钝性心脏损伤手术救治43例

Blunt cardiac injury:experience in 43 cases treated operatively

目的探讨钝性心脏损伤的早期诊断、手术救治和疗效.方法回顾性分析2003年9月至2018年8月43例钝性心脏损伤手术患者病历资料,包括性别、年龄、伤因、术前诊断、手术距受伤时间、手术方式和效果.损伤原因中交通事故占48.8%(21/43),其中方向盘伤占71.4%(15/21).26例术前诊断依靠胸部CT、超声心动图等影像学方法;17例因典型心包压塞征或大量血胸伴休克紧急剖胸,术中证实.伤后1 h内手术占27.9%(12/43).手术行心包减压、血心包清除和心脏修补36例;心包疝钳闭松解和心脏复位3例;心包膈疝还纳修补4例.急诊室剖胸7例,成功率42.9%(3/7).结果全组死亡14例(32.6%),分别死于急诊室剖胸(4例)、术中(5例)和术后(5例).死因包括心脏损伤9例(1例主动脉横断);合并伤5例(肝伤大出血3例、特重型颅脑伤1例、颈髓损伤呼吸衰竭1例).29例生存患者中,心内结构损伤4例(二尖瓣2例、三尖瓣1例、室缺1例),2例分别于术后2周和3个月行瓣膜成形术,另2例临床观察和影像学复查证实自行改善.术后并发症包括肺不张3例(经气管切开、纤支镜和呼吸机等治疗后肺复张)、感染性心内膜炎1例(抗生素治愈).随访6~36个月,生存患者心功能和健康状况正常.结论及时诊断并行紧急剖胸术是钝性心脏损伤患者获救的关键.不提倡术前大量扩容和心包穿刺,必要时应果断实施急诊室剖胸.

Objective To explore early diagnosis, surgical intervention and efficacy for blunt cardiac injury. Methods 43 patients with blunt cardiac injury treated operatively were studied retrospectively in respect of sex, age, cause of injury, preoperative diagnosis, operative time from injury, surgical procedures, and therapeutic efficacy. The study lasted for 15 years between September 2003 and August 2018. The main cause of injury is road traffic accident with a rate of 48.8%(21/43);and steering wheel injury accounted for 71.4%(15/21). Preoperative diagnosis was based on computer scaning, echocardiography in 26 cases. In remaining 17, initial judgement of cardiac wound was done because of obvious cardiac tamponade, or massive hemothorax with shock;and was proved during emergent thoracotomy. Surgical intervention was started within one hour in cases of 27.9%(12/43). Main procedures included pericardial decompression, clear off hemopericardium, and cardiorrhaphy in 36 cases;relief of pericardial herniation with strangulation of the heart in 3 cases, and repair of diaphragmatic hernia involving pericardium in 4 cases. Of all 43 cases, 7 cases underwent Emergent Department Thoracotomy(EDT) with a resuscitative rate of 42.9%(3/7). Results Overall mortality rate was 32.6%(14/43);4 cases died at EDT, 5 cases intraoperatively, and 5 cases postoperatively. The cause of deaths was directly related to BCI in 9 cases(associated with transected aorta in 1 case);and associated injuries in 5 cases including liver trauma(3 cases), brain trauma(1 case), and cervical spinal trauma(1 case). In 4 of 29 survivors, intracardiac injury was proved by echocardiography postoperatively, including mitral valve in 2 cases, tricuspid in 1 case, and ventricular septum in 1 case. Of these 4 cases 2 received valvuloplasty 2 weeks and 3 months after initial operation respectively;and other 2 restored spontaneously which were ensured by echocardiography. Postoperative complications included atelectasis in 3 and infectious endocarditis in 1 respectively. They were cured . All survivors were followed up from 6 to 36 months, with a normal cardiac function and healthy condition. Conclusion Early diagnosis and emergent thoracotomy in time are essential to improve survival rate. Preoperative massive transfusion and pericardiocentesis are not advocated. If it is necessary, EDT should be exercised decidedly.