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婴幼儿法洛四联症外科治疗若干问题探讨

Clinical study of ventilator-associated pneumonia in children after surgical correction for tetralogy of Fallot

ObjectiveTo investigate the incidence, pathogens, risk factors and clinical outcomes for ventilator- associated pneumonia (VAP) in children after tetralogy of Fallot (TOF) surgical correction, in order to offer reliable data for the prevention of VAP.MethodsThis was a retrospective study performed in Guangdong General Hospital and 181 children (121 males, 60 females, mean age of 11.2±10.4 months) undergoing surgical correction for TOF were included. ALL the children who received mechanical ventilation for 48 hours or longer between January 2013 and December 2017 were classified into a VAP group (n=44) and a non-VAP group (n=137). T test, χ2 test and multiple logistic regression analysis were used to identify the possible risk factors for VAP.ResultsThis study enrolled 181 patients , of which 44 were diagnosed as VAP. And the incidence of VAP was 24.3%. The most frequent isolated pathogen was Gram-negative bacteria (69.7%). Single factor analysis showed that the variables significantly associated with a risk factor of VAP were: hypoxic spells, preoperative pneumonia, preoperative mechanical ventilation support, cardiopulmonary bypass (CPB) time, reintubation, pulmonary atelectasis, low cardiac output syndrome (LCOS), intra-abdominal drainage and transfusion of fresh frozen plasma. The multiple logistic regression showed CPB time (OR=1.011), reintubation (OR=14.548), pulmonary atelectasis (OR=6.139) and LCOS (OR=3.054) were independent risk factors for VAP in children after TOF surgical correction. Patients with VAP had prolonged duration of mechanical ventilation, a longer ICU stay and longer hospitalization time.ConclusionsThe VAP rate in this population is higher than that reported abroad, which leads to prolonged duration of mechanical ventilation and a longer hospital stay. The effective measures for prevention of VAP should be taken according to the related risk factors for VAP to decrease the incidence of VAP in children after TOF surgical correction.

法洛四联症术后肠道感染致急性呼吸窘迫综合征一例

体肺动脉侧支栓塞在法洛四联症治疗中的作用

法洛四联症（TOF）合并体肺动脉侧支（APC）是一种复杂的先天性心脏病，外科治疗是重要手段，但APC的处理是外科治疗的难题，手术难度大，风险高，术后并发症多且较严重。上世纪70年代开始通过介入方式进行侧支血管栓塞治疗，经过技术的不断进步和经验的不断积累，实践证明栓塞治疗可显著降低外科手术风险，提高手术效果，是TOF合并APC的重要治疗手段之一，现就其目前的研究进展作一综述。

法洛四联症患者围手术期凝血功能变化及意义

目的 探讨法洛四联症（TOF）患者围术期凝血功能变化及临床意义，以减少术后血液系统并发症的发生。 方法 将2005年1月至2008年8月我院收治的65例接受外科手术治疗的TOF患者纳入研究（实验组），选择同期手术的65例非紫绀型先天性心脏病患者作为对照（对照组）。检测两组患者术前及手术后1周的血气、血常规、血浆凝血酶原时间（PT）、活化部分凝血活酶时间（APTT）、血浆Ⅷ和Ⅸ因子活性，并对各项指标术前、术后变化情况进行分析。 结果 组内比较：术后7 d实验组血红蛋白（Hb)和APTT均低于术前，动脉血氧分压(PaO2)、凝血因子Ⅷ和凝血因子Ⅸ均高于术前，PT变化不明显。组间比较：实验组术前Hb和APTT均高于对照组,PaO2、凝血因子Ⅷ和凝血因子Ⅸ均低于对照组（Plt;0.01）。 结论 TOF患者术前存在内源性凝血功能障碍，可能是自身凝血功能代偿以降低高粘血症带来的血栓形成危险，术后能得到改善，可能与血氧分压提高有关。

