Aortic and mitral valve replacement with retrograde perfusion in the beating heart

心脏不停跳主动脉瓣及联合瓣膜替换术(英文)

Objective To estimate the value of aortic valves and combined mitral valve replacement with retrograde perfusion in beating hearts.Methods Continuous retrograde coronary sinus perfusion with beating hearts was used in 83 patients undergoing aortic valve or aortic valve combined with mitral valve replacement,without application of cardioplegia.After aortic valve replacement,the retrograde perfusion wes changed to antegrade perfusion for mitral valve replacement or correction of the other deformities(group A).Cold blood cardioplegia solution(15℃)was infused at intervals in 20 cases(group B).The following parameters were tested:lactate,ET,CTn-T and MDA in blood;myocardial ultra-structure;and cardiac rhythm and cardiac output (co).Results All biochemical values increased after cardiopulmonary bypass(P ＜ 0.05 - 0.01).Empty and beating heart sinus rhythm was maintained in group A.Myocardial ultrastructure did not change significantly.The pump was stopped smoothly as the surgical procedure finished.No postoperative low cardiac output syndrome or arrhythmia was observed.Eight-one patients recovered smoothly,two died from renal failure or infective shock.When the pump stopped,all patients in group B were supported by 5 - 10 μg· kg-1· min-1 dopamine.Transient pacing was used in 9 patients.One patient died from low cardiac output syndrome.Conclusion This method is a good myocardial protection which simulates physiologic status.It is applicable to aortic valve and combined mitral valve replacement of patients with large heart or heart failure and long time aortic cross-clamping.Ideal clinical effect can be achieved.

目的 评价逆行灌注心脏不停跳主动脉瓣及联合瓣膜替换术的价值。方法 经冠状静脉窦逆行持续灌注机器氧合血 ,使心脏在有节律的空跳中完成主动脉瓣和二尖瓣替换 ,或改为非置管顺行灌注 ,再行二尖瓣替换或其他合并症的处理 ,共 83例 (A组 ) ;随机选择 2 0例在间歇灌注冷血K+心停搏液下完成手术 (B组 )。检测血液乳酸 (LA)、心肌磷酸肌酸激酶同功酶 (CK MB)、心肌肌钙蛋白 (CTn T)、丙二醛(MDA) ,前乳头肌观察超微结构改变。Swan Ganz管测定心排血量 (CO)。结果 B组的LA、CK MB、CTn T、ET 1、MDA比A组的显著增高 (P <0 0 5 )。A组心肌超微结构无明显变化 ;术后无多巴胺等正性肌力药物依赖和严重心律失常。 81例恢复顺利 ,2例分别死于急性肾功能衰竭和感染性休克。B组均需 5 - 10 μg·kg 1·min 1多巴胺才能脱离体外循环机 ,9例术后使用临时起搏器 ,1例死于低心排。结论 逆行灌注心脏不停跳法是一种较接近生理状态的心肌保护新方法 ,适宜用于重症主动脉瓣及联合瓣膜替换 。