心血管外科疾病

心血管外科疾病

先心病外科冠心病外科

瓣膜病外科

主動(dòng)脈及大血管外科

微創(chuàng)心臟外科

體外循環(huán)

心臟移植Heart先心病外科

發(fā)病率約為7‰左右現(xiàn)存先心病約150萬，據(jù)報(bào)道每年出生的新生兒有近20萬先心??；先心病手術(shù)約占心臟手術(shù)總數(shù)的60～65%

如果不及時(shí)治療，20～60％會(huì)在一年之內(nèi)自然死亡，其中30％會(huì)在新生兒期死亡。先心病外科動(dòng)脈導(dǎo)管未閉（PDA）（左向右分流）肺動(dòng)脈口狹窄（PS）房間隔缺損（ASD）（左向右分流）室間隔缺損（VSD）（左向右分流）主動(dòng)脈縮窄主動(dòng)脈竇瘤破裂（左向右分流）法洛四聯(lián)癥（TetralogyofFallot）（紫紺型）先心病外科

發(fā)展方向嬰幼兒和新生兒復(fù)雜畸形矯治簡(jiǎn)單先心病的微創(chuàng)化

動(dòng)脈導(dǎo)管未閉胎兒期連接主動(dòng)脈峽部及左肺動(dòng)脈根部的生理性血流通道（動(dòng)脈導(dǎo)管）未閉合。管型；窗型；漏斗型體肺循環(huán)分流：肺動(dòng)脈壓力增高

Eisenmengersyndrome臨床表現(xiàn)：癥狀：無明顯癥狀-充血性心衰癥狀-差異性發(fā)紺體征：雜音（L2連續(xù)機(jī)器樣雜音）-震顫輔助檢查：ECGX-ray（肺血情況）

UCG

右心導(dǎo)管

動(dòng)脈導(dǎo)管未閉

動(dòng)脈導(dǎo)管未閉治療：手術(shù)適應(yīng)癥；禁忌癥經(jīng)胸腔結(jié)扎、縫閉、切斷縫合導(dǎo)管封堵體外循環(huán)下結(jié)扎、縫閉

肺動(dòng)脈狹窄右心室和肺動(dòng)脈之間存在的先天性狹窄畸形。肺動(dòng)脈瓣膜；右室漏斗部；肺動(dòng)脈瓣環(huán)、主干及分支輕度：壓差<40mmHg中度：40-100重度：>100mmHG臨床表現(xiàn)：癥狀：右心衰表現(xiàn)體征：雜音（L2噴射樣收縮期雜音）-震顫；P2減弱輔助檢查：ECGX-ray（肺血情況）

UCG

右心導(dǎo)管

肺動(dòng)脈狹窄

肺動(dòng)脈狹窄治療：手術(shù)適應(yīng)癥：中度以上狹窄肺動(dòng)脈瓣球囊擴(kuò)張?bào)w外循環(huán)下心內(nèi)直視手術(shù)

房間隔缺損心房間隔發(fā)育不全導(dǎo)致的左右心房間異常交通。原發(fā)孔房缺（心內(nèi)膜墊缺損）；繼發(fā)孔房缺：中央；上腔；下腔；混合左向右分流；肺動(dòng)脈高壓臨床表現(xiàn)：癥狀：分流量；心功能不全表現(xiàn)；房顫體征：雜音（L2-3吹風(fēng)樣收縮期雜音）-震顫；P2亢進(jìn)分裂輔助檢查：ECGX-ray（肺血情況）

UCG

右心導(dǎo)管房間隔缺損房間隔缺損治療：手術(shù)適應(yīng)癥；禁忌癥封堵體外循環(huán)下心內(nèi)直視手術(shù)

室間隔缺損心室間隔發(fā)育不全導(dǎo)致的左右心室間異常交通。膜部；漏斗部；肌部左向右分流；肺動(dòng)脈高壓；感染性心內(nèi)膜炎臨床表現(xiàn)：癥狀：分流量；心功能不全表現(xiàn)；SBE體征：雜音（L2-4粗糙響亮收縮期雜音）-震顫；P2亢進(jìn)分裂輔助檢查：ECGX-ray（肺血情況）

UCG

右心導(dǎo)管室間隔缺損室間隔缺損治療：手術(shù)適應(yīng)癥：缺損大小，合并癥禁忌癥

封堵體外循環(huán)下心內(nèi)直視手術(shù)主動(dòng)脈縮窄降主動(dòng)脈起始部先天性狹窄導(dǎo)管前型；導(dǎo)管后型近端壓力增高，左室負(fù)荷加重遠(yuǎn)端缺血側(cè)枝循環(huán)：差異性發(fā)紺/動(dòng)脈瘤臨床表現(xiàn)：癥狀：上身高血壓，下身缺血體征：上下肢血壓；雜音（L2-3噴射性收縮期雜音）；差異性發(fā)紺輔助檢查：ECGX-ray（肺血情況）

