体外膜肺氧合救治大动脉转位调转术后脱机困难  

Extracorporeal membrane oxygenation for failure to separate from bypass after arterial switch operation

作　　者：叶莉芬[1] 范勇[1] 张泽伟[1] 吴秀静[1] 舒强[1] 林茹[1] Ye Lifen;Fan Yong;Zhang Zewei;Wu Xiufing;Shu Qiang;Lin Ru(Heart Institute,Children＇ s Hospital,Zhejiang University,Hangzhou 310000,China)

机构地区：[1]浙江大学医学院附属儿童医院心脏中心,杭州310000

出　　处：《中华胸心血管外科杂志》2018年第8期457-460,共4页Chinese Journal of Thoracic and Cardiovascular Surgery

基　　金：国家科技支撑计划项目（2012BAI04B05）,浙江省卫生领军人才项目,浙江省基础公益研究项目（LGF18H020005）

摘　　要：目的总结体外膜肺氧合（ECMO）救治大动脉转位调转术后脱机困难的临床经验。方法回顾2007年7月至2016年6月8例调转术后脱机困难实施ECMO的大动脉转位患儿的临床资料，分析该类患儿的ECMO适应证、运行管理、主要并发症及相应的处理。全组男6例，女2例，年龄1天～3．5岁，体质量2．7-11．0kg。室间隔完整型大动脉转位3例，室间隔缺损型大动脉转位5例，主动脉弓缩窄、左心室流出道狭窄、肌部室间隔缺损各1例。因术后难以脱离体外循环（低心排血量综合征6例、低心排血量综合征合并肺动脉高压2例），从传统体外循环转为静脉一动脉模式ECMO。结果ECMO运行22~300h。5例成功撤离，其中4例出院，1例撤离后12天再次左心衰，左心室辅助装置辅助236h后撤离，50天后并发大量胸腔积液及乳糜胸死亡。3例心功能不能恢复无法撤离ECMO死亡。出血、心包压塞是主要并发症。结论ECMO是大动脉转位患儿调转术后低心排血量综合征脱机困难的有效辅助治疗手段。解剖畸形纠正满意，冠状动脉走行正常者脱机成功率高且预后良好，壁内型冠状动脉者疗效差。出血是该群体ECMO期间的最常见并发症，严密外科止血和精准的出、凝血管理是保证辅助循环顺利运行的关键。Objective To summary the clinical experience of ECMO for failure to separate from bypass after arterial switch operation of TGA. Methods 8 TGA patients （6 boys and 2 girls, aged 1 day to 3.5 years and weighing 2.7 - 11.0 kg, 3 VSD intact and 5 with VSD, others complicated malformation including COA, left ventricular outtract stenosis ） were treated with VA ECMO owing to failure to separate from bypass caused by low output syndrome after ASO between July 2007 and June 2016. We collected the medical records and analyzed the indication, management and complication of ECMO for this patient population. There were two stages of ECMO supporting for low output after ASO, The first stage was to improve tissue perfusion and correct inner environment by high flow supporting, and the second stage was ventricular function training. ECMO was weaned when the blood pressure was more than 60 mmHg and the difference value of systolic pressure and diastolic pressure was 15-20 mmHg under medium dose inotropics supporting. Volume infusion was limited strictly during ECMO. Results The run- ning time were 22 - 300 h. 5 patients were weaned from ECMO successfully and 4 patients discharged to home. The long-term follow-up of echocardiograpby indicated normal cardiac function in 3 patients. 1 older child had left cardiac failure again after weaning from ECMO 12 days later; he was supported by LVAD subsequently. LVAD was weaned after 236h supporting, unfor- tunately, He died from cardiac failure 50 days after LVAD weaning. 3 patients could not wean from ECMO and died. The main complications were bleeding and pericardial tamponade. Conclusion VA ECMO was effective treatment for failure to separate from bypass after switch operation of TGA. The high mortality was seen in patients with intramural coronary arterial. The myo- cardial structure perhaps changed secondary in older TGA children, ECMO and LVAD can be used as short-term circulatory transition to artificial heart or transplant. Bleeding was the main complication of this population

关 键 词：体外膜肺氧合 大血管错位 心脏外科手术 

分 类 号：R726.5[医药卫生—儿科]