右腋下小切口心内直视手术治疗小儿室间隔缺损1539例

Intracardiac Surgery under Direct Vision via Right Subaxillary Oblique Incision at the Right Axilla for Ventricular Septal Defect in Children:Report of 1539 Cases

目的评估右腋下小切口在小儿室间隔缺损（ventricular septal defect,VSD）手术中的应用价值。方法2001年11月-2008年12月右腋下小切口施行小儿VSD修补术1539例。在腋中线和腋前线之间以第4肋间为中心做一直或斜行切口,经第4肋下缘骨膜下进胸,心包的右侧缘固定在开胸器上,按常规建立体外循环并完成心内操作。结果1539例均顺利完成手术,阻断循环时间11-48 min,（22.8±11.4）min;CPB时间27-64 min,（33.0±14.9）min。术后24 h内死亡2例（0.13%,2/1539）：1例死于鱼精蛋白严重过敏;1例术中损伤左冠状动脉,未及时发现,致左心室术中保护不良,开放循环后复苏困难,被迫再次阻断,切开升主动脉探查才发现,术后4 h死于重度低心排血量。血管切口感染3例,肺不张9例,灌注肺5例,低心排血量5例,感染性心内膜炎3例,急性肾功能衰竭4例,此29例均经过治疗痊愈出院。1446例随访6-91个月,（47.0±11.2）月,5例出现小型残余漏,其他患者无异常。结论右腋下小切口心内直视手术治疗小儿VSD,微创、安全、疗效满意,但应严格掌握手术适应证。

Objective To evaluate the value of thoracotomy through small right subaxillary oblique incision for pediatric ventricular septal defect （VSD）. Methods From November 2001 to December 2008, 1539 children with VSD underwent thoraeotomy through small right subaxillary oblique incision in our hospital. At the fourth intercostal space between the anterior and middle axillary lines, a straight or oblique incision was made, then along the inferior edge of the fourth rib the chest was opened, and the right edge of the pericardium was fixed at the thoracic retractor. Afterwards, off-pump circulation was established and minimally invasive cardiac surgery was carried out. Results The procedure was completed successfully in all the 1539 patients. The crossclamp time was （22.8±11.4） min （11 to 48 min）, and CPB time was （33.0±14.9） min （27 to 64 min）. Two patients （0.13%, 2/1539） died in 24 hours after the operation. One of them died of severe allergic reaction to protamine. And the other died of severe low cardiac output in 4 hours after the surgery, because of an injury to the left coronary artery. In this series, the postoperative complications included incisional infection in 3 cases, ateleetasis in 9, perfusion lung in 5, low cardiac output in 5, infectious endocarditis in 3 and acute renal failure in 4. These 29 cases were discharged after the complications being cured. Follow-up was available in 1446 cases for （47.0 ± 11.2） months （range, 6 -91 months）. During the period, small residual shunts in the VSD were detected in 5 cases, and other cases showed no abnormalities. Conclusions Thoracotomy through small right subaxillary oblique incision is minimally invasive, safe and effective for pediatric VSD.