UCGCTA；MR；主動(dòng)脈造影主動(dòng)脈縮窄主動(dòng)脈縮窄治療：手術(shù)適應(yīng)癥：上下肢動(dòng)脈收縮壓差>50mmHg，狹窄>50%，上肢動(dòng)脈收縮壓>150mmHg；合并癥；4-6Y

禁忌癥

球囊擴(kuò)張血管重建、成形、移植主動(dòng)脈竇瘤破裂右冠竇-右室；無冠竇-右房阻礙右室流出道血流左向右分流冠脈竊血臨床表現(xiàn)：癥狀：病史或誘因；右心衰，病情可較急體征：雜音（右室：L3-4收縮中期增強(qiáng)的連續(xù)機(jī)器樣雜音）；周圍血管征；右心衰表現(xiàn)輔助檢查：ECGX-ray（肺血情況）

UCG

主動(dòng)脈造影主動(dòng)脈竇瘤破裂主動(dòng)脈竇瘤破裂治療：手術(shù)適應(yīng)癥：限期手術(shù)

體外循環(huán)下心內(nèi)直視手術(shù)

法洛四聯(lián)癥右室漏斗部或圓錐發(fā)育不良所致，具有特征性肺動(dòng)脈口狹窄和室缺。肺動(dòng)脈狹窄-室間隔缺損（基礎(chǔ)）：左右心室收縮壓峰值相等心內(nèi)分流情況肺血流減少慢性缺氧

臨床表現(xiàn)：癥狀：發(fā)紺；喜蹲踞；缺氧體征：紫紺，杵狀指；雜音（L2-4噴射性收縮期雜音）；P2減弱或消失輔助檢查：ECGX-ray（肺血情況）

UCG

右心導(dǎo)管法洛四聯(lián)癥法洛四聯(lián)癥

法洛四聯(lián)癥10%(紫紺性50-90%)

年齡1歲左右術(shù)式根治手術(shù)；姑息手術(shù)適應(yīng)證LVDEV>30ml/m2McGoon>1.2NaKada>150

死亡率早期2.5%

晚期2~6%后天性心臟病心臟瓣膜病冠心病心包疾病心臟腫瘤HeartValvularDiseasesAnatomyofheartvalves(1)

Thereare4valvesintheheart:

TricuspidvalvePulmonaryvalveMitralvalveAorticvalve

二尖瓣(Mirtral)狹窄(Stenosis)三尖瓣(Tricuspid)主動(dòng)脈瓣(Aortic)關(guān)閉不全(Incompetence)肺動(dòng)脈瓣(Pulmonary)

心臟瓣膜（Valves）病變（Disease）HeartValves

MitralStenosis

Rheumaticfevercausesmitralstenosisin95%ofcasesRheumaticfeverisaninflammatorydisease.Developafteraninfectionwitbacteria

Streptococcus

pharyngitis(suchasstrepthroatorscarletfever).Thediseasecanaffecttheheart,joints,skin,andbrain.Incidencerate(RHDs)inCHINA

2.5million

Normalmitralorificearea:

(4~6cm2)(3cm2/m2BSA)Lessthan2.0cm2mildstenosis1.5cm2

moderatestenosis1.0cm2

severestenosis

Mitralcomplexbecomesarigidfunal-shapedstructure(fish-mouthopening)Pathologyofheartvalves

HeartValveCalcificationCalciumusuallydepositedinclumpsonvalveleafletsHeaviercalcificdepositsinmenthanwomenClinicalFeaturesHeartpalpitation

－Increaseswithactivity,decreaseswithrest

Cough,possiblybloody,hemoptysis

orwheezingDifficultybreathingShortnessofbreath,duringorafterexerciseorwhenlyingflatFatigue,tiredeasily,weakness,dizzinessFrequentrespiratoryinfectionssuchasbronchitis

Swellingoffeet,anklesorabdomenHeartmurmurdiastolic

murmuratthecardiac

apexComplications

Arrhythmia(Atrialfibrillation,AF)Emboli(migrationofclot)totheintestines,kidneys,orotherareasPulmonaryedema/hypertension

Right-sidedheartfailure

右心衰、腹水全心衰二尖瓣面容DiagnostictestsEchocardiogram(UCG).ChestX-ray.

Electrocardiogram(ECG).

Cardiaccatheterization.

