DeVega术或人工成形环成形三尖瓣。结果:先天性心脏病合并重度肺动脉高压,尚未发展到艾森门格氏综合征的患者71例,术前肺、体循环血量比为1.11-2.61(平均1.65±1.38),肺、体动脉收缩压比为1.21±0.30,肺、体动脉平均压比为0.97±0.13,全肺血管总阻力为(12.3±3.7)Wood单位,急性肺血管反应试验阳性为67例,肺、体循环血流量比≥1.25为69例,左向右分流量和右向左分流量均超过30%心排量为7例;术后平均肺动脉压显著下降[(90.4±22.6)mmHg比(73.7±28.1)mm-Hg,P<0.05],体动脉氧分压显著升高[(60.1±9.6)mmHg比(76.8±12.4)mmHg,P<0.01],手术并发症发生率为19.7%(14/71),其中呼吸道感染为7.0%(5/71),右心功能不全11.3%(8/71),5例经治疗好转后出院,3例死亡,手术死亡为5.3%(4/71),主要死亡原因为右心功能衰竭。结论:伴有重度肺动脉高压致双向分流的先天性心脏病,漂浮导管检查提示急性肺血管反应试验阳性和/或大量双向分流的患者,外科治疗有助于改善右心功能和缺氧。

Surgical Indicators of Congenital Heart Disease with Severe Pulmonary Hypertension

Objective: To study hemodynamic characteristics and surgical treatment of congenital heart disease with the bi-directional shunt due to advanced pulmonary hypertension.Methods: Hemodynamics,acute pulmonary vasoreactivity test and drug sensitivity test were evaluated through floating catheter.Cardiac defects were repaired by unidirectional valve patch,while the tricuspid valve surgery procedures consisted of DeVega tricuspid annuloplasty,or ring annuloplasty.Results: There were advanced pulmonary hypertension and bidirectional shunt in 71 patients with congenital heart disease who underwent operations.Floating catheter monitor demonstrated that pulmonary/systemic blood flow(Qp/Qs) ratio was 1.11-2.61(mean 1.65±1.38),the ratio of pulmonary/systemic artery systolic pressure was 1.21±0.30,mean pulmonary/systemic artery pressure ratio was 0.97±0.13,and the total pulmonary vascular resistance was(12.3±3.7) Wood units.Qp/Qs ratio was more than 1.25 in 69 cases.The acute pulmonary vasoreactivity test was positive in 67 cases.Bidirectional shunt volume was more than 30% of cardiac outputs in 7 cases.Postoperative mean pulmonary artery pressure decreased significantly from(90.4±22.6) mmHg to(73.7±28.1) mmHg(P<0.05).Arterial PO2 increased significantly from(60.1±9.6) mmHg to(76.8±12.4) mmHg(P<0.01).Surgical complication rate was 19.7%(14/71),with right ventricular dysfunction 11.3%(8/71,3 cases death),respiratory infection 7.0%(5/71),and operative mortality 5.6%(4/71).The main cause of death was right heart failure.Conclusion: The correction of cardiac malformation can improve right heart function and anoxia of the patients with congenital heart disease and severe pulmonary hypertension if they present positive acute pulmonary vasoreactivity test and/or a large amount of bi-directional shunt which are verified by floating catheter examination.