Inofungidzirwa nguva yekuverenga: 10 Mineti
Zviri Mukati
- Zvinhu zvekufunga nezvazvo panguva yePre-Procedure Evaluation
- Kutungamirirwa kweSystolic Dysfunction
- Zviyero uye Sarudzo Yemudziyo muKuvharwa Kwepercutaneous
- Kushandiswa kweTTE uye TEE
- Postoperative Evaluation (Mushure mekuvharwa kwePDA)
- Hemodynamic Kuchinja
- Clinical Status yeMurwere
- Kurapa uye Kutevera
- Residual Flow uye Management
- Postoperative Matambudziko
BruceBlaus, CC BY-SA 4.0 https://creativecommons.org/licenses/by-sa/4.0, kuburikidza ne Wikimedia Commons
Kurapa kwekurapa kunoderedza uye kunofanira kushandiswa chete kudzikamisa varwere vane zviratidzo vasati vagadzirisa kupindira kana kune varwere vane kusagadzikana kwakanyanya munguva ye postoperative. Zvichienderana nekuoma uye rudzi rwepathophysiology, diuretics, vasodilators, positive inotropic agents, uye antiarrhythmics inofanira kushandiswa mumamiriro ezvinhu aya.
Definitive kurapwa kwePDA, kuvharwa kwe ductus arteriosusIyi nzira inoratidzwa mumhuka dzese dzine hemodynamically yakakosha kuruboshwe-ku-kurudyi shunt. Kwemakore akawanda, kuvhiyiwa ligation ndiyo chete sarudzo yekuvharwa kwePDA. Kana ikaitwa nevanovhiya vane ruzivo, kuvhiyiwa ligation kune kubudirira kwepamusoro. uye chiyero chayo chekunetseka chakaderera. Iyi nzira ichiri kushandiswa munzvimbo dzisina midziyo uye unyanzvi hunodiwa pakuvhara kwepercutaneous, pamwe chete nembwa duku uye katsi uye kune varwere vane mhando ye3 PDA pasina pulmonary stenosis (mamiriro asingabvumiri kugadzikana kwechigadzirwa).
PDA's kuvhara kwepercutaneous zve a Amplatz canine ductal occluder (ACDO) iri kushandiswa parizvino ndiyo nzira yekutanga inosarudzwa Iyi nzira yave ichishandiswa zvakanyanya pasi rose kwemakore akawanda. Kana ikaitwa navanachiremba vane ruzivo, nzira yacho inokurumidza, inoshanda, uye haina ngozi.
Kukanganisa kwepercutaneous maitiro mashoma uye anonyanya kuenderana nekukura kwemurwere. Kune imbwa dzakawanda dzinorema zvisingasviki 2 kg, iyo femoral artery idiki kwazvo kubvumira kuiswa kwevascular access device inodiwa pakuita.
Kuvhiya ligation hakuna kukodzera muimbwa diki nekatsi, diki vascular plugs kana "Off-label" kushandiswa kwemakoiri anodzorwa-anoburitswa Mamwe maitiro mashoma ekupindira anogoneka, akadai se: Inokwanisa kupfuura nepakati pe4 Fr delivery catheter Yakagadzirwa nenzira iyi.
Zvinhu zvekufunga nezvazvo panguva yePre-Procedure Evaluation
1. Clinical Status yeMurwere:
• Mamiriro ehutano hwemurwere uye kana hurongwa hwemwoyo wake hwakagadzikana hunoongororwa.
• Pathophysiological stage ve dhigirii yeanatomical uye inoshanda kugadzirisa kweiyo kuruboshwe ventricle (LV) inofanira kuongororwa.
2. Mamiriro Ezvinhu Anoda Kudzikamiswa:
• Congestive heart failure,
• Systolic dysfunction (kuderera kwesimba rekudonhedza kwemoyo),
• Arrhythmias (atrial fibrillation kana tachyarrhythmias).
Muzviitiko izvi, chirwere chemurwere chinofanira kugadzikana pamberi pekuita. Izvi zvinogona kuwanikwa nemishonga yemishonga (diuretics, inotropic agents, antiarrhythmic drugs).
3. Kunodiwa Imaging uye Diagnostic Examinations:
• Chifuva X-ray: Kuvapo kwekuwedzera kwemoyo (cardiomegaly) uye pulmonary edema inotariswa.
• Electrocardiogram (ECG): Inoshandiswa kuona moyo rhythm kusagadzikana.
