成人房间隔缺损外科治疗疗效剖析.docVIP

成人房间隔缺损外科治疗疗效剖析 　　【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,15mm 4例。12 例心房水平存在双向分流以左向右分流为主,重度肺动脉高压 2 例,中度肺动脉高压 12例。术前行右心导管检查 6 例。 　　2 方法和结果 　　2.1 方法 所有病例均在全麻中度低温和中度血液稀释体外循环下施行手术。对长径较长的房缺用补片修补,避免直接缝合房缺致心房内牵拉张力增高。缺损边缘较脆弱容易撕裂者用垫片水平褥式间断缝合。对房缺较小者采取直接缝合。有三尖瓣明显返流者行三尖瓣成行术。合并动脉导管未闭者,行动脉导管未闭结扎术或缝扎术。其中25 例补片修补,12例直接缝合。对有合并症者, 22例二尖瓣关闭不全中, 因瓣膜器质性病变 6 例行二尖瓣