摘要
目的分析法洛三联症矫正术后急性肺栓塞患者的临床资料,探讨该病的临床特点与诊断治疗。方法回顾性分析2017年5月解放军第九四医院心胸外科收治的1例成人法洛三联症矫正术后第5天发生急性肺栓塞患者的临床特点、治疗方法,并结合相关文献进行复习讨论。结果患者术后第5天突发胸前疼痛,进行性加重,呼吸心率增快,血压指脉氧进行性降低,立即查动脉血气分析、床边X线胸片、床边心电图辅助诊断,呼吸机辅助呼吸,前列地尔改善微循环等治疗,症状缓解后查CT肺动脉造影示右下肺基底干动脉栓塞,明确诊断后予强心利尿稳定心功能、抗凝、改善微循环、脏器支持等对症处理后最终痊愈出院。结论成人法洛三联症作为一类发绀型心脏病术后发生肺栓塞危险因素多,其临床表现与原有心脏疾病有较多共同点,易漏诊、误诊,快速明确诊断及早期对症治疗是提高患者生存率及预后的有效手段。
Objective To analyze the clinical data of patients with surgical correction of Trilogy of Fallot after acute pulmonary embolism( PE),to investigate the clinical characteristics and the diagnosis and treatment of the disease. Methods Retrospective analysis on one adult patient with Trilogy of Fallot from department of cardiothoracic surgery the Chinese PLA 94 th Hospital in May 2017 with occurrence of acute PE 5 days after surgery was done,the clinical characteristics,treatment and related literature were analyzed and discussed. Results On fifth days after surgery the patient bursted progressively aggravating outchest pain,breath and heart rate acclerating,progressive blood pressure,pulse oxygen decreasing,immediate check of the arterial blood gas,bedside chest X-ray,bedside electrocardiogram,ventilator assisted breathing,alprostadil treatment were given to improve microcirculation and relieve symptoms. Pulmonary artery CT revealed right inferior pulmonary basilar artery embolism. After clear diagnosis to stabilize cardiac function,cardiac diuretics,anticoagulation,microcirculation improving and organ support were given as symptomatic treatment which lead to complete recovery and discharge from hospital. Conclusion Adult Trilogy of Fallot as a kind of cyanotic heart disease has multiple risk factors of postoperative PE,and the clinical manifestations have more in common with the original heart disease,which may be easily misdiagnosed and missed diagnosed,therefore rapid diagnosis and early treatment is an effective way to improve the survival rate and prognosis of the patients.
引文
[1]中华医学会心血管病学分会肺血管病学组.急性肺栓塞诊断与治疗中国专家共识(2015)[J].中华心血管病杂志,2016,44(3):197-211.
[2]邓东安,侯传举.先天性心脏病影像诊断学[M].沈阳:辽宁科学技术出版社,1988:121-122.
[3]刘梦杰,徐红春.彩色超声多普勒对法洛三联症冠状静脉及肝静脉反流的分析[J].中华现代影像学杂志,2008,5(4):363.
[4]黄家驷.外科学[M].北京:人民卫生出版社,2008:2178-2179.
[5]钱伟民,张伟,王国祥.法洛三联症的外科治疗[J].徐州医学院学报,2002,22(2):168-169.
[6]万钧,翟振国,王辰.《2014欧洲心脏学会急性肺栓塞指南》解读[J].国际呼吸杂志,2015,35(24):1841-1845.
[7]马清艳,刘晖.肺栓塞的诊断现状及进展[J].国际呼吸杂志,2012,32(2):152-156.
[8]Wolfe TR,Allen TL.Syncope as an emergency department presentation of pulmonary embolism[J].J Emerg Med,1998,16(1):27-31.
[9]Cohen AT,Agnelli G,Anderson FA,et al.Venous thromboembolism(VTE)in Europe.The number of VTE events and associated morbidity and mortality[J].Thromb Haemost,2007,98(4):756-764.
[10]翁欣,傅强,巩传勇.外科术后急性肺血栓栓塞症的溶栓与抗凝治疗[J].中国危重病急救医学,2012,24(7):441-442.
