基层医院开展大动脉调转手术的特殊性与早期经验教训  

Experiences and the special medical conditions for a Chinese secondary hospital on the early stage of arterial switch operation

作　　者：陈凯明[1] 刘浪[1] 曹勇[1] 赖锋华[1] 胡楝[1] 朱伯卫[1] 王茂生[1] 

机构地区：[1]广东省高州市人民医院心血管外科,525200

出　　处：《中华胸心血管外科杂志》2014年第5期269-272,共4页Chinese Journal of Thoracic and Cardiovascular Surgery

基　　金：广东省茂名市科技计划项目（20110804）

摘　　要：目的探讨基层医院在开展复杂先天性心脏病手术时所面临的特殊问题，以期为在我国多层级医院普及开展先天性心脏病外科治疗提供技术性帮助。方法2006年1月至2011年12月，共接诊32例大动脉转位患儿，11例因多种原因未手术，21例接受大动脉调转手术。21例手术患儿中，男15例，女6例。16例合并室间隔缺损（TGA／VSD）患儿，年龄30天-1岁，体质量3．4—8．5kg，平均（5．33±1．42）kg；5例室间隔完整（TGA／IVS）的患儿，年龄13天-1个月，体质量3．1—5．5kg，平均（3．75±1．17）kg。全部患儿均接受I期大动脉调转手术，无快速Ⅱ期病例。术毕当天及出院前常规行心脏超声检查，并术后后3、6个月及其后每年常规随访。结果术后早期死亡2例，占9．5％。延迟关胸2例，分别为1天和3天。无伤口感染及愈合不良；再次开胸止血2例，占9．5％。16例TGA／VSD患儿体外循环（151±33）min，主动脉阻断（119±26）min；术后患儿呼吸机辅助24～159h，住ICU3～17天；出院前超声心动检查提示1例残存VSD，穿隔血流直径小于2mm，未见心室壁反常运动；2例肺动脉血流速度稍增快（分别为2．0m／s及2．2m／s），2例肺动脉血流速度明显增快（分别为3．1m／s及3．7m／s），3例主动脉血流速度超过2m／s，（1例2．5m／s）。5例TGA／IVS患儿体外循环（170±52）min，主动脉阻断（137±48）min；术后呼吸机辅助51～144h，住ICU4～14天；出院前超声心动检查提示提示2例肺动脉血流速度稍增快，达2m／s，1例主动脉血流速度达到2．0m／s。出院前心电图提示21例均无心肌梗死。结论我国基层医院与大型医疗中心之间存在着收治先天性心脏病患儿病种、医护人员素质、医疗设备及耗材使用等多方面差异，这导致基层医院在开展大动脉调转等复杂先天性心脏病手术时面临一系列特殊问题。在以普通先�Objective This retrospective study is to analysis the special medical conditions that most Chinese secondary hospitals are facing with, and to review the safeguards and pitfalls for arterial switch operations, in order to probe intothe feasi- bility of this procedure for Chinese secondary hospitals and provide our experiences to help other surgeons to avoid pitfalls on complex procedures. Methods Between January 2006 and December 2011, totally 21 newborns and infants with TGA/VSD and TGA/IVS underwent arterial switch operation. There were 15 males and 6 females. In the TGA/VSD group, there were 16 cases, ranging from 30 days to 1 year at surgeries, and weight from 3.4 - 8.5 kg with average of （5.33 ± 1.42） kg. In the TGA/IVS group, there were 5 cases, ranging from 13 days to 1 month at surgeries, and weight from 3.1-5.5 kg with average of （ 3.75 ± 1.17 ） kg. All patients underwent one stage of arterial switch operation. Routine follow-up checking points are set at discharging, 3 months , half year and every year after operation. Results The early death rate is 9.5% （2/21） , and the re- exploration rate is 9.5 % （2/21）. In the TGA/VSD group, average cardiopulmonary bypass time is （151 ± 33 ） minuntes with the aortic crossclamp time is（ 119 ± 26） minutes. Ventilator support time is 24-159 hours, and the length of ICU stay is 3 - 17 days. 1 case has residual VSD with the diameter less than 2 mm. The pulmonary flow velocity in 2 cases increase mildly to 2.0 m/s and 2.2 m/s,and another 2 cases increase severely to 3.1 m/s and 3.7 m/s. The aortic flow velocity in 3 cases in- crease to 2.0m/s. ECG instructs no case has myoinfarction signs. In the TGA/IVS group, average cardiopulmonary bypass time is （ 170 ± 52 ） minuntes with the aortic crossclamp time is （ 137 ± 48 ） minutes. Ventilator support time is 51 - 144 hours, and the length of ICU stay is 4 - 14 days;The pulmonary flow velocity in 2 cases increase mildly to 2.0 m/s. The aortic flow velocity in I cases increase to 2.0 m/s.

关 键 词：心脏缺损 先天性 大动脉调转术 死亡率 手术后并发症 基层医院医疗资源 

分 类 号：R725.4[医药卫生—儿科]