浅低温体外循环心脏不停跳心内直视手术2962例临床研究(1)
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【摘要】 目的 总结浅低温体外循环不停跳心内直视手术的方法和经验。方法 并行循环，不阻断升主动脉，不灌注心脏停搏液；需逆行灌注者，阻断升主动脉后经冠状静脉窦逆行持续灌注机器氧合血，鼻咽温维持在30℃～32℃，在心脏空跳条件下完成心内直视手术。应用该技术实施心脏手术2 962例，其中先天性心脏病1 873例，心脏瓣膜病和升主动脉瘤患者1 089例。结果 全组术后住院死亡率为1.45%(53/2 962)，其中先天性心脏病死亡率为1.33%(25/1 873)，心脏瓣膜病死亡率为2.57%(28/1 089)；全组无气栓和永久性房室传导阻滞病例，术后低心排量综合征发生率0.37%(11/2 962)。结论 浅低温体外循环不停跳心内直视手术良好的心肌保护效果，降低了低心排量综合征和严重心律失常的发生率，从而明显降低术后死亡率，是临床上可以选择的好方法之一。
【关键词】 心内直视手术；不停跳；体外循环；浅低温
The experience of 2962 cases with intracardiac operation on beating heart under mild hypothermia by cardiopulmonary bypassLIN Shan-chang,HE Wei,chenMing-wu，et al.Department of Cardiothoracic Surgery,the First Affiliated Hospital of Guangxi Medical University,Nanning 530021, China
, 百拇医药
【Abstract】ObjectiveTo summarize the method and experience of intracardiac operation on beating heart under mild hypothermia by cardiopulmonary bypass. MethodsParalleling circulation is needed without aortic root cross-clamping and cardioplegia solution perfusing;When the retrograde perfusion is required,blood from the oxygenator was delivered continuously into the coronary vessels via coronary sinus,immediately after the aorta was cross-clamped. Intracardiac procedures went on with the empty heart beating rhythmically when the temperature at nasopharynx was kept from 30℃-32℃.Among 2962 cases receiving operation with these methods ,1 873 of them were with congenital heart diseases (CHD) and the other 1 089 with valvular heart diseases (VHD) or ascending aortic aneurysms. ResultsThe postoperative hospital mortality was 1.45%(53/2962) as a whole,while it was 1.33%(25/1873) in patients with CHD, and 2.57% (28/1089) in those with VHD or ascending aortic aneurysms. In the group,there was not a patient complicated with systemic air embolism or permanent A-V(atrioventricular) block,and there was 11 cases with LOS(low output syndrome) after operation whose incidience was only 0.37%.
, http://www.100md.com
作者单位：530021 广西医科大学第一附属医院心胸外科
13517812614，E-mail:lscaboy@126.com
ConclusionIntracardiac operation on beating heart should be one of good methods clinically because of its positive effect on myocardial preservation,which cut down the incidence of LOS and serious cardiac arrhythmias after operation,accordingly,degraded the postoperative mortality obviously.
【Key words】 Open heart surgery; Beating heart; Cardiopulmonary bypass; Mild hypothermia
, http://www.100md.com
近年来，国外一些心脏中心在不停跳心内直视手术的实验及临床研究方面不断取得进展[1-5]，我院作为较早探索不停跳心内直视手术的研究单位[6-7]，自1992年12月至2006年12月,在浅低温体外循环心脏不停跳下进行心内直视手术2962例，疗效满意，现总结如下。
1 资料与方法
1.1 临床资料
本组2 962例患者中，男1 775例，女1 187例, 年龄2个月～76岁，体质量3～86 kg。先天性心脏病手术1 873例，见表1；瓣膜置换术+ Bentall术1 089例，见表2，其中，心胸比率≥0.70占30.95%(337/1 089)；心胸比率≥0.80占6.33%(69/1 089)；重症心脏瓣膜病占45.18%(492/1 089)，其中二次换瓣118例，双瓣膜置换233例，急诊换瓣20例，合并冠状动脉病变19例，合并细菌性心内膜炎47例，扩张术后换瓣者34例，心源性恶病质6例，升主动脉瘤15例。
1.2 手术方法
静脉复合麻醉，胸骨正中切口，常规建立体外循环，视情况放置左心引流管。并行体外循环灌注，不阻断升主动脉，不灌注心脏停搏液，主动脉灌注压80～100 mm Hg(1 mm Hg=0.133 KPa)，平均动脉压60～80 mm Hg；需逆行灌注者，阻断升主动脉后经冠状静脉窦逆行灌注机器氧合血(图1)，灌注压40～50 mm Hg。体外循环灌注流量成人2.4～2.8 L/(m2•min),儿童2.8～3.0 L/(m2•min),控制鼻咽温度在30℃～32℃范围，即可在心脏缓慢空跳状态中进行心内直视手术。, 百拇医药(林善昌 何 巍 陈铭伍 周华富 郑宝石 郭建极 刘 翔)