顺逆灌结合开放前温血灌技术在双瓣膜置换手术中的应用

The Application of Antegrade/Retrograde Cardioplegia Combined with Warm Blood Retrograde Before Releasing Aortic Cross-Clamp in Double Valve Replacement

目的研究顺逆灌结合开放前温血灌技术在双瓣膜置换手术中应用的方法和效果。方法随机选取双瓣膜置换术患者34例,分为两组：A组（顺逆灌结合温血灌组）17例;B组（间断顺灌组）17例。心肌保护方法：A组（顺逆灌结合温血灌组）采用首次顺行灌注1520 ml/kg 4∶1冷含血心脏停搏液,之后每隔2030 min逆行灌注510 ml/kg停搏液,在主动脉阻断钳放开前58 min开始逆行灌注温血直至开放;B组（间断顺灌组）采用首次顺行灌注1520 ml/kg 4∶1冷含血心脏停搏液,之后每隔2030 min再顺行灌注510 ml/kg停搏液。在CPB开始、术后2 h和24 h分别抽动脉血测定心肌钙蛋白T（cTnT）、肌酸激酶（CK）、肌酸激酶同功酶（CKMB、CKMM）浓度。结果术中转流平稳,血流动力学稳定,监测指标均在正常范围。顺逆灌结合温血灌组的平均CPB时间和主动脉阻断时间分别为（100.9±19.6）min和（65.6±13.4）min;间断顺灌组的平均CPB时间和主动脉阻断时间分别为（99.1±19.8）min和（69.8±22.1）min。顺逆灌结合温血灌组的82%自动复跳率高于间断顺灌组的47%。两组中的cTnT、CK、CKMB和CKMM浓度,在术后均逐步升高,与CPB开始时比较有统计学差异（P〈0.05）,顺逆灌结合温血灌组上升的幅度小于间断顺灌组,在术后2 h两组中的cTnT、CK和CKMM浓度的差异有统计学意义（P〈0.05）。结论在双瓣膜置换手术中,采用顺逆灌结合开放前温血灌技术,方法安全可靠,心肌保护效果优于常规的间断顺灌方法,值得在临床上广泛推广。

OBJECTIVE To study the effects of antegrade/retrograde cardioplegia combined with warm blood retrograde before releasing aortic cross-clamp on double valve replacement surgery.METHODS 34 patients undergoing double valves replacement surgery were involved and divided into two groups： antegrade/retrograde cardioplegia combined with warm blood retrograde group（group A,n=17） and intermittently antergrade group（group B,n=17）.In group A,antergrade cool blood cardioplegia was infused followed by intermittent retrograde cardioplegia every 20-30 minutes,and then retrograde warm blood was infused before releasing aortic cross-clamp.In group B,antergrade cool blood cardioplegia was infused followed by intermittent antergrade cardioplegia every 20-30 minutes.Blood was taken to measure the concentrations of the cardiac tropinin T（cTnT）,Creatine Kinase（CK）,Creatine Kinase MM（CKMM）,Creatine Kinase MB（CKMB） at 2 hours or 24 hours after operation.RESULTS The concentrations of cTnT,CK,CKMM and CKMB were increased obviously after operation in two groups.At 2 hours after operation the values in group A were lower than that in group B（P〈0.05）.CONCLUSION In double valve replacement,the application of antegrade/retrograde cardioplegia combined with warm blood retrograde before releasing aortic cross-clamp is safer and more effective than the conventional intermittent antergrade myocardial preservation.