心脏瓣膜置换术同期改良迷宫术的麻醉处理

Anesthetic Treatment of Radiofrequency Maze Procedure during Valve Replacement

目的：本文回顾性分析总结32例心脏瓣膜置换术同期改良迷宫术患者的麻醉处理。方法：32例瓣膜病合并心房颤动患者，ASA分级Ⅱ-Ⅳ级，心功能Ⅲ-Ⅳ级，采用以芬太尼为主的全身麻醉，术中以硫酸镁和艾司洛尔调控应激反应，复温后多联合使用多巴胺或（和）多巴酚丁胺5～10μg／kg·min、硝酸甘油或硝普钠0．5～5μg／kg·min等血管活性药物以达到扩张血管增强心肌收缩力、降低心脏负荷、维持循环稳定的目的。停机后预防性安置心外膜起搏导线，使用异丙肾上腺素后心率仍慢者，及时运用临时起搏，保证有效的心肌收缩和稳定的心率。结果：射频消融时间为32±5分钟，主动脉阻断时间89±12分钟；体外循环时间109±20分钟。心脏自动复跳29例，电除颤复跳3例，32例患者术后均为窦性心律。5例患者使用临时起搏器。结论：完善的术前准备和围术期重视心肺功能的支持治疗，合理调控应激反应等措施是手术成功的重要基础。

Objective： Retrospectivly analyzed and summarized experience of anesthetic treatment of radiofrequency maze procedure during valve replacement. Methods： Thirty-two cases with ASA Ⅱ-Ⅳ grade, heart function Ⅲ-Ⅳ grade, undergoing radiofrequency maze procedure during valve replacement were anesthetized with fentanyl anesthesia. Inhibition of stress reaction was utilized with magnesium sulfate and esmolol. After rewarming, dopamine, dobutamine and nitroglycerin（or sodium nitroprusside） were utilized to augment cardiac contractility, decrease heart afterload and maintain a steady hemodynamics. After CPB, pacing conductors were utilized prophylactically to provide with effective myocardiac contractility and steady heart rate. Results： The radiofrequency time was 32± 5min. The aortic block time was 89±12 min. And the CPB time was 109±20 min. 29 cases regained heart beat automatically, while 3 cases regained heart beat through electric defibrillation. All cases remained sinus rhythm. 5 cases were utilized temporary pacemaker, Conclusion： Consummate preoperotive preparation, reasonable inhibition of stress reaction and emphasis of postoperative supportive treatment were important foundation.