CRRT/UF“1+1”在终末期心脏瓣膜外科治疗中的作用(Ⅱ)-内环境改善的生化评价

Combination of ultrafiltration and continuous renal replacement therapy(1+1) 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,EF0.20～0.32,病程5～41年,均为心功能Ⅳ级。先进行CRRT治疗3天,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治疗后新型融合蛋白第三天由6.3±0.3mmol/L降低到3.0±1.1mmol/L水平(p<0.05),尿素氮和补体分别由17.6±3.2mmol/L和267.3±21.1μmol/L降低到5.2±2.8mmol/L和89.3±10.5μmol/L(p<0.01).术毕心脏自动复跳12例,电复律3例,均顺利脱机,返回ICU后发生低心排综合证2例,植主动脉内坏囊反搏(IABP)入μ辅助,24～36h后顺利撤离。机械辅助呼吸8～32h。术毕乳酸脱氢酶(LDH)和肌酸肌酶工酶(CK-MB)开始升高,24h达高峰,分别达到499.4±28.1U/L和177.0±3.8U/L,48h后开始下降。T-Bil和D-Bil术后是升高的,但24h后下降,BUN和Cr均呈下降趋势。LA术后升高特别明显,达13.3±2.3mmol/L,但24h后下降,48h后趋于正常水平。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 explore the effectiveness of ultrafiltration （UF） plus continuous renal replacement therapy （CRRT） （ 1 ＋ 1 ） in the operation for end - stage cardiac valve disease. Methods Eighteen （ male 10. female 8 ） patients conformed to the standard of AHA of end - stage cardiac valve disease were treated with UF and CRRT from Aug 2005 to Dec 2006. The median age of the patients was 41.6 years （ range froml8 to 72）. The treatment of CRRT was taken three days before operation. and followed by supplementary UF in the CPB. Surgery was performed in 15 patients including 8 MVR ＋ TVP. 2 DVR ＋ TVP. 2 AVR. 1 AVR ＋ MVP ＋ CABG. 1 MVP ＋ CABG and 1TVP. The clinic statistics of cardiac dynamics and biochemistry were analyzed. Results After 3 days treatment of CRRT. LA decrease from 6.3 ±0. 3 mmHg to 3.0 ± 1.1 mmHg occurred at d3; the distinct improvements were observed in BUN and Cr. which declined from 17.6 ±3.2mmol/L and 267. 3±21. 1 umol/L to 5. 2 ±2.8mmol/L and 89.3± 10. 5umol/L respectively at d3. 12 of 15 patients recovered rhythm automatically. and 3 by electrical conversion. LDH and CK -MB rose at 24h post operation with the peak of 499. 4±28.1 u/L and 177.0 ± 3. 8u/L respectively and decreased at 48h; the distinct rise of LA occurred at 24h and reached up to 13.3±2. 3mmol/L. then turned to the normal at 48h. No hospital death occurred among these patients. Conclusion Combination of CRRT and SF （ 1 ＋ 1 ） is effective and safe in the operation for end - stage cardiac valve disease.