Total vena cava-arterial connection is an effective method for the treatment of a single ventricle of complex congenital heart disease. In the past, atrial stenosis or tubing was used to connect the vena cava with the pulmonary artery. The intracardiac operation was complicated, and complications such as atrial flutter were prone to occur in the advanced stage. . We used an extracardiac total vena cava-pulmonary connection for the treatment of 11 cases of complex congenital heart disease without death. The surgical technique and treatment experience were discussed.
1 Subjects and methods 1.1 Subjects 1998-)1/1999-11 The complex cyanotic congenital heart disease admitted to our department was 11 (male 6, female 5), with an average age of 9.8 (3- 20) years. The average body mass was 26.1 (3~56) kg. The disease was AI and All-type single ventricle with pulmonary stenosis in 9 cases and Ib type tricuspid atresia in 2 cases. Patients showed cyanosis, decreased exercise tolerance, percutaneous oxygen saturation 60% to 85%, hemoglobin (Hb) 16 to 22 g, hematocrit (HCT) 45% to 60%. Cardiac function (NYHA). Preoperative diagnosis by two-dimensional color echocardiography and cardiovascular angiography, right ventricular catheter detection of pulmonary vascular resistance <4Wood.m-1. 1.2 method using normal temperature and in vitro parallel circulation, the heart does not stop.
The median approach of the sternum is to fully dissect the left and right pulmonary artery and the superior and inferior vena cava of the main pulmonary artery. The ascending aorta pericardium is treated as a cardiac tube, and the right anastomosis is placed distally in the superior and inferior vena cava. After the extracorporeal bypass, the superior and inferior vena cava were blocked, and the superior vena cava was intubated in the superior vena cava. The proximal vena cava was sutured continuously with a 5-0 prolene line. The distal end of the distal and right pulmonary arteries were 5-0 Prolene. The lower end of the continuous closed occlusion forceps cut the inferior vena cava and suture the right atrium continuously. The 20-cm diameter Gore-Tex official tract (10 cases) was selected, one end was anastomosed at the distal end of the inferior vena cava, and the other end was anastomosed to the lower edge of the right pulmonary artery. At the same time, the main pulmonary artery was ligated or the pulmonary artery was closed. The left superior vena cava remains in agreement with the left pulmonary artery. In the other case, the whole vena cava and the pulmonary artery were connected by a tube in the in-situ reel of the body pack. The free margin of the right atrial pericardium was cut into a rectangular *TT shape, which was close to the upper and lower ends of the base of the pericardium (near right pulmonary vein). The right pulmonary artery and the inferior vena cava are opened, and the free edge of the pericardium is rolled to the lower left (inner layer), and is connected with the base of the right atrial wall of the proximal pulmonary vein to form a tube with a diameter of about 1.6 cm. The lower pulmonary artery and the inferior vena cava are connected. Open the superior and inferior vena cava, empty the gas in the pipeline, gradually stop the extracorporeal assistance, and 1:1.5 protamine neutralizes heparin.
2 Results 182 (average 136) min, hemodynamic stability after shutdown, heart rate 7屮140min-1, sinus rhythm, blood pressure average 8~11kPa, central venous pressure 13~18kPa, postoperative patient upper body 45* lower limb 30 * Position, ventilator assisted 6 ~ 18h. Supplemented with small doses of dopamine 2 ~ 4, ug.min "kg 丨, sodium nitroprusside 0.5Mg.min-1.kg-1iv, appropriate supplementation of plasma or albumin. Patients with sable Disappeared, exercise endurance was obviously strong, percutaneous oxygen saturation increased from 65% to 85% to 9% to 96*, and the short-term effect was satisfactory. After 4 to 24 months of follow-up, the heart function was stable and there was no long-term death.
3 Discussion The treatment of total vena cava pulmonary artery as an effective surgical procedure for the treatment of complicated cyanotic complex congenital heart disease has become more and more widely used in clinical practice. It has expanded the indications of a series of improved Fontan surgery and achieved positive results.
3.1 surgical features of the previous in-situ barrier or tube-connected vena cava-arterial artery connection, although greatly improved the hemodynamics after Fontan, reducing the incidence of heart rhythm disorders (1), but the operation in the atrial complex, room Endocardial hypertension and intraventricular leakage can still affect cardiac endocrine and hemodynamics, and there are complications of advanced atrial flutter. The use of extracardiac total vena cava-arterial connection does not require changes in the anatomy of the heart chamber, avoiding exposure of the atrial tissue to the higher pressure systemic venous system. It has the following advantages: 1 The stenosis is only cut off, and the surgical operation is simpler. 2 does not destroy the structure of the heart, without intracardiac operation, has little effect on hemodynamic cardiac endocrine and cardiac function.
3 After the diversion, the blood flow is more straight, the energy consumption is less, the venous return is smooth, the cardiac load is obviously reduced, and the hemodynamic requirements are more in line. 4 intraoperative treatment of the superior vena cava away from the sinus node area, is not easy to hurt the sinus node and sinus node pressure, effectively reducing the incidence of chest exudation and late complications of atrial flutter. 6 In vitro parallel circulation does not block the ascending aorta, which is more conducive to myocardial protection and cardiac function. However, the biggest drawback of extracardiac total cavopulmonary connection is that the tube cannot grow with age, and the tube distortion and pseudomyxoma can cause pressure gradient or obstruction of the systemic circulatory system. Therefore, we use the in situ pericardial tube to connect the whole vena cava with the pulmonary artery, which greatly meets the requirements of future growth and development of the child, and has good histocompatibility, no anticoagulant therapy, no thromboembolism. Compared with the aforementioned artificial pipeline, the pericardial duct has poor pressure bearing property and the surgical operation is slightly complicated.
