CAJ | 학술논문

目的探讨先天性心脏病(先心病)合并重度肺动脉高压患者的手术适应证、围手术期处理和术后降肺动脉压治疗方法.方法回顾2005年6月至2010年10月收治的76例先心病合并重度肺动脉高压的患者,男24例,女52例;年龄(19.4±12.6)岁.超声心动图估测肺动脉收缩压64～126mmHg,平均(92.8 ±15.3) mmHg(1 mmHg =0.133 kPa).53例行右心导管检查:吸氧前肺动脉平均压56～102 mmHg,平均(79.0±11.1) mmHg;Qp/Qs 0.60～ 3.33,平均1.48 ±0.78,肺血管阻力40.5～262.7 kPa·s·L-1,平均(128.9±51.2) kPa·s·L-1;吸氧试验后肺动脉平均压51 ～ 96 mmHg,平均(72.8±11.2) mmHg;Qp/Qs 0.96～ 5.33,平均1.98 ±0.89;肺血管阻力22.2～214.1 kPa·s· L-1,平均(90.2 ±38.4)kPa·s·L-1.经降肺动脉压治疗后,行心内畸形矫治术,术后加强心肺护理,继续降肺动脉压治疗.生存患者定期随访.结果围手术期院内死亡6例,生存70例.术后1～2周复查超声心动图,估测肺动脉收缩压31～ 106 mmHg,平均(63.8 ±15.8) mmHg,较术前下降31.3％.随访2～5年,失访6例;随访64例中6例肺动脉压渐进性升高,其中3例术后2年内死亡.结论经过降肺动脉药物治疗调整后,右心导管检查吸氧试验后Qp/Qs＜1为手术绝对禁忌证;≥1.0～1.3,术后肺动脉压下降不明显,甚至继续进展,不建议手术;≥1.3～1.5,术后早期并发症多、风险高,手术需谨慎;≥1.5～2.0,多可手术,长期预后尚需随访观察;＞2.0,术后肺动脉压多可得到较好控制.围手术期的处理直接影响到手术的近期疗效,而术后的综合、长期、个体化的降肺动脉压治疗,可以改善生活质量和预后.
목적 탐토선천성심장병(선심병)합병중도폐동맥고압환자적수술괄응증、위수술기처리화술후강폐동맥압치료방법.방법 회고2005년6월지2010년10월수치적76례선심병합병중도폐동맥고압적환자,남24례,녀52례;년령(19.4±12.6)세.초성심동도고측폐동맥수축압64～126mmHg,평균(92.8 ±15.3) mmHg(1 mmHg =0.133 kPa).53례행우심도관검사:흡양전폐동맥평균압56～102 mmHg,평균(79.0±11.1) mmHg;Qp/Qs 0.60～ 3.33,평균1.48 ±0.78,폐혈관조력40.5～262.7 kPa·s·L-1,평균(128.9±51.2) kPa·s·L-1;흡양시험후폐동맥평균압51 ～ 96 mmHg,평균(72.8±11.2) mmHg;Qp/Qs 0.96～ 5.33,평균1.98 ±0.89;폐혈관조력22.2～214.1 kPa·s· L-1,평균(90.2 ±38.4)kPa·s·L-1.경강폐동맥압치료후,행심내기형교치술,술후가강심폐호리,계속강폐동맥압치료.생존환자정기수방.결과 위수술기원내사망6례,생존70례.술후1～2주복사초성심동도,고측폐동맥수축압31～ 106 mmHg,평균(63.8 ±15.8) mmHg,교술전하강31.3％.수방2～5년,실방6례;수방64례중6례폐동맥압점진성승고,기중3례술후2년내사망.결론 경과강폐동맥약물치료조정후,우심도관검사흡양시험후Qp/Qs＜1위수술절대금기증;≥1.0～1.3,술후폐동맥압하강불명현,심지계속진전,불건의수술;≥1.3～1.5,술후조기병발증다、풍험고,수술수근신;≥1.5～2.0,다가수술,장기예후상수수방관찰;＞2.0,술후폐동맥압다가득도교호공제.위수술기적처리직접영향도수술적근기료효,이술후적종합、장기、개체화적강폐동맥압치료,가이개선생활질량화예후.
Objective To investigate surgical indications,perioperative management and postoperative treatment of congenital heart disease(CHD) with severe pulmonary arterial hypertension(PAH).Methods 76 patients of CHD with severe PAH underwent surgical operation from Jun 2005 to Oct 2010 in our hospital.Ultrasound cardiograph estimation of their pulmonary artery systolic pressure were between 64 mmHg to 126 mmHg,with an average of(92.8 ± 15.3) mmHg.Right cardiac catheterization illustrated that mean pulmonary artery pressure ranged from 56 mmHg to 102 mmHg[mean(79.0 ± 11.1) mmHg] without oxygen inhalation administration,Qp/Qs 0.60-3.33 (mean 1.48 ± 0.78),pulmonary vascular resistance (PVR) 40.5-267.6 kPa · s · L-1 [mean (128.9 ± 51.2) kPa · s · L-1].After oxygen inhalation administration,pulmonary artery pressure ranged from 51 mmHg to 96 mmHg [mean (72.8 ± 11.2) mmHg] ; Qp/Qs 0.96-5.33 (mean 1.98 ± 0.89),PVR 22.2-214.1 kPa · s · L-1 [mean(90.2 ±38.4) kPa · s · L-1].Patients had operations to correct cardiac anomaly after the preparation of antihypertensive treatment.Cardiorespiratory care and antihypertensive measures of pulmonary pressure were administered after surgery.Results Follow-ups were made for the survival cases.Results 6 patients died in-hospital and 70 cases survived.Ultrasound cardiograph examination of pulmonary artery systolic pressure ranged from 31 mmHg to 106 mmHg[mean(63.8 ± 15.8) mmHg] with decline of 31.3％ compared to preoperative stage.6 cases were lost in followup.In 2 to 5 years reexamination,6 patients'pulmonary artery pressure increased progressively and 3 cases died in 2 years after surgery.Conclusion After medical therapy of pulmonary hypertension,right cardiac catheterization with oxygen inhalation test demonstrates that when value of Qp/Qs ＜ 1.0,it is absolute contraindication.When Qp/Qs ranging from 1.0 to 1.3,pulmonary artery pressure will decrease a little and will continue to progressed,it should not be recommend to surgery.When values of 1.3 to 1.5,it implies that there will be more early complications and high risk for surgery.When values of 1.5 to 2.0,it has indications of surgery and follow-up needed to appraise long-term prognosis; When values more than 2.0,it means good results of surgery.Perioperative management directly affects the surgical outcome,however,postoperative comprehensive,longterm and individualized treatment of pulmonary hypertension could improve life quality and prognosis.