重症婴儿先天性心脏病手术的体外循环策略

Cardiopulmonary bypass strategies of surgical treatment for severe congenital heart disease in infant

目的探讨重症婴儿先天性心脏病外科治疗的体外循环策略。方法回顾性分析接受心内直视手术治疗的354例重症先心病婴儿的临床资料。术前合并有心血管系统、呼吸系统、消化系统等严重并发症患儿318例(89.8%)。根据不同手术方式,术中采用浅度低温(80例,22.6%)、中度低温(191例,54.0%)和深低温低流量灌注(79例,22.3%)以及深低温停循环(4例,1.1%)的体外循环方法;心肌保护措施采用不阻断主动脉心脏不停跳(80例)或阻断主动脉根部间断灌注4∶1冷血停搏液(274例);复温后行平行超滤与改良超滤联合应用。结果心脏停跳体外循环时间为(112.11±31.37)min,阻断主动脉时间(56.12±22.17)min;心脏不停跳体外循环时间为(79.3±19.1)min,阻断腔静脉时间(39.1±11.8)min;4例采用深低温停循环体外循环下行心内畸形矫治术,体外循环时间为114～161 min,阻断主动脉时间56～116 min,停循环5～16 min。253例开放主动脉后自动复跳,自动复跳率为92.3%(253/274),全组8例停机困难,术后死亡11例,死亡率为3.1%。结论针对具体患儿制定合理的预充预案、选择高质量的体外循环管道和氧合器,术中选择合理的体外循环方案、常规进行超滤和加强重要脏器保护是重症婴儿先天性心脏病外科治疗成功的保障。

Objective To analyze the cardiopulmonary bypass strategies of surgical treatment for severe congenital heart disease in infant.Methods The clinical data of 354 infants with severe congenital heart disease underwent open heart surgery were retrospectively analyzed.Complications related to cardiovascular system,respiratory system,digestive system were occurred in 318 cases（89.8%）.Mild hypothemia cardiopulmonary bypass（CPB） with beating heart,moderate hypothermia CPB,profound hypothermia low flow perfusion CPB and profound hypothermia circulation arrested CPB were performed according to different procedures.Heart arrest was performed by open heart surgery without occluding aorta and infusion of cold blood fluid through aortic root in proportion as 4︰1（274 cases）.Paralleled and modified ultrafiltration were executed after rewarming.Results The duration of CPB without heart beating was（112.11±31.37） minutes and that of aortic occlusion was（56.12±22.17） minutes.The duration of CPB with heart beating was（79.3±19.1） minutes and that of vena cava occlusion was（39.1±11.8） minutes.Heart sugery under profound hypothermia circulation arrested CPB was performed on four cases,the duration of CPB was 114～161 minutes,those of aortic occlusion and occlusion arrest were 56～161 minutes and 5～16 minutes.Totally 253 cases（92.3%）recovered heart beating automatically after removing clamp.There were 8 cases experienced difficulty in stopping circulation,11 cases died,the mortality rate was 3.1%.Conclusion Reasonable priming,high quality of membrance oxygenator during CPB,corrected CPB plans and modified ultrafiltration were keys to improve CPB for critical infants with CHD.