婴幼儿先天性心脏病术后肢体动脉栓塞的临床分析  

Clinical analysis in infants with limb arterial embolism after cardiac surgery

作　　者：夏源园 吴秀静[1] Xia Yuanyuan;Wu Xiujing(Heart Center,The Children's Hospital,Zhejiang University School of Medicine,National Clinical Research Center for Children's Health,Hangzhou 310052,China)

机构地区：[1]浙江大学医学院附属儿童医院心脏中心,国家儿童健康与疾病临床医学研究中心,杭州310052

出　　处：《中华小儿外科杂志》2021年第7期598-603,共6页Chinese Journal of Pediatric Surgery

摘　　要：目的探讨婴幼儿先天性心脏病术后合并肢体动脉栓塞患儿的临床表现、治疗方法和预后情况。方法收集2018年7月至2020年4月在浙江大学医学院附属儿童医院心脏中心收治的5例先天性心脏病术后合并肢体动脉栓塞患儿的临床资料。所有患儿中,男4例,女1例;早产儿2例,低出生体重儿2例;中位出生体重为2.52 kg,出生体重范围为1.8~3.8 kg;中位手术年龄为102 d,手术年龄范围为11 d至1岁10 d;紫绀型先天性心脏病4例,非紫绀型先天性心脏病1例。手术前,4例紫绀型先天性心脏病患儿的血红蛋白均处于正常高限或高于正常值,中位凝血酶原时间(prothrombin time,PT)为12 s,中位活化部分凝血活酶时间(activated partial thromboplastin time,APTT)为31.1 s,中位纤维蛋白原(fibrinogen,Fib)为2.21 g/L,中位血小板计数(blood platelet,PLT)水平为319×109/L,中位D-二聚体水平为0.38 mg/L。5例患儿均在体外循环下行心脏畸形矫治术,手术均取右心房切口,术中常规行动脉穿刺置管,结束后充分排气,中位体外循环时间为154 min,时间范围为134~393 min。结果术后5例患儿均存在低心排血量综合征。3例患儿符合2017年中国弥散性血管内凝血诊断标准。所有患儿在术后出现肢体动脉栓塞,初期经血管超声检查均提示存在不同程度的血流信号减少,除1例因严重低心排而死亡的患儿外,余4例患儿均在确诊肢体动脉栓塞后接受抗凝治疗,予静脉输注前列腺素E改善微循环、复方右旋糖酐40注射液降低血液黏滞度,从出现肢体动脉栓塞的症状至接受抗凝治疗的中位时间为16.5 h,范围为1~52 h,抗凝治疗后2例患儿的D-二聚体水平进行性下降,临床症状好转。最终2例治愈,1例肢端坏疽截肢,1例肢端坏疽放弃治疗后死亡,1例死亡。结论对先天性心脏病术后患儿,应密切关注其凝血功能,早期识别并尽早干预有助于改善预后,持续的肢体缺血往往提示预后�Objective To explore the clinical features,treatments and outcomes in infants with limb arterial embolism after cardiac surgery.Methods From July 2018 to April 2020,clinical manifestations,laboratory and imaging findings,diagnosis,treatment and prognosis were reviewed for 5 children with limb arterial embolism after cardiac surgery.There were 4 boys and 1 girl with a median operative age of 102(11-375)days and a median birth weight of 2.52(1.8-3.8)kg.Infants were premature(n=2)and low-birth-weight(n=2).Congenital heart disease(CHD)was cyanotic(n=4)and non-cyanotic(n=1).In 4 children with cyanotic CHD,the preoperative hemoglobin levels were at or above a normal high limit.Median prothrombin time(PT)was 12s,median activated partial thromboplastin time(APTT)31.1 s,median fibrinogen 2.21 g/L,median blood platelet 319×109/L and median D-dimer 0.38 mg/L.All 5 children underwent cardiopulmonary bypass for correcting cardiac deformity.The median time of cardiopulmonary bypass was 154(134-393)min.Right atrial incision was made and arterial puncture performed routinely intraoperatively.After operation,there was full exhaust.Results All 5 children had low cardiac output syndrome after operation.Three of them fulfilled the 2017 Chinese diagnostic criteria of disseminated intravascular coagulation.Varying degrees of lower hemodynamic signal appeared on transvascular ultrasound in the early stage of clinical manifestations of limb arterial embolism.Except for 1 child dying of severely low cardiac output,the remainders received anticoagulant therapy after a diagnosis of limb arterial embolism.At the same time,prostaglandin E was given intravenously to improve microcirculation and compound dextran 40 injection to reduce blood viscosity.The median time from symptom onset to anticoagulation therapy was 16.5(1-52)hours.After anticoagulation,D-dimer decreased and clinical symptoms improved in 2 cases.Finally there were cure(n=2),gangrene amputation(n=1),death after giving up treatment for gangrene(n=1)and death(n=1).Conclusions For

关 键 词：心脏缺损 先天性 动脉栓塞 抗凝治疗 

分 类 号：R726.5[医药卫生—儿科]