128先心病教案 统一版(1).ppt

,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,Six clinical professional units(more than 200 beds)Pediatric Cardiac SurgeryAdult Cardiac SurgeryGeneral Thoracic Surgery CPB Group ICU(36 beds)Eight Operation Rooms,胸心血管外科简介Introduction of the department of thoracic-cardiacvascular surgery,More than 3500 cardiac operations to be performed per year.More than 1500 of which are pediatric cardiac surgery.The clinical and basic research are ranked top 8 in China.,Introduction of the department of thoracic-cardiacvascular surgery,A young,high level of qualified team,211 clinical staffs in total 6 professors 10 associate professors 14 attending doctors,Introduction of the department of thoracic-cardiacvascular surgery,At present，we can perform CABG,Valvular replacement,Aortic/thoracic aortic aneurism replacementCongenital heart diseases:neonatesHeart transplantation,Other difficult cases,Introduction of the department of thoracic-cardiacvascular surgery,Research Centers,Biomaterial Research CenterGene Engineering Research CenterThe Heart Valve Research CenterHeart and Lung Protection Research CenterThe Research Office of ultrasound imaging,Introduction of the department of thoracic-cardiacvascular surgery,Researchs of leading level in ChinaCPB in deep hypothermia experiments and clinical application Cardiovascular biomaterialsCardiovascular disease-related gene diagnosis and treatment,Introduction of the department of thoracic-cardiacvascular surgery,Overview of The Pediatric Cardiac Surgery,Established in the 1980s20 years of development3 professor,2 associate professor,3 attending doctors and 6 residents,Introduction of the department of thoracic-cardiacvascular surgery,All surgical procedures for CHD can be performed in the unit,吴忠仕 Zhongshi Wu(MD.PhD)A pediatric cardiac surgeon within the Department of cardiac surgeryPerform pediatric heart surgical procedures 250 cases each yearBe able to perform multiple cardiac operations,such as repair of TOF with PS or PA,cAVSD,TAPVC,DORV,aortic coarctation,commontrunks,et al,with favorable results,Introduction of the department of thoracic-cardiacvascular surgery,Excellent academic performanceFirstman to undertake the research on Bovine Jugular vein conduit as the pulmonary artery surrogate and introduce it into clinical use in China.Applied an invent patent for the novel method of preparing of bovine jugular vein conduit.Got a better result(12/13)of DORV with remote VSD repair with intracardiac conduit technique 50 papers and 6 SCI papers(total IF 20)pubilshed Trained 31 postgraduator,Introduction of the department of thoracic-cardiacvascular surgery,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 Cardiopulmonary bypass,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,5,1953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,von Schraeder 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,血液稀释法优点,节省大量血液 降低血液粘滞度 改善微循环 减少红细胞破坏 减少凝血机理紊乱 增进肾脏排泄功能,体外循环方法，,常温,浅低温：32-35 Q:2.2-2.0 L/mim/m2中低温：28-32 Q:1.6 L/mim/m2,深低温：18-28 Q:1 L/mim/m2,深低温停循环：15-18 用于婴幼儿心内直视和 成人主动脉瘤手术,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（Cardioplegia）的基本要素 心停搏剂 高钾 低温 04 基质 调节PH值 调节渗透压 稳定细胞膜,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，2040mmol/L 高镁，10 20 mmol/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04 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,停搏液灌注法 顺行灌注法(antegrade Cardioplegia)主动脉根部灌注 逆行灌注法(Retragrade Cardioplegia)冠状静脉窦灌注,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,Cardiac I C U,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 Surgical Treatment of Congenital Heart Disease The Second Xiangya Hospital Wu zhongshi,高肺血流 低肺血流非紫绀Acyanotic 紫绀Cyanotic 紫绀 Cyanotic(L R shunt)(R L shunt)VSD TGA TOFPDA TAPVD Abstein anomaly ASD Tric atr Pulm atresiaAVSD Single ventricleAP Window Truncus,先心病分类,Death rate of children born with CHD,胎儿血液循环（Fetal blood Circulation）,卵圆孔开放 Patent oval fossa 动脉导管开放 Patent ductus arteriosus,动脉导管未闭(Patent Ductus Arteriosus),出生前 PDA 是正常的结构 但出生后18 hrs 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respiratory distress 在高纬度出生的婴儿,导管开放的影响因素,AO,PDA,PA,(L R Shunt),LV 负荷,LV,LA肥大，扩大,高肺血流,肺血管阻力PVR 肺动脉高压 P H,(R L Shunt)Eissenmger Syndrome,Difference cyanosis 分离性紫绀,病理生理,临床表现 Clinical features,反复肺部感染 Recurrent lung infection 发育不良 malnutrition左心衰 Left heart failure 紫绀 cyanosis,小导管无症状：Asymptomatic,连续性机器样杂音 Continuous or machinery type murmur,P2亢进,脉压增宽,水冲脉 bounding pulses,临床体征 Signs,重度肺高压,only syst