外科治疗的心血管疾病

外科治疗的心血管疾病,心外科DeptofCardiovascularSurgery席振山教授ProfessorXiZhenshan,一、先天性心脏病Congenitalheartdiseases1肺动脉狭窄(pulmonarystenosis),震颤(tremor)、杂音(murmur)：L2、SM、P2X线片(X-ray)：肺血少、右心大、肺动脉窄后扩张心电图(ECG)：肺型P、电轴右偏、右室肥大超声心动图(Echocardiography)心导管和心血管造影(cardiaccatheterizationandcardioangiography)CT的MRI显示肺动脉及其分支,治疗(treatment)闭式肺动脉瓣切开(closedpulmonaryvalvulotomy)直视肺动脉瓣切开(pulmonaryvalvulotomyunderdirectvision)常温或低温体外循环流出道梗阻解除2动脉导管未闭(PatentDuctusArteriosus),举例：动脉导管未闭(PDA)病理解剖(pathologicoanatomic)（图2）,血流动力学(hemodynamics)和临床表现分流量(shuntvolume)的多少取决：主-肺动脉压力差大小导管直径粗细肺血管阻力高低震颤(tremor)杂音(murmur)心电(ECG)X线片(X-ray)超声心动图(echocardiography)心导管及心血管造影(cardiaccatheterizationandcardioangiography),治疗(treatment)导管结扎(ductusligation)导管切断(ductusamputation)体外导管缝合(suture)胸腔镜导管闭合导管阻塞,3房间隔缺损(AtrialSeptalDefect)举例：房间隔缺损(ASD)病理解剖特点(pathologicoanatomic)（图3）,血流动力学(hemodynamics)和临床表现症状(signs)杂音(murmur)：L2、SM、P2X线片(X-ray)心电图(ECG)超声心动图(echocardiography)心导管及心血管造影(cardiaccatheterizationandcardioangiography),治疗低温阻断房间隔缝合深低温停循环房间隔修补体外循环房间隔缺损修补房间隔伞修补术4室间隔缺损(VentricularSeptalDefect)病理解剖特点(pathologicoanatomic)（图4）,血流动力学(hemodynamics)和临床表现震颤(tremor)、杂音(murmur)：L3、4SMX线片(X-ray)心电图(ECG)超声心动图(echocardiography)心导管及心血管造影(cardiaccatheterizationandcardioangiography),治疗深低温停循环室间隔缺损修补术体外循环室间隔缺损修补术,5法鲁氏四联症(TetralogyofFallot)病理解剖特点(pathologicoanatomic)（图5）,血流动力学(hemodynamics)和临床表现右向左分流杵状指（趾）clubbedfinger(toe)紫绀(cyanosis)杂音(murmur)X线片(X-ray),心电图(ECG)超声心动图(echocardiography)化验检查(laboratoryfindings)心导管及心血管造影(cardiaccatheterizationandcardioangiography)治疗分流术深低温停循环体外循环,二、后天性心脏病AcquiredHeartDiseases,（一）心包炎(pericarditis)1急性化脓性心包炎(acutepurulentpericarditis)2慢性缩窄性心包炎(chronicconstrictivepericarditis)（二）风湿性心脏病,1风湿性二尖瓣狭窄(rheumaticmitralstenosis)2风湿性二尖瓣关闭不全(rheumaticmitralinsufficiency)3主动脉瓣狭窄(aorticstenosis)4主动脉瓣关闭不全(aorticinsufficiency)5联合瓣膜病6三尖瓣病变(tricuspiddiseases),（三）冠状动脉硬化性心脏病(CoronaryHeartDisease)1左主干狭窄50%2三支以上血管明显狭窄70%3单支以上还有前降支严重狭窄90%,4心肌梗死后并发症(complicationsofmyocardialinfarction)室间隔穿孔(perforationofinterventricularseptum)乳头肌、腱索断裂(ruptureofpapillarymuscles,choradetendinca)二尖瓣关闭不全室壁瘤(ventricularaneurysm)室性心律紊乱(ventriculararrhythmias),（四）心肌病(cardiomyopathy)1扩张型心肌病(dilatedcardiomyopathy)2肥厚型心肌病(hypertrophiccardiomyopathy)3限制型心肌病(restrictivecardiomyopathy),三、心脏肿瘤(cardiactumors)（一）原发性心脏肿瘤(primary)1良性心脏肿瘤(benign)2恶性肿瘤(malignant)（二）转移瘤(metastatic)（三）主动脉瘤(aorticaneurysm),心内手术基础措施,一、体外循环（CPB,cardiopulmonarybypass)1、体外循环的定义：2、体外循环的组成：a血泵b氧合器c变温器d滤器e各种管道及插管,体外循环装置示意图,变温器,氧合器,血泵,过滤器,体外循环的施行,1、显露心脏2、肝素化（23mg/kg，ACT480-600s)3、建立各种管道4、体外循环5、心内直视手术6、鱼精蛋白中和7、拔出各种插管,体外循环后的生理变化,1、代谢改变：代酸或呼碱2、电解质失衡：低钾3、血液改变：贫血、凝血机制障碍4、肾、肺等器官功能的改变：肾衰、肺功不全。,体外循环后的处理,1、力求血液动力学稳定2、纠正酸碱失衡和电解质紊乱3、