三阶段法处理主动脉瓣狭窄患者瓣膜置换术中顽固性心室颤动

Three steps to manage recurrent ventricular fibrillation during aortic valve replacement in patients with valvular aortic stenosis

目的研究主动脉瓣狭窄患者瓣膜置换术中顽固性心室颤动的处理。方法100例因主动脉瓣狭窄行主动脉瓣置换术的患者进入研究。主动脉开放后心室颤动的患者进行三个阶段的处理过程：第一阶段为常规处理：包括调整内环境，升温，给予利多卡因100mg，20～30W／s除颤；仍然呈现心室颤动的患者进行第二阶段处理：静脉注射去甲肾上腺素提高平均动脉压，将平均动脉压维持于70～90mmHg（1mml／g=0．133kPa），再次除颤；仍无反应患者进行第三阶段处理：给予硫酸镁1g和／或胺碘酮150nag治疗后再次除颤。比较各阶段患者术前的左室质量指数以及复苏成功时的平均动脉压、血钾水平、鼻咽温、红细胞压积。结果所有患者均复苏成功。自动复跳的患者有56例，进行第一阶段处理的患者有16例，进行第二阶段处理的患者有10例，进行第三阶段处理的患者有18例。自动复跳以及进行第一阶段处理的患者术前左室质量指数[（t84±43）、（178±51）g／m^2]显著低于进行第二、三阶段处理的患者[（237±61）、（242±46）g／m^2]，P〈0．05；进行第二、三阶段处理的患者平均动脉压显著高于自动复跳以及进行第一阶段处理的患者。结论三阶段法处理可以用于主动脉瓣狭窄患者瓣膜置换术中主动脉开放后的顽固性心室颤动。

Objective To study rational method for managing recurrent ventricular fibrillation during aortic valve replacement in patients with valvular aortic stenosis. Methods One hundred consecutive patients with valvular aortic stenosis who scheduled to receive aortic valve replacement were enrolled into the study. Three steps method was applied when ventricular fibrillation occurred after aortic unclamping. The first step was to correct disturbance of internal environment, intravenous lidocaine （100 mg） and defibrillation （20-30 W/s ） ; the second step was to inject norepinephrine to maintain mean arterial pressure 70-90 mm Hg （1 mm Hg = 0.133 kPa）, then repeated defibrillation; the third step was infusion of magenisum sulphate （ 1 g） and/or amiodarone （ 150 mg）, then repeated defibrillation. Preoperative left ventricular mass index, mean arterial pressure, nasopharyneal temperature, serum potassium level and hematocrit after aortic unclamping were collected and compared. Results After aortic unclamping, 56 patients recovered spontaneous rhythm without defibrillation, after the first step, 16 patients could be defibrillated successfully, other 10 patients recovered spontaneous rhythm after the second step, still other 18 patients remained unresponse untill the third step. Patients who recovered spontaneous rhythm without defibrillation or needed the first step management had significant lower left ventricular mass index when comparing with patients who entered the second step and third step management respectively [ （ 184 ± 43 ）, （ 178± 51 ） g/m^2 vs （237 ± 61 ）, （242 ± 46） g/m^2, P 〈 0.05 ]. Patients who needed the second step or third step management also had significant higher mean arterial pressure than the other patients. Conclusion Three steps method can be used to manage recurrent ventricular fibrillation during aortic valve replacement in patients with valvular aortic stenosls.