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慢性缩窄性心包炎手术径路的选择

目的 探讨慢性缩窄性心包炎的外科最佳手术径路选择，总结临床经验。方法 回顾性分析 1970年9月至 2009年 9月中国医科大学附属第一医院收治 538例慢性缩窄性心包炎患者的临床资料，按手术径路不同将其分为两组，胸骨正中切口组： 324例，男 204例，女 120例，年龄（ 44.5±10.0）岁；左胸前外侧切口组： 214例，男 130例，女 84例，年龄（ 46.5±6.8）岁。比较两组患者术后心功能和并发症发生情况。结果 胸骨正中切口组死亡 1例，术后 2 d死于顽固性室性心律失常。左胸前外侧切口组死亡 9例，其中死于多器官功能衰竭 1例，呼吸衰竭 2例，低心排血量综合征 2例，严重肺部感染 3例；1例于第 3次复发手术中发生左心室破裂死亡。胸骨正中切口组心功能较左胸前外侧切口组明显改善，中心静脉压较左胸前外侧切口组降低，胸腔积液、肺炎和脓胸发生率均低于左胸前外侧切口组（ P＜ 0.05）。随访 385例（胸骨正中切口组 231例、左胸前外侧切口组 154例），随访时间 3个月～ 15年，心功能明显改善，均恢复正常工作和学习。胸骨正中切口组缩窄性心包炎复发 4例，左胸前外侧切口组复发 17例，均经相应的治疗治愈或好转。结论 心包剥脱术是治疗慢性缩窄性心包炎的有效手段，胸骨正中切口径路是外科治疗慢性缩窄性心包炎最佳的手术径路。

慢性缩窄性心包炎的外科治疗

目的 总结慢性缩窄性心包炎的外科治疗经验。方法 78例患者术前均被明确诊断为慢性缩窄性心包炎，均在全身麻醉下经胸部正中切口行心包剥脱术。结果 术后中心静脉压6.5～14.0mmHg（1kPa=7.5mmHg），平均8mmHg。死亡1例，再次开胸止血2例，发生低心排血量综合征3例。术后病理检查：心包纤维结缔组织增生、玻璃样变性60例，呈于酪样结核病变18例（伴结核肉芽肿形成7例）。随访65例，随访时间3个月～10年，心功能（NYHA）均为I级，无心包缩窄复发和死亡。结论 手术是治疗慢性缩窄性心包炎惟一有效的方法，胸部正中切口是较佳的手术径路，心包切除范围应根据具体病情而定，力争将心包彻底松解切除。

Management and prognosis of constrictive pericarditis during pericardiectomy

Objective To estimate the relationship of methods and drugs for management of constrictive pericarditis during pericardiectomy. Methods We reviewed the records of 45 patients (mean age, 40.24±15.34 years) with a diagnosis of constrictive pericarditis who underwent pericardiectomy in our hospital from 2012 through 2014 year. During operation, inotropic agents, vasodilators and diuretics were used. According to the diuretics, patients were divided into two groups including a furosemide group(group F) with 38 patients and a lyophilized recombinant human brain natriuretic peptide (lrhBNP) group with 7 patients(group B). Results Preoperatively, 30 patients were pulmonary congestion, which was diagnosed by chest radiographs. Pericardiectomy was finished by off pump in 43 patients. Another 2 patients required cardiopulmonary bypass (CPB) for pericardiectomy. In the group F 52.6% of the patients needed vasodilators to reduce cardiac preloading following pericardiectomy. None of other vasodilators were used in the group B. After pericardiectomy, the fluctuation of systolic and diastolic pressure decreased significantly in the group B (P=0.01, respectively). In the group F, the fluctuation of diastolic pressure decreased significantly (P＜0.05). Low cardiac output was the most common postoperative problem. One patient accepted postoperative extracorporeal membrane oxygenation (ECMO) support. Postoperative poor renal function was found in 42.2% of the patients. Three of them needed hemofiltration. Postoperative poor renal function accompanied by poor hepatic function was found in 15.6% of the patients. One of them used dialysis and artificial liver. Three patients were respiratory failure with longer mechanical ventilation and tracheotomy. The overall perioperative mortality rate was 6.7% (3 patients). All patients, who died or used with hemofiltration, artificial liver and ECMO were found in the group F. Conclusion More stable haemodynamics after pericardiectomy may occur with using lrhBNP. lrhBNP may reduce postoperative major morbidity and mortality. Because of the small group using lrhBNP in our study, more patients using lrhBNP for pericardiectomy need to be studied.

缩窄性心包炎合并冠状动脉粥样硬化性心脏病两例