Ziemer G, Karck M, Müller H, Luhmer I
Division of Thoracic Surgery, Children's Hospital, Hannover Medical School, FRG.
Eur J Cardiothorac Surg. 1992;6(2):91-5. doi: 10.1016/1010-7940(92)90081-8.
Chest closure after cardiac surgery occasionally results in cardiac compression leading to circulatory failure. In shunt-dependent circulation, the arterial oxygen saturation may decrease significantly due to the increase in pulmonary vascular resistance caused by chest closure. Temporary patch implantation with delayed sternal closure facilitates circulatory and/or pulmonary stabilization (temporary chest wall patch plasty, TCWPP). Between July 1986 and June 1991, 42 patients underwent staged chest closure (TCWPP) after open heart surgery for congenital lesions (4.9% of 854 patients). TCWPP was performed when either primary hemodynamic deterioration or an increase in cyanosis (palliative procedures only) followed by hemodynamic deterioration occurred during attempted or shortly after sternal closure. Overall mortality was 40.4% (17/42). It was 32.3% (11/34) when the patch was inserted primarily at the end of the operation. If the patch was inserted emergently 4-24 h postoperatively, mortality was 75% (6/8). Definite chest closure was performed from 4 h to 6 days (mean 72 h) postoperatively. In 2 patients closure had to be performed emergently (single ventricles); 7 patients died before chest closure. One mediastinal microbiology examination was positive. Deep sternal infection necessitating operative revision occurred in one other patient. In conclusion, TCWPP may considerably lower mortality of the illest patients after surgery for complex congenital heart disease. A timely decision as to the performance of staged chest closure is mandatory. This procedure rarely causes infection. We now apply this technique liberally, by cardio-mediastinal size judgement in over 30% of our TCWPP candidates even without a prior trial of primary closure.
心脏手术后关闭胸腔偶尔会导致心脏受压，进而引发循环衰竭。在依赖分流的循环中，由于关闭胸腔导致肺血管阻力增加，动脉血氧饱和度可能会显著下降。植入临时补片并延迟胸骨关闭有助于循环和/或肺部稳定（临时胸壁补片成形术，TCWPP）。1986年7月至1991年6月期间，42例患者在接受先天性病变的心脏直视手术后接受了分期胸腔关闭术（TCWPP）（占854例患者的4.9%）。当在尝试胸骨关闭期间或之后不久出现原发性血流动力学恶化或紫绀加重（仅姑息性手术）并伴有血流动力学恶化时，进行TCWPP。总体死亡率为40.4%（17/42）。当补片主要在手术结束时插入时，死亡率为32.3%（11/34）。如果在术后4 - 24小时紧急插入补片，死亡率为75%（6/8）。术后4小时至6天（平均72小时）进行确定性胸腔关闭。2例患者必须紧急进行关闭（单心室）；7例患者在胸腔关闭前死亡。一次纵隔微生物学检查呈阳性。另一名患者发生了需要手术翻修的深部胸骨感染。总之，TCWPP可能会显著降低复杂先天性心脏病手术后病情最严重患者的死亡率。必须及时决定是否进行分期胸腔关闭。该手术很少引起感染。我们现在在超过30%的TCWPP候选患者中，通过心脏纵隔大小判断，即使没有事先尝试一期关闭，也广泛应用该技术。
