七年制医学课件 专外 24心脏病的外科治疗（中英）

心脏病的外科治疗心脏病的外科治疗 CardiacsurgeryCardiacsurgery 第一临床学院心胸外科教研室第一临床学院心胸外科教研室 Dept. of Dept. of CardiothoraxCardiothorax, First Clinic , First Clinic CollegyCollegy 副教授副教授 硕士导师硕士导师 Associate Professor Master TutorAssociate Professor Master Tutor 向小勇向小勇 Xiang Xiang XiaoYongXiaoYong overviewoverview 概述 概述 1:classification1:classification 分类分类 2:anatome2:anatome 解剖解剖 3:Hemodynamic mechanism3:Hemodynamic mechanism 血流动力学机制血流动力学机制 4:Purpor of 4:Purpor of cardiacsurgerycardiacsurgery 心脏外科的目的心脏外科的目的 classification classification . . 分类分类 Heart diseaseHeart disease： 紫绀型紫绀型 cyanosis cyanosis ：F F 4 4 先天性先天性 congenital congenital 左向右分流左向右分流 LR shunt ASD,VSD,PDA LR shunt ASD,VSD,PDA 非紫绀型非紫绀型 non-cyanosisnon-cyanosis 无分流无分流 no shuntno shunt：PSPS 后天性后天性 Acquired: Acquired: 风湿性心瓣膜病风湿性心瓣膜病 rheumatic valve diseaserheumatic valve disease 缩窄性心包炎缩窄性心包炎 constrictive constrictive pericarditispericarditis 冠心病冠心病 coronary heart diseasecoronary heart disease 2:anatomy2:anatomy 解剖解剖 两动脉两动脉 two arteriestwo arteries 两两静脉静脉 two veinstwo veins 四瓣膜四瓣膜 four valvesfour valves 四腔室四腔室 four chambersfour chambers 瓣膜解剖瓣膜解剖 MitrialMitrial, , tricuspid tricuspid aortic aortic pulmonarypulmonary 房室及瓣膜解剖房室及瓣膜解剖 AtriumAtrium ventricleventricle AortaAorta Pulmonary .APulmonary .A Super (inferior)Super (inferior) venous cavavenous cava SVC IVCSVC IVC 3:3: hemodynamic mechanisms 血流动力学机制血流动力学机制 瓣膜开放、关闭瓣膜开放、关闭 valve open or closevalve open or close 血流方向血流方向 Blood stream directionBlood stream direction 腔室完整腔室完整 chambers intactchambers intact 心肌收缩心肌收缩 myocardium contractionmyocardium contraction 动动 力力motilitymotility 心肌舒张心肌舒张 myocardium relaxmyocardium relax (1):To restore myocardial motility (1):To restore myocardial motility 恢复心肌动力恢复心肌动力 (2):To correct (2):To correct hemodynamichemodynamic disorder disorder 纠正血流动力学紊乱纠正血流动力学紊乱 4: 4: PurporPurpor of of cardiacsurgerycardiacsurgery The surgical The surgical treatment of treatment of congenital heart congenital heart diseasedisease 先天性心脏病的外科治疗先天性心脏病的外科治疗 overview 1:Incidence rate 1% ;(发病率) 2:Etiology not clear;(病因) 3:Severe patients may die of recurent respiratory infection or heart failure in their infancy; mild patients may be troubled in their growth and development, or school and employment(重者在婴幼儿期可因呼吸道反复感染或心衰而死亡,轻者影响生长发育 ，升学业) 4:Surgery is the only treatment;(手术治疗是唯一治疗方法) 5:severe patients treated in infancy, mild befor school; (重症患者应在婴幼儿期早期手术；轻者一般在学龄前手术) 6:Surgery effects satisfactory: early treatment, benefit for all life.(手术治疗效果良好：早期手术，终身受益)。 