【www.zhangdahai.com--自我介绍】
【摘要】 目的 总结成年人房间隔缺损的手术治疗经验。 方法 选取48例 22 岁以上继发性房间隔缺损患者,年龄 22~65岁,其中男15例,女33例,合并肺动脉高压14例,心律失常28例房缺修补采用直接连续缝合或补片修补。 结果 全组 48 例无手术死亡,随访半年以上心功能较术前均有明显改善。 结论 成人房间隔缺损应尽早手术,采用补片修补时,自体心包为首选。围手术期肺动脉高压以及合并症的正确处理是手术成功的关键。
【关键词】 房间隔缺损;体外循环;外科治疗;成年人
【Abstract】 Subject Summarize the experience of surgical treatment of adult atrial septal defect (ASD).Methods Forty eight patients which were aged 22 65 years old with secondary atrial septal defect were enrolled in this study.The population was composed by 15 male and 33 female cases,and in which 20 patients were complicated with pulmonary hypertension and 28 patients were complicated with arrhythmia.All the patients with ASD were treated by direct continuous saturation or patch.ResultsThere is no one died from surgery. The cardiac function of patients were all improved after the 6 months follow up.Conclusion Surgery should be done as early as possible in the adult ASD patients.Autologous pericardium is the best choose for patch.The key to achieve the successful surgery is appropriate handling on pulmonary hypertension and the other complications in the peroperative period.
【Key words】 Atrial septal defect; Extracorporeal circulation; Surgical treatment; Adult
房间隔缺损(ASD)是先天性心脏病中最常见的疾病之一。患者年龄越大预后越差,手术危险性也越大,继发孔型房间隔缺损占成人先天性心脏病(先心病)发病率的第三位[1]。我院自2005年4月至2009年8月手术治疗的48例,效果良好,现报告如下。
1 资料与方法
1.1 临床资料 本组48例中男15例,女33例,年龄22~65 岁,术前均有活动后心慌,气短,胸闷等症状。出现症状时间最短 4 个月,最长12 年。术前心功能Ⅰ级10例,Ⅱ级29例,Ⅲ级8 例,Ⅳ级1例(NYHAC分级),患者均可在胸骨左缘第2到3肋间闻及Ⅱ到Ⅳ期收缩期杂音,肺动脉瓣第二音增强或亢进,固定分裂。全胸片均提示肺充血和肺动脉段突出,心电图示不完全性右束支传导阻滞21 例,完全性右束支传导阻滞 12 例,房颤 8例。X线胸片示右心明显增大,心胸比率 0.62~0.81, 肺血增多。心脏彩超示:中央型 28 例,上腔型 5 例,下腔型15例。合并三尖瓣关闭不全 15例,合并二关瓣关闭不全 22 例。房间隔连续中断15~35mm 16例,5 cm者,均应行三尖瓣瓣环环缩术。本组5例(10.4%)有明显的三尖瓣反流均行DeVega成形术。房缺合并二尖瓣关闭全较少,主要见于年龄较大和分流量大者,术后往往不能恢复且影响左心功能,应积极处理。功能性二尖瓣关闭不全可行二尖瓣成形术,器质性二尖瓣病变行瓣膜置换术。本组病例中有6例(12.3%)行二尖瓣成形术,效果良好。房缺患者心律失常的发生随年龄增加而增多,特别高龄ASD 患者,长期合并冠心病、高血压、糖尿病等,手术风险相应增大,且高龄ASD 患者血流 动力学改变已持续很长时间,围手术期应做好肺动脉高压及心律失常的处理。术前给予患者吸氧,纠正心功能不全,补充能量合剂,有心律失常者应抗心律失常治疗。肺动脉高压者必要时一氧化氮吸入。术中注意心肌保护,近20 年来,冷钾心脏停跳液结合浅 中度低温体外循环已成为大多数医疗机构常规的心肌保护方法。同时严守心内手术操作原则,对合并房室传导阻滞者常规放置临时起博电极。术后适当应用强心,利尿,扩血管镇静药物,加强左心功能的支持和辅助,可用多巴胺,多巴酚丁胺强心,减轻心脏负荷。同时重点防治肺血管痉挛,适当延长呼吸机辅助时间。
参考文献
[1] Ckinson DF,Arnol dR,Wilkinson JL.Congenital heant disease among 160,480liveborn in liverpool 1960 to 1969:implications of surgical treatment.Br Heart J,1981;46(1):55 62.
[2] CampbeII M.Natural history of atrial septal defect.Br Heart J,1970,32:820 826.
[3] Cooley DA,Frazier OH.The past 50 years of cardiovascular surgery.Circulation,2000,102:87 91.
[4] Markman P,Howitt G,Wade EG.Atrial septal defect in the middle aged and elderly.Q J Med,1965,34:409 426.
[5] Ward C.Secuudum atrial septal defect:routine surgical treatment is not proven benefit.BrHeartJ,1994,71(3):219
[6] Gatzoulis MA,Redington AN,Somerville J,et al.Should Atrial Septal Defects in adults Beclosed AnnThoracSurg,1996,61(2):657.
