法洛四联症根治术后低心排血量综合征患者的临床分析

Clinical analysis of low cardiac output syndrome in patients after radical correction of tetralogy of Fallot

目的探讨法洛四联症(tetralogy of Fallot,TOF)患者一期根治术后早期低心排血量综合征(low cardiac output syndrome,LCOS)发生的原因及处理方法。方法2015年12月至2017年12月期间高州市人民医院心外科行TOF一期根治术患者共167例,其中47例术后出现LCOS,回顾性分析此组患者的临床资料。结果LCOS原因分析:术后血容量不足17例,右心室流出道残余梗阻11例,严重心律失常9例,左心室功能衰竭8例,心包压塞2例。处理方法:LCOS患者均使用血管活性药物,根据血流动力学参数,调整循环功能状态;其中行腹膜透析术16例,透析(3.5±1.4)d;跨肺动脉瓣压差>50mmHg(1mmHg=0.133kPa)的1例患者围术期重返手术室再次体外循环下疏通右心室流出道,2例再次手术行房间隔造孔术。4例体肺侧支>3mm且存在灌注肺的患者送介入室行侧支封堵;1例室间隔残余缺损>4mm的患者于围术期行缺损修补术。2例心包压塞患者其中1例再次开胸探查止血,1例更换引流管。死亡8例(17.0%),因多脏器功能障碍综合征死亡5例,重症感染死亡2例,完全性房室传导阻滞死亡1例。余39例患者康复出院。结论严格把握手术适应证,完善手术技术,注重心肌保护,术后加强监护,积极寻找LCOS病因并及时纠正,必要时二次手术,可提高LCOS治愈率。

Objectives To investigate the causes and treatment of early low cardiac output syndrome(LCOS)in 49 patients with tetralogy of Fallot(TOF)after primary radical operation.Methods From December 2015 to December 2017,167 patients underwent TOF primary radical operation in the Cardiac Surgery Department of Gaozhou People′s Hospital,47 patients of them had LCOS after operation.Clinical data of these patients were analyzed retrospectively.Results The causes of LCOS were as follows:insufficient blood volume in 17 cases,residual right ventricular outflow tract obstruction in 11 cases,severe arrhythmia in 9 cases,left ventricular pump failure in 8 cases and cardiac tamponade in 2 cases.Processing methods:All LCOS patients used vasoactive drugs to adjust their circulatory function according to hemodynamic parameters;16 patients underwent peritoneal dialysis with an average dialysis duration of(3.5±1.4)days;1 patient with transpulmonary valve pressure difference greater than 50 mmHg(1 mmHg=0.133 kPa)returned to the operating room to open the right ventricular outflow tract under cardiopulmonary bypass during perioperative period,and 2 patients underwent atrial septum ostomy again.Four patients with systemic pulmonary collateral branch > 3 mm and perfused lung were sent to the interventional ventricle for collateral branch occlusion,and one patient with residual ventricular septal defect > 4 mm underwent perioperative defect repair.Of the 2 patients with cardiac tamponade,1 case underwent thoracotomy for hemostasis and 1 case changed drainage tube.Eight cases(17.0%)died:5 cases died of multiple organ dysfunction syndrome,2 cases died of severe infection and 1 case died of complete atrioventricular block.The remaining 39 patients recovered and discharged.Conclusions The cure rate of LCOS can be improved by strictly grasping operation indications,perfecting operation technique,paying attention to myocardial protection,strengthening postopera.tive monitoring,actively searching for the etiology of LCOS and correcting it in time and reoperating if necessary.