肺动脉闭锁姑息术式的比较及开窗术在改良Fontan术中应用的研究

发布时间：2018-06-07 03:36

本文选题：肺动脉闭锁 + 粗大体肺侧枝　；参考：《北京协和医学院》2017年博士论文

【摘要】：目的:体肺分流术与右室肺动脉连接术都是应用于肺动脉闭锁患者的姑息手术,两种术式均通过重建肺动脉内的前向血流以期恢复发育不良的固有肺动脉。但目前两种术式在临床中的应用仍存有争议,我们对分别接受两种术式的患者进行对比,拟判断两种术式差异,及对患者的不同影响。方法:回顾性分析2011年1月至2016年1月98例在我院接受姑息手术治疗的患者,其中44例患者接受体肺分流手术,54例患者接受右室肺动脉连接术,对其围术期及远期临床资料进行对比。相较于右室肺动脉连接术患者,体肺分流患者具有更小的术前肺动脉指数(68.57±38.25 vs.112.62±61.63 mm2/m2,p0.01)。结果:与右室肺动脉连接术患者相比较,体肺分流术患者具有更短的呼吸机辅助时间(26.73±27.20 vs.40.88±36.93 hours,p = 0.045),更短的 ICU 住院时间(3.6±3.9 vs.5.7±5.5 days,p = 0.033),以及更短的住院时间(9.9±3.9 vs.14.7±11.9,p = 0.014),远期累积根治率及累积生存率两组患者无显著差异。结论:体肺分流术可以在肺动脉发育更差及体肺侧枝更多的患者中应用,而且体肺分流术患者较右室肺动脉连接术患者实现了更好的术后临床疗效,并有效的保留了患者的肺动脉瓣环结构。总体而言,我们认为体肺分流术可使肺动脉闭锁伴室间隔缺损合并粗大体肺侧枝的患者获益更多。目的:对比我院不同危险度开窗与不开窗患者术后资料,以期探求开窗对于不同危险度Fontan患者的作用,指导临床决策。方法:回顾性研究我院自2004年1月至2013年6月183例行心外管道Fontan手术患者。根据以往研究公认的危险因素,将患者分为低危组(93例)和高危组(90例)并分别对比两组开窗患者与不开窗患者的临床资料。结果:两组开窗与不开窗患者在术前及术中资料方面均没有显著统计学差异。两组开窗患者的血氧饱和度均显著低于不开窗患者(P0.01)。在高危组中,开窗患者的胸腔引流量(1153 ml vs.1739 ml,p=0.021)及胸腔引流时间(11.9 days vs.17.0 days,p=0.028)均低于不开窗患者,而低危组中开窗患者与不开窗患者在胸腔应流量及胸腔引流时间方面无显著统计学差异。两组中开窗患者与不开窗患者在并发症发生率及死亡率方面无显著统计学差异(P0.05)。结论:尽管开窗导致患者较低的血氧饱和度,但高危组开窗患者具有更短的胸腔引流时间及胸腔引流量。考虑到低危组开窗患者与不开窗患者相类似的术后早期结果,我们建议对高危患者行开窗治疗。
[Abstract]:Objective: Body-pulmonary shunt and right ventricular pulmonary artery connection are palliative procedures for patients with pulmonary atresia. However, there is still controversy about the application of the two surgical methods in clinical practice. We compared the two surgical procedures to judge the difference of the two methods and their effects on the patients. Methods: from January 2011 to January 2016, 98 patients underwent palliative operation in our hospital. Among them, 44 patients received monopulmonary shunt surgery and 54 patients received right ventricular pulmonary artery connection (RVPA). The perioperative and long-term clinical data were compared. Compared with the patients with right ventricular pulmonary artery connection, the preoperative pulmonary artery index was 68.57 卤38.25 vs.112.62 卤61.63 mm / m ~ 2 / m ~ (2) P _ (0.01). Results: compared with the patients with right ventricular pulmonary artery connection, There was no significant difference in long-term cumulative radical cure rate and cumulative survival rate between the two groups. The patients had shorter ventilator assisted time (26.73 卤27.20 卤36.93 hours), shorter ICU hospitalization time (3.6 卤3.9 vs.5.7 卤5.5daysP = 0.033) and shorter hospitalization time (9.9 卤3.9 vs.14.7 卤11.9p = 0.014). Conclusion: Body-lung shunt can be used in patients with lower pulmonary artery development and more lateral branches of body and lung, and better clinical effect is achieved in patients with pulmonary shunt than those with right ventricular pulmonary artery connection (RVPA). The pulmonary annulus structure of the patient was effectively preserved. In general, we believe that the pulmonary artery atresia with ventricular septal defect with bulky lateral branch of the lung can benefit more. Objective: to compare the postoperative data of patients with different risk of fenestration and non-fenestration in order to explore the effect of fenestration on patients with different risk of Fontan and to guide the clinical decision. Methods: from January 2004 to June 2013, 183 Fontan patients underwent extracardiac catheterization in our hospital. According to the accepted risk factors, the patients were divided into low risk group (93 cases) and high risk group (90 cases). Results: there was no significant difference in preoperative and intraoperative data between the two groups. The blood oxygen saturation of the two groups was significantly lower than that of the non-fenestration patients (P 0.01). In the high risk group, the thoracic drainage volume of 1153ml / ml vs.1739 / ml p0. 021) and the time of thoracic drainage were lower in the patients with fenestration than in the patients without fenestration, and the time of thoracic drainage was 11. 9 days vs.17.0 / d. 028). In the low risk group, there was no significant difference between the patients with fenestration and the patients without fenestration in the pleural volume and the time of thoracic drainage. There was no significant difference in the incidence of complications and mortality between patients with and without fenestration between the two groups (P 0.05). Conclusion: although fenestration leads to lower blood oxygen saturation, the patients in high risk group have shorter thoracic drainage time and thoracic drainage volume. Considering the early postoperative outcomes of patients with low risk and non-fenestration, we suggest that high risk patients should be treated with fenestration.
【学位授予单位】：北京协和医学院
【学位级别】：博士
【学位授予年份】：2017
【分类号】：R726.5

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