膈肌折叠术治疗婴幼儿先天性心脏病矫治术后膈肌麻痹的临床疗效分析

Diaphragm Plication for the Treatment of Diaphragmatic Paralysis in Infants after Surgical Correction for Congenital Heart Diseases

目的 分析并评估膈肌折叠术治疗婴幼儿先天性心脏病矫治术后膈肌麻痹的临床效果。 方法 回顾性分析2009年12月至2012年12月13例先天性心脏病婴幼儿行矫治手术后发生膈肌麻痹的临床资料，其中男5例、女8例；年龄35 d 至 11个月［（6.6±3.2）个月］；体重3.5～9.6 （6.2±1.8） kg。膈肌折叠术在心脏直视手术后（19.08±4.29） d施行。所有患者均无法顺利脱离呼吸机，或脱机后因严重呼吸困难反复行气管内插管，13例患儿均行单侧或双侧膈肌折叠术。 结果 发生呼吸机相关性肺炎2例，发生率15.4%，其中1例痰培养为复合鲍曼不动杆菌阳性、血细菌培养阴性；另1例为法洛四联症合并肺动脉闭锁患儿，双侧膈肌麻痹，行双侧膈肌折叠术后第11 d痰培养和血培养均为铜绿假单胞菌阳性，并因多脏器功能衰竭死亡。所有患儿膈肌折叠术后胸部X线片提示膈肌下降至正常位置。膈肌折叠术后患儿脱离呼吸机时间为 （5.38±3.09） d。膈肌折叠术后患儿动脉血氧分压（PaO2）较术前明显增高 ［（90.22±8.47） mm Hg vs. （80.69±6.72） mm Hg ；P＜0.05］，动脉血二氧化碳分压（PaCO2）较术前明显降低 ［（39.87±6.31） mm Hg vs. （56.38±7.19） mm Hg ；P＜0.05］ 。随访12例，随访时间24个月，１例患儿行双侧膈肌折叠术，出院后6个月内反复2次出现肺部感染，其余患儿呼吸功能正常。所有随访患儿心功能Ⅰ～Ⅱ级（NYHA）。 结论 先天性心脏病婴幼儿行心脏直视手术后发生膈肌麻痹时，难以顺利脱离呼吸机，行膈肌折叠术是较安全、简便、有效的治疗手段，能提高患者的生存率，降低院内感染几率。

Objective To evaluate clinical outcomes of diaphragm plication for the treatment of diaphragmaticparalysis （DP） in infants after surgical correction for congenital heart diseases. Methods Clinical data of 13 infants who had DP after surgical correction for congenital heart diseases from December 2009 to December 2012 were retrospectivelyanalyzed. There were 5 male and 8 female patients with their age of 35 days-11 months （6.6±3.2 months） and body weightof 3.5-9.6 （6.2±1.8） kg. Diaphragm plication was performed 19.08±4.29 days after open heart surgery. All the patients were not able to wean from mechanical ventilation,or were repeatedly reintubated because of severe respiratory failure after extubation. All the 13 patients received diaphragm plication for single- or double-sided DP. Results Two patients had ventilator associated pneumonia （15.4%） including 1 patient with positive sputum cultures for Acinetobacter baumannii but negative blood culture. Another patient who had double-sided DP after surgical correction for tetralogy of Fallot withpulmonary atresia underwent double-sided diaphragm plication and later died of multiple organ dysfunction syndrome,whose sputum and blood cultures were both positive for Pseudomonas aeruginosa on the 11th day after double-sided diaphragmplication. Chest X-ray of all the patients showed plicated diaphragm in normal position after diaphragm plication. The averagetime from diaphragm plication to extubation was 5.38±3.09 days. After diaphragm plication,arterial partial pressures of oxygen （PaO2） significantly increased （90.22±8.47 mm Hg vs. 80.69±6.72 mm Hg,P〈0.05） and arterial partial pressuresof carbon dioxide （PaCO2） significantly decreased （39.87±6.31 mm Hg vs. 56.38±7.19 mm Hg,P〈0.05）. Twelve patientswere followed up for 24 months after discharge. During follow-up,1 patient who received double-sided diaphragm plicationhad 2 episodes of pneumonia within 6 months after discharge. Respiratory function of all the other patients was normal. All the patients were in NYHA class Ⅰ-Ⅱ. Conclusion Diaphragm plication is a safe,easy and effective treatment to increase survival rate and decrease the incidence of hospital-acquired infection for infants who have DP and are unable to wean from mechanical ventilation after surgical correction for congenital heart diseases.