幼儿期先天性心脏病心脏直视术后心脏功能与氧代谢变化的对比研究

Contrast study of cardiac output and oxygen metabolism in infants with congenital heart disease after cardiopulmonary bypass

目的对比研究幼儿期先天性心脏病（先心病）心脏直视术后心脏功能与氧代谢的变化规律。方法回顾性研究2006年1月至2009年1月，北京安贞医院小儿心脏科幼儿期先心病患儿55例，其中男34例，女21例。分为2组：简单组30例，包括单纯室间隔缺损（室缺）15例；室缺＋房间隔缺损（房缺）9例；室缺＋房缺＋动脉导管未闭6例，均合并肺动脉高压。复杂组25例，包括法洛四联症12例，肺动脉狭窄型右室双出口8例，完全型肺静脉异位引流心上型5例。均在静吸复合麻醉中低温体外循环辅助下完成心脏直视手术。分别于手术完成后即刻（术后0h）、术后4、8、12、24、48、72h时热稀释法测定心排血量（CO）。经桡动脉及漂浮导管顶端抽取血标本行血气分析。计算心排血量指数（CI），氧供应指数（DO2I）、氧消耗指数（VO2I）、氧摄取率（O2ER）。同时记录中心温度、动脉血乳酸、混合静脉血氧饱和度（ScVO2）及正性肌力药物用量。对比分析两组间心脏功能与氧代谢的变化规律。结果（1）术后8h时ScVO2两组患儿最低（简单组68％±14％；复杂组65％±9％）；术后12h时CI（L·min^-1·m^-2）两组患儿最低（简单组3．29±0．65；复杂组2．88±0．54）；DO，I（ml·min^-1·m^-2）、VO，I（ml·min^-1·m^-2）复杂组最低（分别为492±153和138±45）；（2）术后DO2I、VO2I、O2ER、ScVO2随CI变化而改变，简单组高于复杂组；（3）术后CI与DO2I、VO2I、ScVO2正相关，与O2ER负相关。结论先心病心脏直视术后心功能下降，氧代谢紊乱，术后12h最重，复杂畸形更明显。术后早期积极提高心排量可以改善组织氧合。

Objective To conduct a contrast study of postoperative cardiac output and oxygen metabolism in infants with congenital heart disease undergoing cardiopulmonary bypass. Methods Retrospective analysis was conducted for 55 case of congenital heart disease from January 2006 to January 2009 at our hospital. There were 34 males and 21 females. And they were divided into simple group （n = 30） and complex group （n = 25）. In the simple group, all had pulmonary arterial hypertension and there were simple ventricular septal defect （VSD） （n = 15）, atrial septal defect （ASD） ＋ VSD （n = 9） and ASD ＋ VSD ＋ patent ductus arteriosus （PDA） （ n = 6） ; in the complex group, there were tetrology of Fallot （TOF） （ n = 12）, double outlet of right ventricular with pulmonary stenosis （DORV） （ n = 8 ） and total anomalous pulmonary vein connection （ TAPVC ） （ n = 5 ）. All completed cardiopulmonary bypass procedures under venous injection and inhalation anesthesia. Cardiac outputs were measured by the thermodilution method with a 4 F Swan-Ganz floating catheter at operation completion and postoperative 4, 8, 12, 24, 48, 72 h. Arterial and mixed venous blood specimens were collected through radial artery and floating catheter for blood gas analysis. The parameters of cardiac index （CI）, oxygen supply index （ DO2I）, oxygen consumption index （ VO2I ） and oxygen intake rate （ O2 ER） were calculated with PHLIPS M： 8007 A. Results （1） At postoperative 8 h, ScVO2 was minimal （simple group 68% ± 14% ; complex group 65%±9% ） ; and postoperative 12 h CI （L ·min^-1·m^-2） bottomed out （simple group 3.29 ±0. 65; complex group 2. 88 ±0. 54） ; DO2I（492 ± 153） ml ·min^-1·m^-2 and VO2I（ 138±45） ml ·min^-1·m^-2 were minimal in complex group. （2） DO2I, VO2I, O2ER and ScVO2 changed with CI and simple group was higher than complex group. （3） Postoperative CI showed a positive correlation with DO2 I, VO2 I, ScVO2 and a negative correlation with O2ER. Conclusions The postoperative cardiac output decreases and oxygen metabolism becomes disordered in congenital heart disease. It is most obvious at postoperative 12 h. And complex CHD is more serious. Cardiac output should be actively boosted to improve tissue oxygen metabolism during an early postoperative period.