心脏瓣膜置换术37例体外循环的管理

MANAGEMENT OF CARDIOPULMONARY BYPASS IN HEART VALVE REPLACEMENT IN 37 CASES

目的探讨37例心脏瓣膜置换术的体外循环(CPB)管理经验。方法37例患者中行二尖瓣置换术24例,主动脉置换术4例,二尖瓣加主动脉双瓣置换术9例。CPB采用中度低温,应用膜式氧合器,心肌保护选用4∶1(血∶晶体)高钾(20mmol/L)停跳液,主张不管温度,尽早开放升主动脉,恢复冠状动脉血流。开放升主动脉前常规应用100mg利多卡因。注意术中电解质特别是钾离子,镁离子的补义。重症瓣膜置换术患者应用超滤、抑肽酶、乌司他丁、白蛋白等。结果体外循环时间78～281min,主动脉阻断时间47～190min。术中平均灌注压45～95mmHg。自动复跳32例,占86%,围术期死亡1例。结论为提高瓣膜置换术的体外循环质量,我们认为:①选用膜式氧合器,以保证长时间转流。②有效的心肌保护以提高自动复跳率。③其他辅助手段的配套使用可加强术中器官保护,增加手术成功率。

Objective To investigate the management experience of cardiopulmonary bypass（CPB） procedures performed during heart valve replacement procedures, Methods Heart valve replacement procedures were performed in 37 cases between 2001 and 2006. Patients age ranged from 14 to 56 years old and body weight, ranged from 34 to 86 kg. Of 37 cases, 24 performed mitral valve replacement （MVR）;4 did aortic valve replacement （AVR）;and 9 did double valve replacement （DVR）. CPB adopts mid- low temperature and membrane oxygenator. Heart protection adopts 4 ： 1 （blood ： crystalloid） hyperkalemia（20mmol/L） cardioplegia. Regardless of temperature, ascending aorta should be opened early to guarantee coronary artery blood flow. 100mg Lidocine should be administered before opening ascending aorta. Electrolytes, particularly potassium and magnesium concentrations should be closely monitored and managed. Ultrafiltration, Aprotinin, Ulinastatin, albumin should be used in serious cardiac patients of valve replacement. Results CPB time ranges from 78 to 281 minutes. Aortic artery block time ranges from 47 to 190 minutes. Average infusion pressure 45 - 95mmHg. The cardiac spontaneous defibrillation rate was 86 %. Peri- operative death present in 1 case, which accounts for 2.7%. Conclusion The following measures can improve success rate of CPB：（1）Use membrane oxygenators to ensure long- term perfusion. （2）Administer effective myocardial protections to improve the ratio of myocardial auto- resuscitation. （3）Other measures to protect vital organs and hence improve success rate of the procedure.