微创体外循环对冠状动脉旁路移植术患者围手术期血液保护的临床研究

Clinical research of minimal extracorporeal circulation in perioperative blood conservation ofcoronary artery bypass graft

目的研究微创体外循环（MECC）对心脏手术围手术期血液保护的临床效果。方法回顾性分析2006年8月至2009年10月接受择期单纯冠状动脉旁路移植手术（CABG）的120例患者的临床资料，按其辅助循环方式分为MECC组、传统体外循环（cECC）组和非体外循环（off-pump）组，每组40例。除常规的体外循环方法外，MECC组采用JostraMECC系统，cECC组采用浅低温体外循环。收集患者围手术期凝血功能和血液细胞学检查结果、血液制品用量和术后24h引流量进行统计分析。结果EuroSCORE术前风险及预期病死率评估MECC组均高于cECC组和off-pump组（P〈0．01）。off-pump组手术时间和远端吻合口数量均低于MECC组和cECC组（P〈0．05），MECC组和cECC组间无差别。比较术后各组内源性凝血功能（活化部分凝血活酶时间），cECC组在转后早期明显较正常值延长，并在转后2h、6h、12h明显高于MECC组和off-pump组（P〈0．05）；而外源性凝血功能（凝血酶原时间）三组问没有差别。MECC组和cECC组患者校正后的血浆游离血红蛋白均在转中明显升高并在停机时达到高峰，转后24h左右下降至转前水平；但cECC组均高于MECC组（P〈0．05）。cECC组术后第1个24h人均胸腔纵隔引流量高于MECC组和off-pump组（P〈0．05）。虽然cECC组血小板计数术中和术终平均值较低，且人均围手术期使用血液制品量较高，但三组间差异没有统计学意义。结论MECC可以减少常规体外循环过程对血液成分破坏和对凝血功能的干扰，减少术后胸腔纵隔引流量，降低心脏手术对异体血液制品的需求。

Objective To analyze the clinical effect of minimal extracorporeal circulation （MECC） in blood conservation perioperatively coronary artery bypass graft （CABG）. Methods The data of 120 cases received simple CABG since August 2006 to October 2009 was analyzed retrospectively. All the patients were divided to three groups according to the mode of circulation support in-operation： MECC, conventional extracorporeal circulation （cECC） or off-pump, 40 cases in each group. Jostra MECC system with normal temperature was used in MECC group, and common membrane oxygenator with moderate hypo-temperature was used in cECC group. Collect the data of coagulation and the blood cytological examination perioperatively, the draining volume during the first 24 h after operation, and consumption of blood products perioperatively. Results Stardard and logistic EuroSCORE were higher in MECC group than the others （P 〈0.01）. The operative time and the number of distal anastomosis of off-pump group were less than MECC and cECC groups （ P 〈 0. 05 ）, while no difference between MECC group and cECC group. Intrinsic coagulation （activated partial thromboplastin time） were much more prolonged early postoperatively in cECC group, and higher than in MECC group and off-pump group at 2 h, 6 h and 12 h postoperatively （P 〈 0. 05）, but no difference in extrinsic coagulation （prothrombin time ） among three group. Adjusted by hematocrit of the same sample, free hemoglobin level rose up during the ECC procedure and reached the maxlmum at the end of ECC in cECC group and MECC group, but the levels were more higher in cECC group than in MECC group （P 〈 0. 05 ）. The draining volum during the first 24 h after operation of cECC group was larger than MECC group and off-pump group （ P 〈 0. 05 ）. Although the decreased platelet count perioperatively and more consumed of the blood products in cECC group, but no difference among the three groups. Conculsion MECC could reduce the ruin to blood cell and interfere to coagulation function during the conventional ECC procedure, decrease the postoperative draining volum and requirement of blood products.