[11]Chatterjee S,Chakraborty A,Weinberg I,et al.Thrombolysis for pulmonary embolism and risk of all-cause mortality,major bleeding,and intracranial hemorrhage:A meta-analysis[J].JAMA,2014,311(23):2414-2421.
[12]IL Wu,JC Tseng.Pulmonary embolism in a patient of tetralogy of Fallot:A diagnostic challenge[J].Am J Emerg Med,2015,33(6):865.e5.
[13]Torbicki A,Perrier A,Konstenfinides S,et al.Guidelines Oil the diagnosis and management of acute pulmonary embolism:the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology(ESC)[J].Eur Heart J,2008,29:2276-2315.
[14]汪雁博,蒋杏杏,范卫泽,等.成年人法洛四联症合并大面积肺栓塞一例报道并文献复习[J].中国全科医学,2017,20(8):1002-1004.
[15]Galie N,Palazzini M,Leci E,et al.Current therapeutic approaches to pulmonary arterial hypertension[J].Rev Esp Cardiol,2010,63:708-724.
[16]Ward JP,Mc Murtry IF.Mechanisms of hypoxic pulmonary vasoconstriction and their roles in pulmonary hypertension:New findings for an old problem[J].Curr Opin,Pharmacol,2009,9:287-296.
[17]徐莉莹,韩宏光,王辉山,等.复杂紫绀型先天性心脏病体-肺动脉分流术后早期并发症及处理措施[J].中国小儿急救医学,2016,23(1):49-52.
[18]王龙,林新宇,王丽娜,等.前列地尔联合高频振荡通气治疗新生儿持续肺动脉高压疗效分析[J].中国新生儿科杂志,2015,30(1):51-53.
[19]张红,宋全军.肺栓塞16例误诊分析中国医药指南[J].2017,15(3):61-62.
[20]王琳凌.心电图正常的急性心肌梗死临床分析[J].医药前沿,2015,5(14):209-210.
[21]Tierala I,Nikus KC,Sclarovsky S,et al.Predicting the culprit artery in acute ST-elevation myocardial infarction and introducing a new algorithm to predict infarct-related artery in inferior ST-elevation myocardial infarction:Correlation with coronary anatomy in the HAAMU Trial[J].J Electrocardiol,2009,42(2):120-127.
[22]张珉.心电图在急性肺栓塞诊断中的应用[J].中国实用医药,2017,12(16):62-63.
[23]Becattini C,Agnelli G,Vedovati MC,et al.Multidetector computed tomography for acute pulmonary embolism:Diagnosis and risk stratification in a single test[J].Eur Heart J,2011,32(13):1657-1663.
[24]徐磊,李军,秦英智,等.应用机械通气治疗急性肺栓塞的临床研究[J].中国危重病急救医学,2008,20(6):367-368.
[25]Gesuete V,Fabi M,Balducci A,et al.Pulmonary embolism in complex corrected congenital heart disease[J].G Ital Cardiol(Rome),2016,17(3):241-242.
[26]张雪萌,朱君荣,洪鲜花,等.心脏瓣膜置换者的二次开胸止血及抗凝的药学监护路径[J].药学与临床研究,2015,23(3):313-316.
[27]白雪洋,褚丽红.华法林治疗血栓性疾病的疗效分析[J].临床医药文献杂志,2016,3(29):5888-5889.
[28]Jacobs BN,Cain-Nielsen AH,Jakubus JL,et al.Unfractionated heparin versus low-molecular-weight heparin for venous thromboembolism prophylaxis in trauma[J].J Trauma Acute Care Surg,2017,83(1):151-158.
[29]Cullen S,Shore D,Redington A,et al.Characterization of right ventricular diastolic performance after complete repair of tetralogy of fallot:Restrictive physiology predicts slow postoperative recovery[J].Circulation,1995,91(6):1782-1789.
[30]徐莉莹,韩宏光,王辉山,等.复杂紫绀型先天性心脏病体-肺动脉分流术后早期并发症及处理措施[J].中国小儿急救医学,2016,23(1):49-52.
