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体重2 500克以下危重先天性心脏病患者的体外循环管理

膜式氧合器在胎羊体外循环中的运用

目的 为了改进胎羊体外循环技术,探讨膜式氧合器在胎羊体外循环中的应用. 方法 将健康怀孕山羊8只,采用Dideco 901膜式氧合器和滚轴泵建立胎羊体外循环,常温(37℃)转流60分钟,氧合器内充低氧混合气体(8% O2和92% N2),监测胎羊的血压、心率、血气、血清乳酸和胎盘血管阻力. 结果 胎羊体外循环中动脉氧分压(PO2)和二氧化碳分压(PCO2)维持在宫内生理水平,胎羊心搏有力,血压正常.但胎羊pH值缓慢下降(P＜0.05),血清乳酸值明显增高(P＜0.01),胎盘血管阻力显著上升(P＜0.01).停体外循环后胎羊出现低氧、高碳酸血症和酸中毒. 结论 胎羊体外循环影响胎盘功能,膜式氧合器可以代替胎盘气体交换功能,体外循环中胎羊生理低水平PO2是否适合其需要值得探讨.

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.

半身体外循环技术在主动脉缩窄矫治术中的应用

目的 探讨心脏不停跳下半身体外循环（partial cardiopulmonary bypass，PCB）在主动脉缩窄矫治术中的应用。 方法 回顾性分析 2016 年 3 月至 2017 年 8 月我院经左后外侧切口行缩窄主动脉段置换术 5 例男性主动脉缩窄患者的临床资料，平均年龄（22.80±14.22）岁。术中经降主动脉和左肺动脉分别插入动脉灌注管和静脉引流管，连接人工膜肺和滚轴泵，建立 PCB。采用心脏不停跳的方法，避免深低温（鼻咽温度 33℃ 以上），控制灌注流量在 15～50 ml/（kg·min），维持上肢血压 60～100 mm Hg 和下肢血压 50～80 mm Hg。 结果 PCB 平均转流时间为（77.40±17.85）min，均平稳脱离体外循环。术后平均住 ICU 时间（25.00±14.17）h。所有患者无截瘫、肾损害等并发症。短期随访没有主动脉再狭窄现象。 结论 心脏不停跳下经降主动脉和左肺动脉插管建立 PCB 的技术在青少年或成人主动脉缩窄矫治术中安全、可行，能避免深低温及内脏和脊髓损伤。

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。

右心辅助在心脏移植术后急性右心衰竭中的临床应用

目的 探讨右心辅助方式治疗合并重度肺动脉高压患者心脏移植术后急性右心衰竭的初步经验。 方法 回顾性分析 2017 年 4～8 月我院行右心辅助 4 例患者的临床资料，其中男 3 例、女 1 例，平均年龄（46.2±1.8）岁。术前行右心导管监测肺动脉阻力为（7.80±0.67）Wood 单位，肺动脉收缩压（69.75±3.47）mm Hg。在心脏复跳后体外循环并行循环时行肺动脉和股静脉插管，建立右心室辅助并撤离体外循环。辅助至右心功能恢复满意，逐步减低流量，撤除右心辅助。 结果 4 例患者全部成功撤除右心辅助并存活。平均供心冷缺血时间为（235.0±18.8）min，体外循环时间为（272.0±41.1）min，并行辅助循环时间为（166.0±32.7）min，平均右心辅助时间为（157.7±27.5）h，全血激活凝固时间（ACT）监测波动于 120～150 s 之间。期间无再次开胸止血事件，无辅助机械障碍发生，无管道内凝血事件发生。 结论 右心辅助比体外膜肺氧合具有机械故障少，辅助时间长，抗凝要求低，出血少，血细胞、血小板和凝血因子破坏少的优点，而且经济效益可观，更加接近生理循环，不会增加左心后负荷。

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