• Transthoracic echocardiography (TTE): Inodiwa kuti uone chimiro chemoyo, saizi yePDA uye chiyero cheshunt.
Pulmonary edema zvakakodzera pamberi pekupindira kana kuvhiyiwa maitiro muvarwere vakaonekwa kugadzikana ne diuretic therapy inofanira kupihwa. Atrial fibrillation kana tachyarrhythmia pamberi pePDA isati yavharwa kurova kwemoyo uye rhythm control inofanira kupihwa.
Kutungamirirwa kweSystolic Dysfunction
Varwere vane systolic dysfunction vanoda kutarisirwa kwakakosha nekuda kwezvikonzero zvinotevera:
• Inotropic rutsigiro (kuwedzera simba rekusimbisa mwoyo),
• Vasodilator mishonga (kuderedza kumanikidzwa kwemoyo),
• Intraoperative uye perioperative monitoring (kuenderera mberi kwekutarisa panguva uye mushure mekuvhiyiwa).
Muvarwere ava, left ventricular (LV) vhoriyamu uye kunyanya kupera-systolic volume kazhinji yakakura kwazvo. Ejection fraction inoderera. S' wave ine low speed uye longitudinal deformation (strain) uye strain rate kuderedzainosimbisa kuvapo kwe systolic dysfunction.
MuImbwa dzine Normal Systolic Basa:
• Kana paine PDA uye yakachengetedzwa systolic basa, VTI (velocity time integral) ve aortic peak velocity inowedzera zvakaenzana kune shunt volume.
Zviratidzo zveSystolic Dysfunction:
• Kuwedzera kwekupedzisira-systolic volume,
• VTI uye aortic peak velocity inoramba yakaderera pane yakajairika kana yakajairika.
Zviyero uye Sarudzo Yemudziyo muKuvharwa Kwepercutaneous
munhu Amplatz canine ductus occluder (ACDO) Muchiitiko chekuvharwa kwepercutaneous kwePDA ne:
• MDD (Minimal Ductus Diameter): dhayamita iyi, duct membranes Chimiro ichi chinopimwa chete pamwero we transthoracic echocardiography (TTE) ile high-resolution probe inogona kuratidzwa nemazvo uchishandisa .
• Distal ampulla dhayamita: Iyi dhayamita inodiwa kuti usarudze saizi chaiyo yeocclusive mudziyo.
Kushandiswa kweTTE uye TEE
TTE (transthoracic echocardiography):
• TTE inoshandiswa pakuyera kwakarurama kweMDD (minimal duct diameter).
• Yakagadzirwa nepamusoro-soro probes uye yekuyera kwakarurama iyo acoustic hwindo yakakodzera anofanira.
TEE (transesophageal echocardiography):
• Kuvhara PDA neACDO TEE imaging inokosha zvikuru panguva
• TEE inoshandiswa kuyera nemazvo ukuru hwe ductus uye kutungamirira nzira.
• Chaiyo-nguva 3D TEE, ductus en-face maonero e pulmonary ostium Izvi zvinopa kuyerwa kwakaringana kwekusarudza mudziyo.
TEE Shandisa Chete:
• Kana mifananidzo yeTEE yakanaka zvakakwana, pasina kushandisa fluoroscopy (x-ray) nzira inogona kutungamirirwa chete neTEE.
• Zvisinei, Kusanganiswa kwe3D TEE uye fluoroscopyndiyo yakachengeteka uye yakarurama kwazvo sarudzo.
PDA yekuvhara maitiroinogona kuitwa nenzira mbiri dzekuvhiya uye dzepercutaneous. Percutaneous ACDO kuvharwaIyo inzira inosarudzika nekuda kwehuwandu hwekubudirira kwayo uye njodzi yakaderera yematambudziko. Pamberi pekuita uku, mamiriro emurwere anofanira kugadzikana. Chifuva X-ray, ECG, uye transthoracic echocardiography (TTE) zvinofanira kuitwa. Systolic dysfunction Inotropic rutsigiro uye intraoperative monitoring yakakosha kune varwere vane TTE uye TEE Kuyera kwakaringana kunofanira kutorwa, uye mudziyo wakasarudzwa unofanirwa kutariswa zvinoenderana. Iyi nzira inowanzobudirira mumbwa dzinorema kupfuura 2 kg.
