再次二尖瓣置换术中严重心血管事件原因分析及应对措施

Clinical Analysis and Management of Severe Cardiac Events in Re-Operation for Mitral Valve Replacement

目的:总结再次二尖瓣置换术中严重心血管事件发生原因及应对措施。方法:对62例再次二尖瓣置换术患者(R组)及同期80例首次二尖瓣置换术患者(F组)进行回顾性研究。结果:两组患者术前合并中重度肺动脉高压分别为41.94%(26/62)和12.50%(10/80),P<0.01,差异有统计学意义;R组纽约心脏病协会NYHA心功能分级明显高于F组,P<0.01,差异有统计学意义;R组术中建立体外循环时间、平均体外循环时间、平均阻断时间、术中严重心血管事件及血液制品用量明显高于F组,P<0.05～0.01,差异有统计学意义;两组死亡率差异无统计学意义(P>0.05)。术中严重心血管事件有:体外循环前发生心室颤动,开胸时大出血,左心室破裂,严重过敏反应,停机后低心排二次转机。R组体外循环前芬太尼用量>20μg/kg的患者体外循环前心室颤动发生率明显低于芬太尼用量≤20μg/kg的患者。结论:再次手术时患者病情加重,术中严重心血管事件发生率增高,麻醉风险增加,充分的术前准备和良好的麻醉体外循环方法能够降低麻醉风险,特别是体外循环前使用大剂量芬太尼(>20μg/kg)能有效降低恶性心律失常的发生率。

Objective： To summarize the cause and management of severe cardiac events in re-operation for mitral valve replacement. Methods： Sixty two patients with rheumatic heart disease who underwent re-operation for mitral valve replacement （R group） , and eighty patients who first underwent mitral valve replacement （F group） were reviewed retrospectively. Results： Before the operation, there were twenty six patients with advanced pulmonary hypertension in R group （26/62, 42.94% ）, and ten patients in F group（ 10/80,12. 5% ）; there was significant difference in two groups by NYHA functional classification. The time of cardio-pulmonary bypass（CPB） and aortic clamping in R group were longer than that in F group, and severe cardiac events and blood transfusion were more inclined to occur in R group. Severe cardiac events included ventricular fibrillation before CPB, massive hemorrhage, left ventrieular rapture, and severe anaphylactic reaction. In R group, the occurrence of ventricular fibrillation before CPB in patients who received fentanyl larger than 20 /xg/kg before CPB was lower than the patients who received fentanyl smaller than 20μg/kg before CPB. Conclusion： The anesthetic risk increased for re-operation of mitral valve replacement. Correct prevention and management that including larger dose of fentanyl （ 〉 20 μg/kg） before CPB could help patients pass through the surgery safely.