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體重2 500克以下危重先天性心臟病患者的體外循環管理

Rational Choice of Mechanical and Bioprosthesis Valve

Heart valve replacement is the major surgical treatment of severe valvular diseases. Due to the durability and reoperation-free, mechanical valves are widely used. Bioprosthesis valves became popular recently because of long service life and no demand for lifelong anticoagulation. However, how to choose the appropriate prosthetic heart valves, especially the application of bioprosthesis valves for patients at 55 to 65 years is still a major problem. This review focuses on more effective and scientific basis for rational choice of mechanical and bioprosthesis valve.

Guidelines on patient blood management for adult cardiovascular surgery under cardiopulmonary bypass

Working Group on Extracorporeal Life Support, National Center for Cardiovascular Quality Improvement developed guidelines on patient blood management for adult cardiovascular surgery under cardiopulmonary bypass, aiming to standardize patient blood management in adult cardiovascular surgery under cardiopulmonary bypass, reduce blood resource consumption, and improve patients outcomes. Forty-eight domestic experts participated in the development of the guidelines. Based on prior investigation and the PICO (patient, intervention, control, outcome) principles, thirteen clinical questions from four aspects were selected, including priming and fluid management during cardiopulmonary bypass, anticoagulation and monitoring during cardiopulmonary bypass, peri-cardiopulmonary bypass blood product infusion, and autologous blood infusion. Systemic reviews to the thirteen questions were performed through literature search. Recommendations were drafted using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system. After five rounds of experts discussions between 2023 and 2024, 19 recommendations were finally formed.

膜式氧合器在胎羊體外循環中的運用

目的 為了改進胎羊體外循環技術,探討膜式氧合器在胎羊體外循環中的應用. 方法 將健康懷孕山羊8只,采用Dideco 901膜式氧合器和滾軸泵建立胎羊體外循環,常溫(37℃)轉流60分鐘,氧合器內充低氧混合氣體(8% O2和92% N2),監測胎羊的血壓、心率、血氣、血清乳酸和胎盤血管阻力. 結果 胎羊體外循環中動脈氧分壓(PO2)和二氧化碳分壓(PCO2)維持在宮內生理水平,胎羊心搏有力,血壓正常.但胎羊pH值緩慢下降(P＜0.05),血清乳酸值明顯增高(P＜0.01),胎盤血管阻力顯著上升(P＜0.01).停體外循環后胎羊出現低氧、高碳酸血癥和酸中毒. 結論 胎羊體外循環影響胎盤功能,膜式氧合器可以代替胎盤氣體交換功能,體外循環中胎羊生理低水平PO2是否適合其需要值得探討.

半身體外循環技術在主動脈縮窄矯治術中的應用

目的 探討心臟不停跳下半身體外循環（partial cardiopulmonary bypass，PCB）在主動脈縮窄矯治術中的應用。 方法 回顧性分析 2016 年 3 月至 2017 年 8 月我院經左后外側切口行縮窄主動脈段置換術 5 例男性主動脈縮窄患者的臨床資料，平均年齡（22.80±14.22）歲。術中經降主動脈和左肺動脈分別插入動脈灌注管和靜脈引流管，連接人工膜肺和滾軸泵，建立 PCB。采用心臟不停跳的方法，避免深低溫（鼻咽溫度 33℃ 以上），控制灌注流量在 15～50 ml/（kg·min），維持上肢血壓 60～100 mm Hg 和下肢血壓 50～80 mm Hg。 結果 PCB 平均轉流時間為（77.40±17.85）min，均平穩脫離體外循環。術后平均住 ICU 時間（25.00±14.17）h。所有患者無截癱、腎損害等并發癥。短期隨訪沒有主動脈再狹窄現象。 結論 心臟不停跳下經降主動脈和左肺動脈插管建立 PCB 的技術在青少年或成人主動脈縮窄矯治術中安全、可行，能避免深低溫及內臟和脊髓損傷。

Extracorporeal membrane oxygenation combined with hypothermia therapy for children patients with refractory cardiac arrest after congenital heart disease surgery: A randomized controlled trial

Objective To explore the value of extracorporeal membrane oxygenation(ECMO) combined with hypothermia therapy for children patients with refractory cardiac arrest after congenital heart disease surgery. Methods From January 2013 to June 2016, we conducted a prospective study of 23 children (18 males, 5 females at age of 7±11 months) who underwent ECMO for refractory cardiac arrest after congenital heart disease surgery. All patients were randomly divided into two groups: a standard group (11 patients) and a hypothermia group (12 patients). The patients of the standard group received standard therapy (the core body temperature maintaining at 37.0℃) and the hypothermia group received hypothermia therapy (the core body temperature maintaining at 33.0℃). The hospital discharge rate, the rate of weaning from ECMO and the morbidity were compared between the two groups. Results Eleven of 23 patients (47.8%) were weaned from ECMO successfully and 7 of 23 patients (30.4%) discharged from hospital. The hospital discharge rate between the hypothermia group (n=6, 50.0%) and the standard group (n=1, 9.1%) had no statistical difference (χ2=4.537, P=0.069). The rate of weaning from ECMO of the hypothermia group (n=9, 75.0%) was higher than that of the standard group (n=2, 18.2%, χ2=7.425, P=0.006). The morbidity between the two groups had no statistical difference. Conclusion Extracorporeal cardiopulmonary resuscitation can improve the survival rate of the children who suffered from refractory cardiac arrest after congenital heart disease surgery. There is no evidence that ECMO combined with hyperthermia therapy is better than the only ECMO in improving the discharge rate. But ECMO combined with hypothermia therapy has higher rate of weaning from ECMO than that of the only ECMO.