Postoperative Evaluation (Mushure mekuvharwa kwePDA)
Kuvharwa kwePDA kunobvumira murwere kuti kamwe-kamwe kuchinja kwehemodynamic balance zvinokonzera. Systemic pressure inowedzera nekuvhara shunt uye iyi situation, reflex bradycardia nekukurudzira baroreceptors (chiratidzo chaNicoladoni-Branham) Izvi zvinowanzoita kuti pave nekuumbwa kwe mumadhamu makuru inova inooneka uye inogona kugara kwemaawa. Kunyanya migero mikuru ve systolic dysfunction Mune varwere vane bradycardia, kubuda kwemoyo kunogona kuderedzwa.
Hemodynamic Kuchinja
• Kuruboshwe ventricular (LV) afterload inowedzera, pulmonary flow uye LV preload normalize.
• Pamberi mu ventricle, iyo yakawedzerwa uye yakagadziridzwa kune yakakura kuzadza vhoriyamu, kuderera kamwe kamwe mukurodha, Inodzima iyo Starling maitiro.
• Izvi, Diastolic uye systolic mavhoriyamu eLV zvinokonzera kuderera uye kuderera kukuru kwechikamu che ejection (EF) zvinoitika.
• Muimbwa diki ve mumarudzi madiki, saizi ye ventricular yekuruboshwe inodzokera kune yakajairika nekukurumidza. Zvisinei, mumbwa huru kana mune avo vakavhiyiwa vakura, kugadzirisa kunoitika zvishoma nezvishoma uye mavhoriyamu eLV anoramba akakwidziridzwa kwenguva yakareba inogona kuramba yakakura kudarika yakajairika.
Clinical Status yeMurwere
• Varwere vane systolic basa rakachengetedzwa, idzi shanduko dzinowanzoshivirirwa zvakanaka.
• Mune varwere vane systolic dysfunction Kana iyo yeruboshwe ventricle-arterial connection yakakanganiswa, yekuruboshwe ventricle-arterial connection inogona kukanganiswa. Izvi zvinogona kutungamirira kumatambudziko akakomba anotevera:
• Fatal arrhythmias,
• Electromechanical dissociation (kutadza kushanda kwemagetsi emoyo kushandura kuita contraction).
Mune varwere vakadaro, mamiriro acho anofambira mberi mune imwe yenzira mbiri:
1. Kudzikamiswa nekusashanda zvine mwero: Murwere, hupenyu hwakanaka uye tarisiro yehupenyu vangave.
2. Kuwedzera kuipa: Mumamiriro ezvinhu aya, zviratidzo zvekukundikana kwemoyo, zvakakomba ventricular arrhythmias ve kufa kamwe kamwe njodzi inowedzera.
Kurapa uye Kutevera
• Vasodilators uye yakanaka inotropic mishonga, zvose panguva yekuvhiyiwa, naizvozvowo mune postoperative intensive care ve mukurapwa kwenguva refu inofanira kushandiswa.
• Varwere vane systolic dysfunction vanofanira kuramba vachiongororwa uye vachitsigirwa nemishonga iyi.
Residual Flow uye Management
• Residual kuyereraPachine zvishoma zvishoma zvekuyerera kweropa kuburikidza ne ductus mushure mokunge PDA yakavharwa.
• Doppler ultrasound inotariswa ne.
• Kana Mavhoriyamu eLV haadzoke shure mushure mekushanda kana kana iri kuwedzera,Izvi, kuvapo kwehemodynamically yakakosha shunt Muchiitiko ichi, kupindira kwechipiri kungave kwakakosha.
Kurapa Sarudzo:
• Kupindira kwekuvhara (Kushandiswa kweAmplatz canine ductus occluder (ACDO) kana coil)
• Kuvhiya ligation (Kunyanya Jackson-Henderson nzira na)
Residual flow inowanzoitika muPDA dzakavharwa nemakoiri zvichionekwa, Mukuvhara kwakaitwa neACDO Residual kuyerera kunowanzo kukonzerwa ne:
• Kumira zvisirizvo kwechishandiso (Izvi zvinowedzera njodzi yekuti mudziyo unozoburitswa gare gare).
• Chigadzirwa chacho chakanyanyisa (Munyaya iyi, kuyerera kunowanzomira nekufamba kwenguva).
• PDA kuvharwainzira inokonzera hemodynamic shanduko.
• Varwere vane systolic dysfunctioninogona kusangana nematambudziko akakomba senge arrhythmias uye kuderedzwa kwemoyo.