法洛四联症矫治术中自体心包梯形补片加宽右心室流出道35例

Surgical Treatment of Tetralogy of Fallot in 75 Adults

Abstract: Objective To evaluate the results of surgical treatment of tetralogy of Fallot in adults． Methods From July 2002 to August 2009，75 adult patients with tetralogy of Fallot received surgical treatment in Xijing Hospital, ForthMilitary Medical University．There were 35 males and 40 females, with age at l7 to 37 years (23.30±3.50 years), and eoperativehemoglobin at 143 to 231 g/L(172.00±31.00 g/L)．All these patients were diagnosed by.echocardiograph before operation. All the patients were received tetralogy of Fallot of corrective operation in the hypothermia cardiopulmonary bypass. A total of 46 patients had a transannular right ventricular outflow tract patch，and 29 patients had a non ansannular patch． Results Operation time was 157 to 276 min(221.32±41.34 min), cardiopulmonary bypass time was 68 to 163 min(91.71±28.35 min) and aorta intercepted time was 37 to 96 min（55.47±23.61 min）. There were 6 operative deaths with an operative mortality at 8.00％. The causes of death were low output syndrome(n=3)，acute renal failure(n=2)， and multiple organ failure(n=1)．Nine patients needed reoperation for postoperative bleeding(12.00％)．We followed up 69 patients from 3 to 56 months (26.31±7.40 months). There were 2 patients with trivial residual shunt. The cardiac function status were New York Heart Association(NYHA) Ⅰ to Ⅱ in the 69 patients．No late death occured． Conclusion The effectiveness of surgical treatment for adults with tetralogy of Fallot is satisfactory．

Cardiopulmonary Bypass Management of the Tetralogy of Fallot in Adults: a Report of 112 Cases

目的探讨成人法洛四联症（tetralogy of fallot，TOf）的体外循环（cardiaopulmonary bypass，CPB）管理策略。 方法回顾性分析2008年1月至2012年12月广东省人民医院收治TOf患者112例的临床资料，其中男51例、女61例，年龄17～49（26.8±11.3）岁。2例行右心室流出道疏通术，余为TOf根治术。CPB降温至中度或深度低温、采用中至低流量灌注。通过CPB开始时放自体血、加大预充液量等调整CPB中红细胞压积（HCT）维持在0.25至术前水平的1/2，持续给予6-氨基己酸、超滤、使用血液回收机等综合措施进行血液保护。心肌保护采用冷高钾含血或晶体心脏停搏液间断灌注，同时运用开放前温血灌注、术野充弥CO2辅助心腔排气等措施提高心肌保护效果。调控CPB中血氧分压，以术前氧分压水平开始CPB、逐渐增加到150 mm Hg左右，并维持至CPB血流复温再进一步升高，以减少全身各组织器官的再氧合损伤。 结果CPB时间60～272（127.5±31.5）min，主动脉阻断时间22～146（78.3±20.4）min，住ICU时间19～1 465（96.9±19.0）h，住院时间12～84（26.2±1.4）d。二次开胸止血12例，胸腔积液9例，急性肾功衰竭2例，乳糜胸2例；死亡4例，其中术后重度低心排血量综合征3例、多器官功能衰竭1例，住院死亡率3.6%。 结论成人TOf的CPB需要特别关注血液保护、心肌保护及减少再氧合损伤，以降低并发症、提高手术效果。

完全性房室间隔缺损合并法洛四联症外科矫治的单中心临床经验

目的分析单个临床中心完全性房室间隔缺损合并法洛四联症的外科治疗经验。方法回顾性分析广东省人民医院心外科 2008 年 5 月至 2017 年 3 月收治的 21 例经超声心动图诊断为完全性房室间隔缺损合并法洛四联症患者的外科矫治经验，其中男 17 例、女 4 例，年龄 10 个月（1 个月～20 岁），体重 10（2.5～68）kg。分析其临床结局，并随访生存病例，以初步了解其预后。结果住 ICU 时间 4（1～23）d，住院时间 12（6～21）d。死亡 3 例。21 例患者中，双心室矫治 6 例，单心室矫治 15 例。平均随访时间 3 年，5 年生存率 80%。结论完全性房室间隔缺损合并法洛四联症外科解剖矫治困难，多数病例仅可施行单心室矫治手术，部分病例可施行双心室矫治手术，远期预后良好。

成人法洛四联症的外科治疗

目的 总结成人法洛四联症的外科手术治疗经验。 方法 回顾性分析2000年1月～2006年3月71例成人法洛四联症患者手术治疗的临床资料，69例在低温体外循环下行法洛四联症根治术，其中55例采用跨瓣环补片加宽右心室流出道及肺动脉,14例仅行右心室流出道扩大补片；2例于非体外循环下行双向腔肺分流术。 结果 住院期间死亡率2.8%(2/71)，死亡原因为:低心排血量综合征1例, 低心排血量综合征、多器官功能衰竭1例。其余患者并发低心排血量综合征3例，肺部感染2例,肺不张1例,胸腔积液17例，气胸1例，乳糜胸1例，均治愈出院。随访2 个月～6年(36.5±19.0个月)，术后复查发现小的室间隔缺损残余漏4例,无1例晚期死亡。心功能分级（NYHA）Ⅰ级63例，Ⅱ级6例。 结论 彻底矫正畸形，加强心肌保护、避免发生低心排血量综合征，加强术后管理，成人法洛四联症均可取得良好的