先天性心脏病合并重度肺动脉高压的手术适应证探讨

Surgical indication for treatment of congenital heart disease with severe pulmonary hypertension

目的利用超声检测心内分流结合血气分析的评判方法探讨先天性心脏病(CHD)合并重度肺动脉高压(PH)的外科治疗手术适应证。方法23例CHD合并重度PH者,年龄2～58岁,平均(24.5±18.2)岁。其中房间隔缺损4例,室间隔缺损17例,动脉导管未闭5例(部分为合并病例),主肺动脉间隔缺损1例。入院测股动脉血氧分压54～82mmHg,平均(72.4±3.8)mmHg,血氧饱和度0.82～0.95,平均0.93±0.01。术前心脏超声检查在缺损处呈双向分流病理改变。以多普勒超声检查左向右分流时间必须≥70%心动周期,右向左分流必须≤30%心动周期,同时,扩血管治疗后股动脉SaO2≥0.94作为手术治疗的重要指征。术中测肺、体循环收缩压比值(Pp/Ps)0.75～1.00,平均0.84±0.08。房缺、室缺均采用补片修补,个别病例外加房间隔缝成1.0cm右向左单向活瓣;动脉导管未闭在并行循环下切开肺动脉缝闭。手术前、后均应用氧疗、硝普钠、前列腺素E1降低肺动脉压。结果术后早期因右心衰死亡2例。16例随访8～56个月,平均(31.3±14.3)个月,除1例6岁病儿右心进行性扩大外,其余恢复良好。无远期死亡。结论采用超声对分流定性分析结合血气分析判断手术适应证,可使部分CHD合并重度PH者获得较满意的手术效果。

Objective To discuss the surgical indieatien for treatment of congenital heart disease （CHD） with severe pulmonary hypertension（PH）. Methods 23 patients who underwent open-heart surgery under CPB for CHD with severe PH were included, 3 ASD, 8 VSD, 5 PDA and 1 APW. The ages were from 2 to 58 （34.5 ± 8.2） years. The ratio of pulmonary/systemic systolic pressure （Pp/Ps） varied from 0.75 to 0.95 with the mean of 0.84 ± 0.08 measured during operation. The femoral arterial PO2 ranging from 54 to 82 （72.4 ± 3.8） mmHg and the SaO2 ranging from 0.82 to 0.95 （0. 920±0.012 ）. The indication of operation was judged by echocardiography： the time of left to right shunt must be ≥ 70% of cardiac cycle and right to left shunt faust be ≥ 30%,at the same time, the femoral arterial SaO2 must be ≥0.94. ASD or VSD was repaired with a patch. PDA were closed during operation, a right to left valve on the atrial septum was created in some patients and combination therapy of oxygen, sodium nitropmsside and prostnglandin E1 was applied during perioperative period. Results There were 2 early deaths postoperative. 16 cases were followed up from 3 to 56 months [（31.3±14.3） months]. The survived well except one whose right heart progressively enlarged. No late death occurred. Conclusion The outcome of surgical treatment of CHD with severe PH is satisfactory. Echoeardiography and analyzed of blood gas.