128先心病教案 统一版

心脏疾病外科治疗吴忠仕教授、博士生导师中南大学湘雅二医院心脏外科Sixclinicalprofessionalunits(morethan200beds)•PediatricCardiacSurgery•AdultCardiacSurgery•GeneralThoracicSurgery•CPBGroup•ICU(36beds)•EightOperationRooms胸心血管外科简介Introductionofthedepartmentofthoracic-cardiacvascularsurgeryMorethan3500cardiacoperationstobeperformedperyear.Morethan1500ofwhicharepediatriccardiacsurgery.Theclinicalandbasicresearcharerankedtop8inChina.Introductionofthedepartmentofthoracic-cardiacvascularsurgeryAtpresent，wecanperform•CABG,•Valvularreplacement,•Aortic/thoracicaorticaneurismreplacement•Congenitalheartdiseases:neonates•Hearttransplantation,•OtherdifficultcasesIntroductionofthedepartmentofthoracic-cardiacvascularsurgeryResearchCentersBiomaterialResearchCenterGeneEngineeringResearchCenterTheHeartValveResearchCenterHeartandLungProtectionResearchCenterTheResearchOfficeofultrasoundimagingIntroductionofthedepartmentofthoracic-cardiacvascularsurgeryResearchsofleadinglevelinChinaCPBindeephypothermiaexperimentsandclinicalapplicationCardiovascularbiomaterialsCardiovasculardisease-relatedgenediagnosisandtreatmentIntroductionofthedepartmentofthoracic-cardiacvascularsurgeryOverviewofThePediatricCardiacSurgeryEstablishedinthe1980s20yearsofdevelopment3professor,2associateprofessor,3attendingdoctorsand6residentsIntroductionofthedepartmentofthoracic-cardiacvascularsurgeryAllsurgicalproceduresforCHDcanbeperformedintheunit吴忠仕ZhongshiWu(MD.PhD)ApediatriccardiacsurgeonwithintheDepartmentofcardiacsurgeryPerformpediatricheartsurgicalprocedures250caseseachyearBeabletoperformmultiplecardiacoperations,suchasrepairofTOFwithPSorPA,cAVSD,TAPVC,DORV,aorticcoarctation,commontrunks,etal,withfavorableresultsIntroductionofthedepartmentofthoracic-cardiacvascularsurgeryExcellentacademicperformanceFirstmantoundertaketheresearchonBovineJugularveinconduitasthepulmonaryarterysurrogateandintroduceitintoclinicaluseinChina.Appliedaninventpatentforthenovelmethodofpreparingofbovinejugularveinconduit.Gotabetterresult(12/13)ofDORVwithremoteVSDrepairwithintracardiacconduittechnique50papersand6SCIpapers(totalIF20)pubilshedTrained31postgraduatorIntroductionofthedepartmentofthoracic-cardiacvascularsurgery牛颈静脉带瓣管道2007年教师节留念心内直视手术的基本条件●心内血液排空●心脏停止跳动●维持生命静止(quiet)、无血(bloodless)的手术野指用一种特殊装置暂时替代心肺工作，进行血液循环及气体交换的技术。