Patent Ductus Arteriosus PDAPDA 动脉导管未闭动脉导管未闭 patent ductus arteriosus PDAPDA动脉导管未闭动脉导管未闭 PathoPatho-anatomy:-anatomy: PDA is located between PDA is located between descending aorta and L descending aorta and L pulmonarypulmonary PDAPDA位于降主动脉与左肺动脉根部之间位于降主动脉与左肺动脉根部之间 Form :分型： 1, Tube 管状 2, infundibular 漏斗状 3, Window 窗状 PDA PDA PathophysiologyPDA Pathophysiology 病理生理病理生理 pulmonary circulation PHpulmonary circulation PH 肺循环量肺循环量 肺动脉高压肺动脉高压 EisenmengerEisenmenger综合征综合征 血流由主动脉分流入肺动脉血流由主动脉分流入肺动脉 aortaaorta pulmonary.A.pulmonary.A. Shunt Shunt L L ventricle output ventricle output L L ventricle enlarged ventricle enlarged 左心排量左心排量 左心增大左心增大 左心衰左心衰L V failureL V failure 动脉灌注减少动脉灌注减少-影响生长发育影响生长发育 心内膜炎心内膜炎endocarditisendocarditis artery perfusion growth developmentartery perfusion growth development Atery perfusion development affected 动脉灌注 影响发育 PDAPDA operation indicationoperation indication: : 手术适应症：手术适应症： all indicatedall indicated, , 原则上均应手术原则上均应手术 optimal age:6-14yoptimal age:6-14y, , 最适年龄最适年龄6 61414岁岁 Operation Operation contraindication: contraindication: 手术禁忌症手术禁忌症 EisenmengerEisenmenger综合征综合征 PDAPDA operation methods:operation methods:手术方法手术方法 ligation ligation 结扎结扎法法 division+suture division+suture 切断缝合法切断缝合法 Suturing through PA under CPB;Suturing through PA under CPB; 体循下肺动脉内缝合法体循下肺动脉内缝合法 transcatheter closure of PDAtranscatheter closure of PDA 经心导管PDA栓堵法栓堵法 Ligation of the ductusLigation of the ductus L. thoracotomyL. thoracotomy 左胸后左胸后外侧外侧切口切口 动脉导管结扎术动脉导管结扎术 Dissection of theductusDissection of theductus 动脉导管结扎术动脉导管结扎术 Ligation of the ductusLigation of the ductus Division and suture of the ductusDivision and suture of the ductus 动脉导管离断缝扎术动脉导管离断缝扎术 Division of the ductusDivision of the ductus 体外体外循环下加片修补动脉导管循环下加片修补动脉导管 Closure of the ductus with a patch under CPBClosure of the ductus with a patch under CPB transcatheter closure of PDAtranscatheter closure of PDA transcatheter closure of ductustranscatheter closure of ductus 体外体外循环术后监护循环术后监护 Pulmonary Stenosis 肺动脉口狭窄肺动脉口狭窄 pulmonary stenosis 肺动脉口狭窄肺动脉口狭窄 Patho-anatomePatho-anatome: : 1, 1, Valve Valve stenosis 瓣膜狭窄瓣膜狭窄 2, Infundibulum stenosis 漏斗部狭窄漏斗部狭窄 3 , pulmonary trunk stenosis 肺动脉干窄肺动脉干窄 pulmonary stenosis 肺动脉口狭窄肺动脉口狭窄 PathophysiologyPathophysiology : : Moderate serious Moderate serious stenosis resistance Loading of RV RV failure; failure; blood blood stasis; stasis; LV LV output output decreased.decreased. 中重度狭窄中重度狭窄 右心阻力负荷右心阻力负荷右心右心 衰衰 瘀血瘀血 左心排量减少左心排量减少 pulmonary stenosis 肺动脉口狭窄 肺动脉口狭窄 operation operation indicationindication 手术适应症手术适应症 mild constriction,mild constriction, Symptomless,no heart patho- Changes,no need of operation. 轻度狭窄，无症状，无心脏改变者不需手术。轻度狭窄，无症状，无心脏改变者不需手术。 Moderateserious Moderateserious constriction; hypertrophty of right heart; trans-valve pressure differences over 60mmHg,should be operated.中重度狭窄，右心肥大，收缩期肺中重度狭窄，右心肥大，收缩期肺 动脉跨瓣压差大于动脉跨瓣压差大于6060mmHgmmHg者，应手术者，应手术. . operation Methods under CPB: 1,Sectioning of the constricted valve; 2, clearing out the constricted infundibulum; 3, widening of the out tract with a patch; 体循下体循下 切开狭窄瓣膜切开狭窄瓣膜 漏斗部疏通漏斗部疏通 补片加宽补片加宽 pulmonary stenosis 肺动脉口狭窄肺动脉口狭窄 肺动脉瓣狭窄切开肺动脉瓣狭窄切开 Sectioning of the constricted valve; 肺动脉瓣狭窄切开肺动脉瓣狭窄切开 clearing out the constricted infundibulum widening of the out tract with a patch; widening of the out tract with a patch; Atrial Septal Defect ASDASD 房间隔缺损 房间隔缺损 atrial septal defectASDASD房间隔缺损 房间隔缺损 PathoPatho- -anatomeanatome: : secundumASDsecundumASD positioned at rear up of Coronary venous sinus orifice . . 