“梨形心”“二尖瓣型P波”UCGMitralRegurgitation

Differenceinheartsize–MSandMR

AorticStenosis

AorticStenosisClinicalTriad

ChestpainSOBSyncopeSyncopeSOBChest

painAorticRegurgitationSurgicalTreatment

OperativeIndications

Heartfunction(NYHAclassIIorgreater)Atrialfibrillation(independentofsymptoms)Embolization

(leftatrialappendage/systemicembolization)

PulmonaryhypertensionLeftventricledilatation(LVED>70mm)forARInfectiveendocarditisOperativeMethodsReplacementofheartvalveValvuloplastyHeartIntervention(valvedilatation)Surgicaltreatment(1)Heartvalvereplacement

Removethenarrowedmitralvalveandreplaceitwithamechanicalvalveoratissuevalvefromapig,coworhuman-cadaverdonor.Surgicaltreatment(2)

ValvuloplastyRepairValveCutting,remodelingCommissurotomyInsertprostheticringsInterventionaltreatment(3)Balloonvalvuloplasty

Usesasoft,thintube(catheter)tippedwithaballoon.Acatheterthroughabloodvessel(elboworgroin)totheheartandintothenarrowedvalve.Onceinposition,aballoonatthetipofthecatheterisinflatedtoopenthenarrowedvalveandstretchesthevalveopening,thendeflatedandguidedbackoutofthebody.IdealReplacementHeartValvePropertiesShouldnotblockbloodflowClosespromptlyandcompletelyNonthrombogenicResistsinfectionLastforalongtimeEasytoimplantpermanentlyPleasingtopatient(noisefree)MechanicalHeartValves

BiologicalHeartValvesSurgicalProcedure(1)GeneralanesthesiaMidlineincisioninsternumCannulationofaortaandbigveinsReroutingbloodfromhearttoH-Lmachine,bumpbloodthroughthebodyandloaditwithoxygen(ExtracorporealCirculation)SurgicalProcedure(2)Heartarrest(hypothermia/cardioplegicsolution)Damagedvalveisrepairedorremovedandreplacedwithnewartificialvalve.RestarttheheartBloodgetsgobacktotheheartagain.ClosechestincisionTransfertoIntensitiveCareUnite(ICU)冠心病外科

冠狀動(dòng)脈旁路移植術(shù)(CABG)

非體外循環(huán)冠狀動(dòng)脈旁路移植術(shù)

(OPCAB)冠心病冠狀動(dòng)脈粥樣硬化心肌氧供：需求>供應(yīng)臨床表現(xiàn)：心絞痛-心梗-室壁瘤/二尖瓣返流輔助檢查：ECG

心肌酶冠脈造影冠心病冠心病治療：搭橋：心絞痛經(jīng)內(nèi)科治療不緩解，主干或主要分支重度狹窄（LM、LAD），合并LCX、RCA兩支以上狹窄。遠(yuǎn)端血流通暢。

合并癥的處理

冠心病外科

OPCAB手術(shù)方法正中切口OPCAB

小切口冠狀動(dòng)脈搭橋術(shù)

(MIDCAB或LICAB)

胸腔鏡輔助下的冠狀動(dòng)脈搭橋術(shù)機(jī)器人輔助冠狀動(dòng)脈搭橋術(shù)冠心病外科

全動(dòng)脈化CABG

左側(cè)乳內(nèi)動(dòng)脈右側(cè)乳內(nèi)動(dòng)脈橈動(dòng)脈胃網(wǎng)膜動(dòng)脈冠心病外科

合并巨大室壁瘤容積大于左心室容積的50%

積極手術(shù)治療恢復(fù)左心室的幾何形狀縮窄性心包炎心包的慢性炎癥病變所致心包增厚、粘連、鈣化，使心臟的舒縮功能受限，心功能減退，循環(huán)障礙。結(jié)核；細(xì)菌；纖維素沉積臨床表現(xiàn)：重度右心功能不全輔助檢查：ECGX-ray，CT，MRUCG

右心導(dǎo)管縮窄性心包炎縮窄性心包炎治療：心包剝脫：順序范圍

主動(dòng)脈及大血管外科胸主動(dòng)脈瘤主動(dòng)脈壁擴(kuò)張或膨出，達(dá)到正常管徑的1.5倍以上。病因：局部；全身部位：升主動(dòng)脈；弓部；降主動(dòng)脈；胸腹病理：真性；假性臨床表現(xiàn)：與發(fā)病急緩、位置、大小有關(guān)；壓迫癥狀輔助檢查：UCGX-rayCTA

主動(dòng)脈造影胸主動(dòng)脈瘤胸主動(dòng)脈瘤

手術(shù)：壓迫癥狀；瘤體直徑>5cm；增長>1cm/年