• Vasodilator uye inotropic therapy, inodiwa pakugadzikana kwevarwere vakadaro.
• Residual kuyerera zvinoitika, nzira yechipiri inogona kudiwa.
• Residual kuyerera mumakoiri maitiro yakawanda, Mukuvhara neACDO njodzi iyi yakaderera.
Ongororo iyi, Zvinonyanya kukosha kuve nechokwadi uye kutarisa kugadzikana kwemurwere mushure mekuvhiyiwa..
Postoperative Matambudziko
Kuvharwa kwePDA, kungave kuvhiyiwa kana percutaneous, kazhinji inzira yakachengeteka uye inoshandaChiyero chekukanganisa chakaderera, asi mune dzimwe nguva, matambudziko akakosha anogona kuitika.
1. Sepsis (Kutapukirwa)
• Postoperative sepsis Kashoma kuonekwa.
• Sepsis, munzvimbo yekuvhara zvinogona kuitika uye mamiriro aya anogona kuitika, munzvimbo ye ligation kana munzvimbo iyo mudziyo wekuvhara wakaiswa zvinogona kukonzera utachiona.
2. Embolization (Mudziyo Dislocation)
• Embolization yeAmplatz canine ductus occluder (ACDO) zvishandiso Kashoma kwazvo.
• Dambudziko iri rakaonekwa mune isingasviki 1% yezviitiko muchiitiko chemunyori.
• EmbolizationIzvi zvinoreva kuti mudziyo watama kubva mugomba uye kupinda muropa. Muchiitiko ichi, nzira yekupindira inogona kuwanzodiwa.
3. Ductus Rupture (Kubvarura)
• Kuputika kwe ductus, zvose panguva yekuvhiya ligation uye kashoma zvinogona kuitika panguva yepercutaneous maitiro.
• Ngozi yekubvaruka, kunyanya muma ducts ane dilated zvakanyanya kana aneurysmal ampullae yakakwirira.
• Kuputika panguva yekuvhiya ligation, Kazhinji kurutivi rworudyi lateral ye ductus zvinoitika. Izvi zvinowanzoitika panguva yekuiswa matinji zvinoitika.
Kupindira muNyaya yeDuctus Rupture
• Kumisa kubuda ropaVanachiremba vane ruzivo rwokuzviwanira vanoshandisa nzira dzokuvhiya kuti vamise kubuda ropa Vanoshandisa hemoclip (blood-stopper clip).
• Kuvharwa kwakasara patent ductusMuchiitiko ichi, kana ductus ichiri kuramba yakavhurika, mudziyo wekuvhara (semuenzaniso. ACDO) inogona kuvharwa ne.
• Nokuti, Jackson-Henderson nzira kana percutaneous interventional approach, mune zvakadaro anatomical zvimiro ndiyo nzira dzinodiwa.
4. Acute Aortic Dissection
• Dambudziko iri harisi nyore, asi mamiriro ezvinhu anotyisidzira upenyu.
• Aortic dissectioninogona kuitika mushure mekuvhara kwe ductus uye inogona kutungamirira kumigumisiro inouraya.
PDA kuvharwa inzira yakachengeteka ine yakaderera complication rate. Nekudaro, zvinotevera zvinonetsa zvinofanirwa kutariswa:
• Infection (sepsis): Kashoma uye kazhinji inokura pane ligation kana yekuvhara mudziyo saiti.
• Embolization (kubvisa mudziyo): Inoonekwa pamwero wepasi pe1%.
• Kuputika kwe ductus: Inogona kuitika kunyanya mune aneurysmal ducts uye panguva yekuvhiya ligation uye panguva yekupfuura kwesutures. Muchiitiko ichi, hemoclip application ve Kuvhara neACDO kupindira kunoitwa nenzira dzakadai se.
• Acute aortic dissection: Chinhu chisingawanzoitiki asi chinogona kuuraya.
Zvizhinji zvematambudziko aya, inogona kutarisirwa zvinobudirira nevavhiyi vane ruzivo uye nyanzvi dzekupindira. Kunyanya Jackson-Henderson nzira ve percutaneous kuvhara maitiro, kumira senzira dzakachengeteka kune varwere vane ngozi yakawanda yekuparara kweductal.
Zvimwe Zvinyorwa Zvaunogona Kufarira
"Mufaro ndicho chinhu choga chinowanza kana uchigoverwa."
Albert Schweitzer