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

目的探討成人法洛四聯癥（tetralogy of fallot，TOf）的體外循環（cardiaopulmonary bypass，CPB）管理策略。 方法回顧性分析2008年1月至2012年12月廣東省人民醫院收治TOf患者112例的臨床資料，其中男51例、女61例，年齡17～49（26.8±11.3）歲。2例行右心室流出道疏通術，余為TOf根治術。CPB降溫至中度或深度低溫、采用中至低流量灌注。通過CPB開始時放自體血、加大預充液量等調整CPB中紅細胞壓積（HCT）維持在0.25至術前水平的1/2，持續給予6-氨基己酸、超濾、使用血液回收機等綜合措施進行血液保護。心肌保護采用冷高鉀含血或晶體心臟停搏液間斷灌注，同時運用開放前溫血灌注、術野充彌CO2輔助心腔排氣等措施提高心肌保護效果。調控CPB中血氧分壓，以術前氧分壓水平開始CPB、逐漸增加到150 mm Hg左右，并維持至CPB血流復溫再進一步升高，以減少全身各組織器官的再氧合損傷。 結果CPB時間60～272（127.5±31.5）min，主動脈阻斷時間22～146（78.3±20.4）min，住ICU時間19～1 465（96.9±19.0）h，住院時間12～84（26.2±1.4）d。二次開胸止血12例，胸腔積液9例，急性腎功衰竭2例，乳糜胸2例；死亡4例，其中術后重度低心排血量綜合征3例、多器官功能衰竭1例，住院死亡率3.6%。 結論成人TOf的CPB需要特別關注血液保護、心肌保護及減少再氧合損傷，以降低并發癥、提高手術效果。

右心輔助在心臟移植術后急性右心衰竭中的臨床應用

目的 探討右心輔助方式治療合并重度肺動脈高壓患者心臟移植術后急性右心衰竭的初步經驗。 方法 回顧性分析 2017 年 4～8 月我院行右心輔助 4 例患者的臨床資料，其中男 3 例、女 1 例，平均年齡（46.2±1.8）歲。術前行右心導管監測肺動脈阻力為（7.80±0.67）Wood 單位，肺動脈收縮壓（69.75±3.47）mm Hg。在心臟復跳后體外循環并行循環時行肺動脈和股靜脈插管，建立右心室輔助并撤離體外循環。輔助至右心功能恢復滿意，逐步減低流量，撤除右心輔助。 結果 4 例患者全部成功撤除右心輔助并存活。平均供心冷缺血時間為（235.0±18.8）min，體外循環時間為（272.0±41.1）min，并行輔助循環時間為（166.0±32.7）min，平均右心輔助時間為（157.7±27.5）h，全血激活凝固時間（ACT）監測波動于 120～150 s 之間。期間無再次開胸止血事件，無輔助機械障礙發生，無管道內凝血事件發生。 結論 右心輔助比體外膜肺氧合具有機械故障少，輔助時間長，抗凝要求低，出血少，血細胞、血小板和凝血因子破壞少的優點，而且經濟效益可觀，更加接近生理循環，不會增加左心后負荷。

Incidence of spinal cord injury in patients with acute type A aortic dissection after expanding the landing zone of frozen elephant trunk: A retrospective study in a single center

ObjectiveTo assess whether expanding the landing zone of frozen elephant trunk (FET) increases the risk of spinal cord injury in patients with acute type A aortic dissection. MethodsPatients with acute type A aortic dissection who were treated in Guangdong Provincial People’s Hospital from 2017 to 2020 were collected. They were divided into two groups according to the landing zone of FET by the image diagnosis of postoperative chest X-ray or total aorta CT angiography, including a Th9 group which defined as below the eighth thoracic vertebral level, and a Th8 group which was defined as above or equal to the eighth thoracic vertebral level. Using the propensity score matching (PSM) method, the preoperative and intraoperative data of two groups were matched with a 1∶2 ratio. The prognosis of the two groups after PSM was analyzed. Results Before PSM, 573 patients were collected, including 58 patients in the Th9 group and 515 patients in the Th8 group. After PSM, 174 patients were collected, including 58 patients in the Th9 group (46 males and 12 females, with an average age of 47.91±9.92 years), and 116 patients in the Th8 group (93 males and 23 females, with an average age of 48.01±9.53 years). There were 8 patients of postoperative spinal cord injury in the two groups after PSM, including 5 (4.31%) patients in the Th8 group and 3 (5.17%) patients in the Th9 group (P=0.738). In the Th8 group, 2 patients had postoperative transient paresis and recovered spontaneously after symptomatic treatment, and 1 patient had postoperative paraplegia with cerebrospinal fluid drainage. After 3 days, the muscle strength of both lower limbs gradually recovered after treatment. There was no statistical difference in complications between the two groups (P＞0.05). ConclusionExpanding the landing zone of FET does not increase the risk of spinal cord injury in patients with acute type A aortic dissection. However, the sample size is limited, and in the future, multicenter large-scale sample size studies are still needed for verification