这一装置称体外循环装置或人工心肺装置★体外循环Cardiopulmonarybypass,CPB★体外循环基本装置●血泵(pump)无搏动泵，搏动泵●氧合器鼓泡式，膜式●变温器●滤过器51953年Gibbon首次将CPB应用于临床2012，开心手术突破20万例2009,我国开心手术16万例2006，我国开心手术10万例1994,每天有约2000例开心手术，一年约65万例1953,Gibbon利用人工心肺机成功实施第一例开心手术（18岁房缺女患者）1934,DeBakey发明了滚压式灌注泵1916,McLean发现肝素（heparin）–使得血液能在人工管道内循环较长时间1882,vonSchraeder制成第一个鼓泡氧合器体外循环发展简史●纵劈胸骨，切开心包显露心脏●肝素化，ACT达480-600s●插升主动脉灌注管插上下腔静脉引流管●分别与已预充好的人工心肺机相应管道连接，即可开始体外循环转流体外循环施行●现在常规采用血液稀释法●预充液应考虑渗透压、电解质含量和血液稀释度●血液稀释度,PCV成人15%，小儿20%●预充用的晶体液通常有乳酸林格氏液，生理盐水●胶体液可选用血、血浆，白蛋白等体外循环预充★心肌保护●心肌缺血再灌注损伤：阻断心脏血流致使心肌缺血缺氧，在心脏循环恢复早期由于积留于心肌氧自由基等有毒物质集中大量释放引起的心脏损害表现心脏复苏困难复跳后搏动无力或顽固性心律失常术后低心排血症、心力衰竭保护心肌，防止或减轻心肌缺血再灌注损伤悠关心脏手术病人的安危和疗效！●常规心肌保护措施：药物心停搏法★心停搏液●心停搏液作用促使心脏迅速停搏避免缺血性电机械做功减少能量需要和耗损●心停搏剂高钾，20~40mmol/L高镁，10~20mmol/L普鲁卡因●低温◆降低心肌代谢和能量需要预防心肌电机械活动再生◆通常0~4℃的停搏液，心肌温度为15℃◆缺血安全时限超过2小时★心停搏液★体外循环后的生理变化●代谢改变：组织灌注不足酸中毒●电解质失衡：尿多低血钾●血液改变:RBC破坏Pt,纤维蛋白原术后渗血●肾、肺等功能减退CPB术后呼吸功能不全●原因血液中微栓氧自由基白细胞激活全身炎症反应●所导致的病理改变间质水肿出血肺泡萎缩CardiacICU★CPB后的处理●维持有效循环血量保持血流动力学稳定●辅助呼吸●及时纠正酸碱失衡电解质失调●应用抗生素预防感染先天性心脏病外科治疗SurgicalTreatmentofCongenitalHeartDiseaseTheSecondXiangyaHospitalWuzhongshi高肺血流低肺血流非紫绀Acyanotic紫绀Cyanotic紫绀Cyanotic(LRshunt)(RLshunt)VSDTGATOFPDATAPVDAbsteinanomalyASDTricatrPulmatresiaAVSDSingleventricleAPWindowTruncus先心病分类0%5%10%15%20%25%一个月以内一岁以内五岁以内15岁以内死亡率DeathrateofchildrenbornwithCHD★胎儿血液循环（FetalbloodCirculation）●卵圆孔开放Patentovalfossa●动脉导管开放Patentductusarteriosus动脉导管未闭(PatentDuctusArteriosus)◆出生前PDA是正常的结构但出生后18hrs自然闭合◆在复杂心脏畸形中PDA是维持肺血流的重要通道●早产Prematurity●呼吸窘迫respiratorydistress●在高纬度出生的婴儿导管开放的影响因素●AOPDAPA(LRShunt)◆LV负荷LV,LA肥大，扩大●高肺血流肺血管阻力PVR肺动脉高压PH(RLShunt)EissenmgerSyndromeDifferencecyanosis分离性紫绀★病理生理临床表现Clinicalfeatures◆反复肺部感染Recurrentlunginfection◆发育不良malnutrition◆左心衰Leftheartfailure◆紫绀cyanosis◆小导管无症状：Asymptomatic◆连续性机器样杂音Continuousor'machinery'typemurmur◆P2亢进,脉压增宽,水冲脉boundingpulses★临床体征Signs重度肺高压,onlysystolicmurmur◆分流量大的病人在心尖有舒张中期柔和杂音●LV肥大双室肥大RV肥大●LA肥大ECG★RadiologicFindings●主动脉结突出Prominentaorticknob●左房左室扩大Dilationofleftatrium,leftventricle●肺门血管扩大，肺纹理增粗Increasedpulmonaryvasculature可示降主动脉与肺动脉之间动脉导管SizeofPDA,Qp/QsSizeofVentricularandatrialchamberEchocardiography诊断Diagnosis●体征连续性机器样杂音●心电图●胸片●Echo★鉴别诊断Identifieddiagnosis●主动脉窦瘤破裂Therupturedaneurysmoftheaorticsinuses●室缺合并主动脉瓣返流VSDwithaorticvalveinsufficiencyPDA合并重度肺高压时，要与VSD鉴别●●肺动脉高压Pulmonaryhypertension●感染性动脉内膜炎Infectiveendarteritis●动脉导管瘤样扩张Aneurysmaldilatationoftheductus并发症Complications★治疗选择Treatmentoptions●早产儿早期可试用消炎痛Prematureinfantsoftenrespondtoprostaglandininhibtor,Indomethacin●症状严重的应进早手术SymptomaticinfantswithalargePDAusuallyrequiresurgeryassoonaspossible●合并心内膜炎的PDA应控制感染下应用CPB手术手术方法Surgicaltreatment(1)左后外侧切口，第四肋间进胸切开后纵隔胸膜，肺动脉干扪及震颤明确诊断游离导管，注意勿损伤喉返神经切口AoPDA导管处理Surgicaltreatment(2)●结扎Ligation●切断缝合Cuttingandsuture适于粗短导管●夹闭Clamping胸腔镜下实行Surg