3.2 Surgical operation points 1 Fully free the common pulmonary artery and left and right pulmonary artery, if necessary, ligation and occlusion of the arterial catheter ligament, so that the pulmonary artery has greater mobility. At the same time, the superior and inferior vena cava were fully dissociated, and a right angle vein cannula was used, as far as possible from the proximal cannula. 2 After the superior vena cava is transected, the anastomosis between the distal and distal pulmonary arteries should be staggered as far as possible to prevent blood flow from escaping, and the anastomosis should be large enough. At present, most scholars advocate that the proximal end of the superior vena cava and the right lower edge of the right pulmonary artery should be biased to the right side as far as possible. The distal end of the superior vena cava and the superior edge of the right pulmonary artery are aligned to the left side. Postoperative vena cava angiography shows that the lungs can be better physiology. State of blood flow distribution. The anastomosis of this group was still near the left end of the vena cava, and the distal end of the heart was mainly to the right. 3 When clamping the right atrium wall of the inferior vena cava, the first assistant pulls the right atrium to the left and holds the right atrium to lengthen the inferior vena cava. The right lower jaw is more convenient to avoid damage to the atrioventricular sulcus. 4 Those who plan to use the self-pericardial tube should open the pericardium as far as possible to the left when opening the chest. The length of the upper and lower sides should be sufficient. The in-situ reel should be tightly sealed to prevent bleeding from the posterior wall. Due to the poor pressure bearing of the pipeline, the right pleural cavity can be opened normally and the chest drainage can be prevented to prevent the pericardial medial block from compressing the blood. 5 After the anastomosis is completed, the main pulmonary artery is placed in the blocking zone, and the main pulmonary artery is ligated according to the blood oxygen saturation and blood gas analysis. 6 All anastomotic stomas were sutured continuously with a 5~0 prolene line, and the anastomosis should be smooth to prevent tube distortion. 7 The intraoperative external flow stress should be stable, and the average perfusion pressure should be maintained at 6.6~8kPa (50~60mmHg) to prevent the heart from expanding. The central temperature can be controlled at around 36C. Stop the blood and enter the gel while giving ultrafiltration to remove excess water. Maintain a minimum central venous pressure required for stable hemodynamics and reduce chest exudation.
3.3 protein-losing enteropathy (PLE) occurred several weeks or even years after Fontan surgery, with progressive plasma protein loss (hypoproteinemia) as the main pathological feature, clinical manifestations of edema, ascites, A group of complications of abdominal discomfort and changes in bowel habits. This condition can occur even in children with a good hemodynamic status after surgery. There are very few clinical studies reported. At present, there are many hypotheses about its pathological mechanism, but none of them can confirm the causal relationship with PLE. Therefore, this means that PLE may be associated with a hemodynamic heterogeneous artery caused by physiological changes in a group of patients after Fontan surgery. Heart rhythm disorder 5 avoids the right atrial system | toe often related, and to! A form that is not known causes destruction of the integrity of the intestinal cells at the molecular level, resulting in leakage of plasma proteins into the intestinal lumen. The diagnosis of PLE is mainly based on clinical symptoms and laboratory tests. Plasma globulin should be higher than Q35g*L-1, and total protein level should be higher than 0.55g*L-1. To further determine the location of intestinal protein loss, blood samples can be taken. Collection of 24h stool line *a-1 anti-trypsin fecal filtration "Whitening enzyme is a protein present in blood and diarrhea. If PLE is present, the content in feces is significantly higher than blood content, suggesting that protein loss is passed. Intestinal faecal pathway. There is no universally accepted treatment for its treatment, which can be summarized as follows: (1) Improve the overall state through diuretic and dietary changes (addition of protein and foods rich in medium-chain triglycerides). Hormone or heparin is treated at the terminal target organ level. 3 Improve hemodynamics and apply drugs such as Kaibotong.
4 improved surgical approach, the use of total vena cava anastomosis or stenosis perforation improved Fontan surgery. 5 heart transplants. In short, the exact mechanism of PLE for selective pathogenesis is unclear and deserves further study. Once the pathological mechanism is well understood, there will be many effective treatments for this thorny disease. We have reported similar problems in the past. Exchange of experience. Article ID: 1000-2790(2000)12-1500-H Zhixie San apply umbilical treatment of 100 cases of infantile diarrhea Liang Yanzhen, Liu Yanying (Liaocheng Traditional Chinese Medicine Hospital Health Department, Liaocheng 252000, Shandong Province) Picture No.: R256.34: B 0 Introduction Diarrhea is the most common disease in children, especially in infants under 2 years of age. The younger the age, the higher the incidence and the more summer. In the fall. After a child is sick, he is afraid of injections, medications, and infusions, which brings some difficulties to treatment. At 12a, we used self-made diarrhea and sputum to treat diarrhea in infants and children, and the effect was good.
1 Subjects and methods 1.1 Subjects 1998-) 6/1999-10 Infant diarrhea peak incidence outpatient cases 100 (male 66, female 34) cases, age 2 months old -5 years old. There were 58 cases of enteritis and 42 cases of simple dyspepsia. 67 cases had been treated several times and 33 cases were newly diagnosed. All children who are treated will stop using other drugs.
1.2 Methods Drug composition: Sichuan pepper 12g, dried ginger 12g, cumin 12g, white peony 20g, Wujing 5g, èœ pull 12g, psyllium 12g. The above drugs are studied in proportion to the fine, bottling spare, all dialectical spleen dampness The diarrhea is treated with this medicine. Prepare a good amount of powder, less than 1 year old children, put the powder into the bag and apply the temperature to the umbilicus: children over 1 year old, put the fresh ginger juice into a paste, placed in the umbilicus, use, No PLE occurred in this group.
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