继发孔型继发孔型ASDASD位于冠状静脉窦开口的后上方位于冠状静脉窦开口的后上方 Form:Form: Oval fossa typetype 圆孔卵型圆孔卵型 SVC type SVC type 上腔型上腔型 IVC type IVC type 下腔型下腔型 房缺分型房缺分型 ASD form ASD autopsy （尸检） Atrial Septal Aefect ASD ASD 房间隔缺损 房间隔缺损 PathophysiologyPathophysiology: : L atriumR atrium shunt L atriumR atrium shunt pulmonary circulation pulmonary circulation PH PH 左房向右房分流左房向右房分流 肺循环量肺循环量 肺动脉高压肺动脉高压 EisenmengerEisenmenger RV loading RV loading RH failure RH failure 右室负荷右室负荷 右心衰右心衰 房缺：右室增大、肺充血房缺：右室增大、肺充血 pulmonary circulation RV enlargedpulmonary circulation RV enlarged atrial septal defectASDASD房间隔缺损 房间隔缺损 Operation indication:Operation indication: 1, In principle,all deed operation; 原则上均应手术原则上均应手术 2,Small ASD(diameter50%, stenosis 50%, 狭窄超过狭窄超过50%50% distal run-off good, distal run-off good, 远端血流通畅远端血流通畅 Diameter of the vessel for anastomosis 1.5mm; Diameter of the vessel for anastomosis 1.5mm; 、 供吻合处冠脉直径供吻合处冠脉直径1.5mm1.5mm以上以上 suitable for bypasssuitable for bypass 适宜搭桥手术。适宜搭桥手术。 CHD pre-operative evaluation:CHD pre-operative evaluation: 术前估价术前估价 2, Left ventriculograpy and LV cardiac function test:2, Left ventriculograpy and LV cardiac function test: 左室造影及左心功能测定左室造影及左心功能测定 LV cardiac function well, LV cardiac function well, 左室功能较好左室功能较好 EF(EF(ejection fraction ) 30%, 30%, EFEF大于大于30%30% suitable for surgery.suitable for surgery. 适宜手术。适宜手术。 CHD pre-operative evaluation:CHD pre-operative evaluation: 术前估价术前估价 右冠造影右冠造影 coronary arteriography: 左冠造影左冠造影 coronary arteriography: 右冠右冠造影造影 左冠左冠造影造影 左室左室造影造影 Left ventriculograpyLeft ventriculograpy operation method:operation method: coronary artery bypass grafting;CABG 1:Aorto 1:Aorto-coronary -coronary saphenous saphenous vein vein bypassbypass 2:Internal mammary artery to coronary artery bypass 2:Internal mammary artery to coronary artery bypass 3:Sequential anastomosis 3:Sequential anastomosis 贯序吻合术贯序吻合术 冠状动脉搭桥术冠状动脉搭桥术 升主动脉升主动脉 冠状动脉的大隐静脉旁路移植术冠状动脉的大隐静脉旁路移植术 胸廓内动脉远段与左冠状动脉吻合术胸廓内动脉远段与左冠状动脉吻合术 surgical treatment of coronary heart diseasesurgical treatment of coronary heart disease operationoperation effect effect: satisfactory: satisfactory 90 90% % patients: patients: symptom symptom( angina) ( angina) relieved; relieved; cardiac cardiac function function improved;improved; return return to work to work, life, life prolonged. prolonged. operation death rate: 1%. 手术效果：术后手术效果：术后90%90%病人症状消失，心功能改善，恢复工作，生命延长，手术死亡率病人症状消失，心功能改善，恢复工作，生命延长，手术死亡率 1%1%左右左右 coronary artery bypass grafting;CABG Aorto-coronary saphenous vein bypass Aorto-coronary saphenous vein bypass