中低温全流量与深低温低流量两种灌注方式在左冠状动脉异常起源于肺动脉矫治术中的应用

The effects of two perfusion methods in the treatment of left coronary artery abnormality originated from pulmonary artery

目的 初步探讨中低温全流量与深低温低流量灌注在左冠状动脉异常起源于肺动脉(ALCAPA)矫治术治疗中的应用效果.方法 2010年4月至2018年8月行左冠状动脉起源于肺动脉矫治术患儿51例,男27例,女24例,年龄8~36(29.19±19.43)个月,体质量7.4~35.0(11.73±9.99)kg,心胸比(C/T)0.70±0.09.按照体外循环辅助方式分为中低温全流量组(A组)和深低温低流量组(B组);均在静脉吸入全身麻醉体外循环下行ALCAPA矫治术,同期矫治合并心脏畸形.A组24例,男13例,女11例,年龄3~36(28.64±16.30)个月,体质量7.4~31.0(12.25±10.33)kg,心胸比(C/T)0.71±0.07.B组27例,男15例,女12例,年龄5~31(25.85±16.60)个月,体质量6.7~35.0 kg(10.38±3.67)kg,心胸比(C/T)0.69±0.06.结果 全组51例术后早期死亡5例,A组3例,B组2例,均死于术后低心排血量综合征(低心排).行体外膜肺氧合辅助7例,A组5例,B组2例.两组患儿住院期间死亡比例差异无统计学意义(P>0.05);术中体外循环时间、升主动脉阻断时间、心肌冷停搏液灌注次数及灌注量、术后体外循环辅助时间、室颤发生率、重症监护室停留时间和呼吸机辅助时间,B组明显低于A组,差异均有统计学意义(P<0.05).术后随访42例(A组20例,B组22例),随访时间17(3~29)个月.术后左心室射血分数均较术前增加(0.53±0.15对0.66±0.14,P<0.05),组间比较差异无统计学意义.结论 采取深低温低流量辅助可以有效缩短术中主动脉阻断时间,提高术中心肌保护效果,减轻手术视野回心血量,减少术后低心排血量综合征发生;改善手术治疗疗效.

Objective To investigate the applicate effects in the treatment of left coronary artery abnormality originated from pulmonary artery ( ALCAPA) with two perfusion methods of Medium-low temperature-full flow and Low-temperature- low flow. Methods From April 2010 to August 2018 , 51 children with ALCAPA were treated with direct coronary artery transplantation in Beijing Anzhen Hospital. According to the circulated perfusion method, All of cases were divided into two groups: the Medium-low temperature full flow ( group A) and Low-temperature low flow ( group B);All patients underwent ALCAPA correct operation under general anesthesia by intravenous inhalation and extracorporeal circulation, and the combined cardiac malformations at the same period. Results The whole of 51 children, including 27 males and 24 females, the aweraged age was(29. 19 ± 19. 43 ) months(8-36 months), the aweraged weight was(11.73 ±9. 99) kg(7. 4 - 35. 0 kg). The cardiothoracic ratio( C/T) was 0. 70 ±0. 09. In group A, 24 patients, including 13 males and 11 females, the aweraged age 3-36 (28.64 ±16.30) months, the aweraged weight 7.4 - 31.0( 12. 25 ± 10. 33) kg, and the cardiothoracic ratio( C/T) 0. 71 ± 0. 07. Group B included 27 patients, including 15 males and 12 females, the aweraged age 5 - 31 (25. 85 ± 16. 60) months, the aweraged weight 6. 7 - 35. 0( 10. 38 ± 3.67) kg, and the cardiothoracic ratio( C/T) of 0. 69 ±0. 06. The postoperative early death were 5 cases in the whole group, there were 3 cases in group A and 2 cases in group B, all of them were died of low cardiac output syndrome. Extracorporeal membrane oxygenation( ECMO) support for 7 cases of 5 in group A and 2 in group B. There was no statistically significant difference in in-hospital mortality between the two groups ( P > 0. 05 ). The Intraoperative extracorporeal circulation time, ascending aorta occlusion time, the number and amount of myocardial cold arrest fluid perfusion ,postoperative extracorporeal circulation assistance time, the incidence of ventricular fibrillation, ICU residence time, and ventilator assistance time were significantly lower in group B than group A, all with statistically significant differences( P < 0. 05 ). A total of 42 cases were followed up after the operation, the follow-up time 17(3 - 29 ) months and the left ventricular ejection fraction increased from 0. 53 ±0. 15 to 0. 66 ±0. 14( P <0. 05 ), there was no statistically significant difference between two groups. Conclusion The perfusion modes of Low-temperature- low flow in the correct operation of ALCAPA can effectively shorten the time of aortic occlusion, improve the effect of intraoperative myocardial protection, reduce intraoperative visual field return blood volume, and reduce postoperative low cardiac output. To improve the curative effect of operation.