肺血减少型复杂性先天性心脏病术后血流动力学观察

Hemodynamic studies of severe complex congenital heart disease with decreased pulmonary flow

目的 探讨肺血减少型复杂性先天性心脏病围术期处理原则。方法 1996年 6月至 1999年 1月 ,手术治疗肺血减少型重症复杂性先天性心脏病 2 6例 ,其中Rastelli手术 12例、Fontan手术 9例及双向Glenn手术 5例。分别于术前、脱离体外循环机后即刻、术后 2、4、8、16、2 4、36、4 8、72h监测血流动力学变化。结果 手术死亡率 11 5 %。Rastelli手术后早期静脉压低 [(12 36± 0 6 9)mmHg(1mmHg =0 133kPa) ]、肺动脉压高 [(18 36± 1 6 0 )mmHg]、胸液量少 [每小时 (0 96± 0 94 )ml kg];Fontan手术后早期静脉压高 [(16 77± 1 11)mmHg]、肺动脉压低 [(14 37± 2 0 6 )mmHg]、胸液量较多 [每小时 (1 0 8±0 38)ml kg];双向Glenn手术后早期上腔静脉压 [(17 2 6± 2 4 3)mmHg]高于下腔静脉压 [(12 6 9± 3 5 8)mmHg],双向Glenn术后有肺动脉搏动性血流的病儿动脉血氧饱和度 (0 90± 0 0 1)高于无肺动脉搏动性血流的双向Glenn术后病儿 (0 81± 0 0 4 )。结论 双心室均发育的复杂先天性心脏病 ,实施解剖性矫治的Rastelli手术 ,术后早期血流动力学效果明显优于生理性矫治手术。对只有一个功能心室且肺血管发育较好、肺动脉压不高的多种复杂先心病 ,实施Fontan类手术可挽救病儿生命 ,提高其生存质?

Objective: To determine the postoperative hemodynamic changes of Rastelli, Fontan and bidirectional Glenn procedures. Methods: 26 children with complex congenital heart disease underwent surgical repair from June 1996 to January 1999. The surgical procedures included Rastelli procedures in 9 patients, Fontan procedures in 12 and bidirectional Glenn procedures in 5. The postoperative hemodynamics were monitored and the protocols of their fluid therapy were studied. Results: The operative mortality was 11 5%. In Rastelli group, there were lower CVP (12 36±0 69)?mm?Hg, higher PAP (18 36±1 60)?mm?Hg and less chest drainage (0 96±0 94)?ml/kg/h. However, In Fontan group, there were higher CVP(16 77±1 11)?mm?Hg, lower PAP (14 37±2 06)?mm?Hg) and more chest drainage (1 08±0 38)?ml/kg/h. In bidirectional Glenn group, the SVC pressure(17 26±2 43)?mm?Hg were higher than the IVC pressure(12 69±3 58)?mm?Hg. The SaO 2 was higher in the patients of bidirectional Glenn with pulsatile pulmonary arterial flow(90 12±1 37)% than in the patients of bidirectional Glenn without pulsatile pulmonary arterial flow(81 44±3 71). Conclusion: For patients with well developed ventricles, Rastelli procedure can achieve better hemodynamic results. For patients with functional single ventricle, the modified Fontan procedure is the choice. The result of bidirectional Glenn procedure is related to pulsatile pulmonary arterial flow.