CRRT/UF“1+1”在终末期心脏瓣膜外科治疗中的作用(一)——心功能指标的临床评价

Combination of ultra-filtration and continuous renal replacement therapy(1+1) applied in the operation for end-stage cardiac valve disease

目的观察和研究超滤(UF)结合连续性肾脏替代疗法(CRRT)“1+1”的方法在终末期心脏瓣膜病人中的应用效果。方法2005年8月至2006年12月间选择18例终末期心脏病患者,男性10例,女性8例;年龄28～72岁,平均年龄41.6岁。其中单纯性二尖瓣重度关闭不全6例、重度二尖瓣关闭不全伴狭窄2例、感染性心内膜炎1例、联合二尖瓣狭窄关闭不全伴主动脉瓣关闭不全4例、重度主动脉瓣关闭不全2例、单纯三尖瓣重度关闭不全2例,主动脉瓣狭窄伴二尖瓣关闭不全1例,非三尖瓣病例均合并不同程度的三尖瓣关闭不全。2例合并有冠状动脉病变,合并不同程度的多脏器功能障碍者16例,心源性恶液质9例,重度肺动脉高压10例,合并有房颤9例,感染性心内膜炎合并脑栓塞者1例,心胸比0.90～0.99,射血分数(EF)0.20～0.32,病程5～41年,均为心功能Ⅳ级。先进行CRRT治疗3d,为手术创造条件,共实行手术15例,在随后的手术中,应用体外循环加UF的方法。结果CRRT治疗后只有静脉氧饱和度(SvO2)由40.0±10.3升高到49.0±8.0,第二天PA由57.9±11.2mmHg降低到46.4±9.3和43.8±7.4mmHg(P(0.05),EF和CI第三天分别由29.2±2.4和30.2±1.0升高到40.9±2.8和38.0±2,2(P(0.05)。LA第三天由6.3±0.3mmol/L降低到3.0±1.1mmol/L水平(p(0.05)。术毕心脏自动复跳12例,电复律3例,均顺利脱机,返回ICU后发生低心排综合征2例,植入IABP辅助,24～36h后顺利撤离。机械辅助呼吸8～32h。手术毕EF和心脏指数(CI)在术后48h开始好转,由34.2±2.4和3.1±2.1L/min/m2升高到48.4±2.0和3.7±0.8L/min/m2。PA在48h开始由42.1±3.1mmHg降低到25.4±1.7mmHg。所有病人均顺利康复出院,术后随访6月,心功能提升1级6例,提升2级8例,未明显改善1例。结论UF和CRRT的“1+1”方法在终末期心脏瓣膜病人的临床治疗中效果显著,值得推广。

Objective To investigate the effectiveness of ultra - filtration（UF） plus continuous renal replacement therapy（CRRT） （ 1 ＋ 1 ） in the operation for end - stage cardiac valve disease. Methods 18 patients （ male 10, female 8） with end - stage cardiac valve disease were treated with UF and CRRT from Aug 2005 to Dec 2006, with mean age being 41.6 years （ range,28 to 72 ）. CRRT was carried out for 3 days before operation, followed by supplementary UF in CPB. Operation were performed in 15 patients, including 8 MVR ＋TVP, 2 DVR ＋TVP, 2 AVR, 1 AVR ＋ MVP ＋ CABG, 1 MVP ＋ CABG, 1 TVP respectively, combined with atrium and ventricular restoration. Results After CRRT treatment for 3 days, all the patients recovered well. SvO2 increased from 40.0 ± 10.3 mmHg to 49.0 ± 8.0 mmHg at d 1 ; PA decreased from 57.9 ± 11.2 mmHg to 46.4 ± 9.3 mmHg at d 2 and further to 43.8 ± 7.4mmHg at d 3. Cardiac function improved later, EF and CI increase from 29.2 ± 2.4 and 30.2 ± 1.0 to 40.9 ± 2.8 and 38.0 ± 2.2 respectively only at d 3. Sinus rhythm recovered spontaneously in 12 patients, electroversion was performed in 3 patients. EF and CI started to improve 48h after operation, increased from 34.2 ± 2.4 and 3.1 ± 2.1 L/min/m^2 to 48.4 ± 2.0 and 3. 7 ± 0.8L/min/m^2 , respectively. PA decreased from 42.1 ± 3.1 mmHg to 25.4 ± 1.7mmHg at 48 h. There was no death during hospital stay. Conclusion The combination of CRRT and SF （ 1 ＋ 1 ） is effective and safe applied in the operation for end - stage cardiac valve disease.