腔静脉-肺动脉连接术后围术期血栓栓塞的治疗与预防

Perioperative Thromboembolic Complications after Cavo-pulmonary Connections

目的分析腔静脉-肺动脉连接术后围术期血栓栓塞的表现、治疗、转归和可能危险因素,评估预防血栓栓塞措施的效果。方法回顾性分析2005年9月至2010年12月期间阜外心血管病医院完成双向Glenn手术264例、全腔静脉-肺动脉连接术(total cavopulmonary connection,TCPC)224例患者的临床资料,其中围术期发生血栓栓塞9例,男5例,女4例;年龄0.9～11.0(5.1±3.7)岁;体重8～30(17±8)kg。5例为双向Glenn手术,4例为TCPC。多数栓塞患者合并至少一个血栓高危因素。术后常规静脉泵入预防量肝素10 U(/kg.h),续以口服阿司匹林1～3 mg(/kg.d)预防血栓。结果 9例中6例血栓栓塞发生于术后7 d之内,3例发生在术后2～4周。9例均给予肝素抗凝治疗,其中1例行下腔静脉-右心房连接术。死亡3例(33%),分别占同期双向Glenn手术和TCPC后早期死亡的33%(1/3)和18%(2/11);其余6例症状和体征改善或消失。结论腔静脉-肺动脉连接术后围术期血栓栓塞的病死率高,是此类手术术后早期死亡的重要原因。围术期预防血栓的策略有效,但仍需注意避免一些相关危险因素。

Objective To analyze the manifestation, treatment, outcome and potentially predisposing risk factors of perioperative thromboembolism after cavo-pulmonary connection, and to assess the effects of our prophylactic antithrombotic strategy. Methods Clinical data of 264 cases of bidirectional Glenn and 224 cases of total cavopulmonary connection （TCPC） operations undertaken from September 2005 to December 2010 in Fu Wai Hospital were retrospectively analyzed. Perioperative thromboembolic complications occurred in 9 patients. 5 of them were after bidirectional Glenn, 4 were after TCPC. Most of the 9 patients had at least one thrombi-related risk factor. The routine prophylactic antithrombotic therapy after these operations were intravenous infusion of heparin 10 U（ kg.h） initially, followed with oral aspirin 1-3 mg/（kg. d ）. Results Thromboembolic events occurred within 7 days after the operation in 6 cases, appeared 2 to 4 weeks after the surgery in 3 cases. All 9 patients received anticoagulation with heparin. One patient also undertook take-down operation. 3 （33%） patients died, accounting for 33% （ 1/3 ）, and 18% （2/11 ） of the early deaths after bidirectional Glenn and TCPC operations. Clinical symptoms improved or disappeared in the remaining 6 patients. Conclusion The mortality ofperioperative thromboembolic complications after cavo-pulmonary connection is high, consisting of the important cause of early deaths after these procedures. Our prophylactic anticoagulation strategy proved to be effective, though some thrombi-related risk factors still need to be avoided.