巨大左室心脏瓣膜置换术的围术期处理

Cardiac Valve Replacement of Large Left Ventricle

目的总结巨大左室心脏瓣膜病的手术治疗经验。方法自2005年1月至2009年1月共施行巨大心脏瓣膜病手术78例。男性47例,女性31例,年龄26～72岁(41.5±8.7),主要病因为风湿性病变、退行性病变、细菌性心内膜炎及先天性瓣膜畸形。主要病理为二尖瓣关闭不全、主动脉瓣关闭不全。术前心功能在Ⅲ～Ⅳ级(NYHA分级),心胸比(CT)(0.73±0.08),左室舒末径(LVEDD):70～99mm(79±7)mm,左室射血分数(EF):0.34～0.52(0.42±0.06)。术前调整心功能,增加心肌能量储备,改善全身营养状况。在全麻低温体外循环下行瓣膜置换术,采用间断氧合血性停跳液心肌灌注,加用平行及改良超滤。二尖瓣大部分保留后叶或全瓣结构,术后早期联合应用强心、扩血管药物,ICU停留2～3周,常规复查心脏彩超、胸部X线片及心电图。结果术后早期死亡3例,死亡率3.8%,1例为术后15h心脏骤停,2例为术后低心排。术中心脏复跳困难12例,术后主要并发症为低心排15例,恶性心律失常8例,多器官功能衰竭2例,二次开胸止血4例,伤口感染清创缝合3例,肺部感染3例。术后2～3周复查LVEDD、EF、CT均较术前明显改善。结论①巨大左室心脏瓣膜病属重症心脏瓣膜病,术前充分准备非常必要;②术中加强心肌保护,提高体外循环条件设置,尽可能保留二尖瓣部分或全部瓣下结构,对双瓣膜置换要注意二个瓣膜型号的匹配,相差不超过2个为宜,术中心脏复苏要综合方法应用,必要时采用2次阻断法;③术后早期联合应用强心、利尿、扩血管及抗心律失常药物,延长呼吸机辅助时间,减少心肺做功。

Objective To sum up the operative experience of the heart valve disease with large left ventricle.Methods From Jan.2005 to Jan.2009,78 patients of the large left ventricle had been carried out with artificial valve implantation.There were 47 male and 31 female patients.The age was from 26 to 72 years old.The main pathogenies were rheumatism,valve decay,bacterial endocarditis and congenital valve malformation.The main pathologies were mitral incompetence and aortic valve incompetence.Before operation,the cardiac function was 3~4 grade（NYHA）,the cardiac thoracic rate was（0.73±0.08）,the left ventricle end diastolic diameter（LVEDD） was 70~99mm（79±7）mm.The left ventricular ejecting fraction（EF） was from 0.34 to 0.52（0.42±0.06）.The cardiac function,the myocardial energy store and the general nutrition were improved before operation.The operations were carried out by general anesthesia and cardiopulmonary by-pass.The interval oxygenation blood cardioplegia and ultra-filter were used during the operation.Part or all mitral valve were preserved in most mitral replacement.Cardiac tonic and blood vessel dilatation drugs were used at the same time.All patients were in ICU 2 to7 days.The color ultra-sonic image of the heart,ECG and the chest X ray image were re-done in 2 to 3 weeks after operation.Results Three patients were dead in the early time after operation.The mortality was 3.8%.One died from cardiac stop suddenly.Two died from low cardiac output after operation.The main complication was the low cardiac output（15patients）.The hearts of 12 patients resumed hardly during operation.8 patients had malignant arrhythmia.2 patients suffered from multi-organic function failure.4 patients carried out again hemostasis operations.3 patients suffered from the cut infection and 3 from the pneumonia.All the LVED,EF and CT improved in 2~3 weeks after operation.Conclusion ①The cardiac valve disease with large left ventricle is the sierious valve disease.It is nessesery to prepare fully before operation.②The myocardium protection should be enhanced during operation.The CPB should be better than that of other operation.Part or all mitral should be preserved as possible.The mechanical valve sizes should be matched each other in double valve replacement.The diffrents of the sizes should not be more than 2.The multi methods of cardiac revivification should be used during operation and two clamping method should be used at essential time.③The cardiac tonic,blood vessel dilation drugs and anti-arrhythmia drugs should be used at early time after operation.The working time of the respirator should be prolonged to reduce the cardiac load.