体外循环心脏手术中肝素耐药的原因及处理措施

Reasons and treatment measures of heparin resistance in nineteen patients undergoing cardiac surgery during cardiopulmonary bypass

目的:探讨体外循环(Cardiopulmonary bypass,CPB)心脏直视手术中肝素耐药的原因及处理措施。方法:对1258例CPB心脏直视手术进行回顾性分析。结果:静注肝素400U/kg后,有19例患者激活全血凝固时间(Activated clotting time,ACT)不能延长到480s或虽延长到480s后很快缩短,需要补充大量肝素才能维持在安全抗凝范围,占1.51%。其中有5例患者补充肝素无效,在输注新鲜冰冻血浆或全血后再补充肝素,ACT才能达到480s以上。分别是心脏粘液瘤7例(36.8%)、风湿性心脏病3例(15.8%)、感染性心内膜炎3例(15.8%)、房间隔缺损2例(10.5%)、法洛氏四联症2例(10.5%)、室间隔缺损1例(5.3%)、右室双出口1例(5.3%)。结论:CPB心脏直视手术中肝素耐药常见于心脏粘液瘤、感染性心内膜炎及紫绀型心脏病等,与血液中出现类似肝素的粘多糖物质、抗凝血酶Ⅲ(ATⅢ)含量及活性低、血小板计数增高、术前抗凝治疗及使用避孕药等因素有关,术中需加强ACT的监测。

Objective：To investigate the reasons and treatment measures of heparin resisitance in patients undergoing cardiac surgery during cardiopulmonary bypass（CPB）.Methods：Retrospective analysis of 1 258 patients undergoing cardiac surgery was made.Results： After 400 U/kg heparin was injected intravenously,the activated clotting time（ACT）could not be extended to 480 seconds or was shortened soon after extended to 480 seconds in nineteen patients（1.51%）including seven patients with cardiac myxoma,three patients with rheumatic heart disease,three patients with infective endocarditis patients,two cases of atrial septal defect patients,two cases of tetralogy of Fallot patients,one cases of ventricular septal defect patient and one cases of double outlet right ventricle patient.A large number of heparin was added to maintain ACT at safe range for anticoagulation.But it was invalid for five patients to add heparin,and then ACT could be extended to 480 seconds after 400～600 ml fresh frezon plasma or blood was transfused.Conclusion：Heparin resistance was commonly encountered in cardiac myxoma,infective endocarditis and cyanotic heart diseases requiring CPB.It was associated with the appearance of similar heparin mucopolysaccharide material in the blood,decrease of antithrombinⅢ（ATⅢ）content and activity,increase of platelet count,preoperative anticoagulant therapy and the use of contraceptives.ACT should be monitored frequently during CPB.