胸骨下段小切口心脏不停跳心内直视手术587例

587 Open Heart Operations of Limited Lower Ministernotomy Associated with on Pump Beating Heart

目的：探讨胸骨下段小切口联合心脏不停跳微创技术在心内直视手术中应用效果。方法：1999年10月至2008年9月，采用胸骨下段小切口联合心脏不停跳微创技术行心内直视手术共587例。其中各种先天性心脏病459例，风湿性心脏瓣膜病128例。结果：全组患者顺利完成不停跳手术。体外循环时间（78．13±18．52）min，上、下腔静脉阻断时间（61．21±16．51）min，呼吸机辅助时间（12．01±8．83）h。术后并发血红蛋白尿21例、低心排血综合症11例、呼吸道感染5例、灌注肺3例。住院死亡13例，死亡原因为低心排血综合症4例，肺动脉高压危象2例，室颤2例，肾功能衰竭、心脏压塞、脑部气体栓塞、感染性心内膜炎及呼吸衰竭各1例。随访2～108月，发现有3mm以下的室间隔缺损残余分流3例，二尖瓣置换术后抗凝不当脑栓塞2例，无晚期死亡。结论：胸骨下段小切口联合心脏不停跳技术，可安全、有效地应用于大多数心内直视手术，既有外科微创和外表美观的优点，又有良好的心肌保护效果。

Objective：To explore application of limited lower ministernotomy associated with on pump beating heart in intracardiac operation underdirect vision. Methods： From Oct. 1999 to Sep. 2008, minimally iuvasive open heart operations with help of extracorporeal circulation （ ECC ） were performed on 587 patients, including 459 cases of various congenital heart diseases, 128 of rheumatic valvular heart diseases. Results：Five hundred and eighty seven patients went through the operations. The average time of ECC, caval veins cross clamping and mechanical ventilation were （78.13 ± 18.52）min, （61.21 ± 16.51 ） rain and （ 12.01 ± 8.83 ） h, respectively. The postoperative complication consisted of hemoglobinuria in 31 patients, low cardiac output syndrome in 11, respiratory infection in 5, perfusion lung in 3. Thirteen patients died, the causes of death included low cardiac output syndrome in 4 cases, pulmonary hypertension crisis in 2, ventricular fibrillation in 2, renal failure, cardiac tamponade, cerebral gas embolism, infective endocarditis and respiratory failure, each 1 case. During the period of follow-up of 2 - 108 months, 3 cases happened residual shunt due to interventricular septal defect less than 3 mm in diameter, 2 suffered from cerebral embolism owing to improper anticoagulation after mitral valve replacement, no one died at advanced stage. Conclusions：The surgical technique of limited lower ministernotomy associated with on pump beating heart is safe and effective for the majority of open heart soperations. The clinical effects are complementary, not only have the merits of minimal invasion and aesthetic ap- pearance, but also have an excellent myocardial protection.