儿科静脉动脉模式体外膜肺氧合左心减压:左侧胸骨旁小切口四例报道

Left artrial decompression by left parasternal incision for pediatric venoarterial extracorporeal membrane oxygenation: a report of 4 cases

目的介绍4例静脉动脉模式体外膜肺氧合(venoarterial extracorporeal membrane oxygenation,VA-ECMO)下左侧胸骨旁小切口左心减压,在儿科暴发性心肌炎救治中的应用经验。方法回顾性分析2017年7月至2018年10月郑州儿童医院和解放军总医院第七医学中心附属八一儿童医院收治的因暴发性心肌炎接受VA-ECMO支持,支持过程中出现左心抑制需左心减压4例患儿的临床资料。结果共有4例暴发性心肌炎VA-ECMO支持患儿接受左心减压,采用左侧胸骨旁小切口左心房插管进行左心减压。左心减压后心脏超声检查左心功能改善,其中1例患儿撤机后仍为Ⅲ度房室传导阻滞,术后1个月予安装永久起搏器。1例胸腔引流量较多,经过调整抗凝后改善。1例因监护人终止治疗死亡,总共存活3例,近期随访结果满意。结论经左侧胸骨旁小切口左心减压可改善VA-ECMO支持下暴发性心肌炎患儿左心功能,创伤小、出血可控,是安全可行的。

Objective To introduce the clinical experience of 4 cases of left atrial decompression via minithoracotomy technique in pediatric application under venoarterial extracorporeal membrane oxygenation(VA-ECMO) in pediatric fulminant myocarditis treatment. Methods The clinical data of 4 patients with VA-ECMO support for fulminant myocarditis admitted in Zhengzhou Children′s Hospital and Bayi Children′s Hospital Affiliated to the Seventh Medical Center of PLA General Hospital from July 2017 to October 2018 were reviewed. Results A total of 4 patients with fulminant myocarditis supported by VA-ECMO received left ventricular decompression, and left atrial decompression was performed by left atrial intubation with a small incision near the left sternum.Left heart ultrasound showed that left heart function improved after decompression.One case with ventilator was still Ⅲ degree atrioventricular block after weaning, and installed permanent pacemaker postoperative 1 month.One case had more pleural drainage and improved after adjusting anticoagulation.One case died due to the termination of treatment by the guardian.A total of 3 cases survived, and the recent follow-up results were satisfactory. Conclusion Left artrial decompression of this minimally invasive technique can improve left ventricular function in children with fulminant myocarditis supported by VA-ECMO.It is safe, feasible with small trauma and bleeding controlled.