心瓣膜置换术中心脏复跳前主动脉根部灌注硝酸甘油的疗效分析

Clinical Outcomes of Nitroglycerin Perfusion via the Aortic Root before Heart Re-beating for Patients Undergoing Heart Valve Replacement

目的探讨心瓣膜置换术中心脏复跳前经主动脉根部灌注硝酸甘油对手术效果的影响。方法 2008年1月至2011年12月北京安贞医院对254例心脏瓣膜疾病患者施行了心瓣膜置换术,根据在体外循环(CPB)中心脏复跳前是否应用硝酸甘油行主动脉根部灌注,将254例患者分为两组,硝酸甘油灌注组(硝酸甘油组):134例,男57例,女77例;年龄(58.47±12.34)岁;在CPB中心脏复跳前应用硝酸甘油5 mg稀释至20 ml,于心脏充分排气后经主动脉根部灌注管注入,并反复抽吸8～10次,待心脏出现自主性搏动迹象后开放主动脉阻断钳,并用手于主动脉根部高频率挤压,务必每次均完全压闭主动脉;对照组:120例,男64例,女56例;年龄(61.85±11.97)岁;在CPB中心脏复跳前不灌注硝酸甘油,按照常规处理。观察两组患者的心脏自动复跳率、心脏复跳后CPB辅助时间、术后正性肌力药物使用量、呼吸机辅助呼吸时间、围术期并发症和住院时间,并进行随访。结果围术期无死亡。硝酸甘油组术中心脏复跳后CPB辅助时间[(12.32±9.76)min vs.(23.43±10.33)min,t=-1.233,P=0.000]、多巴胺[(3.45±2.33)μg(/kg min)vs(.5.67±3.12)μg(/kg min),t=-0.943,P=0.034]和肾上腺素[(0.026±0.013)μg(/kg min)vs.(0.056±0.021)μg(/kg min),t=-0.822,P=0.027]使用量短于或少于对照组,心脏自动复跳率(97.01%vs.66.67%,χ2=-2.115,P=0.000)高于对照组。硝酸甘油组随访121例,随访时间2～36个月,随访期间无死亡;失访13例。结论在心瓣膜置换术中良好的应用开放前主动脉根部灌注硝酸甘油、应用去甲肾上腺素和快速挤压升主动脉的心肌保护方法可明显提高心脏自动复跳率和减少CPB辅助时间,改善术后效果。

Objective To explore clinical outcomes of nitroglycerin perfusion via the aortic root before heart re-beating for patients undergoing heart valve replacement. Methods A total of 254 patients with valvular heart diseases underwent heart valve replacement in Beijing Anzhen Hospital from January 2008 to December 2011. According to whether or not they received nitroglycerin perfusion via the aortic root before heart re-beating during cardiopulmonary bypass （CPB）, all the 254 patients were randomly divided into two groups, the nitroglycerin group and the control group. There were 134 patients in the nitroglycerin group including 57 males and 77 females with their average age of 58.47___ 12.34 years. They received aortic root perfusion of 5 mg nitroglycerin diluted into 20 ml after full de-airing of the heart, and repeated aspiration was performed 8 to 10 times before heart re-beating during CPB. Aortic cross-clamp was released after the heart showed signs of automatic re-beating, and the aortic root was squeezed in high frequency by hand to make sure that the aorta was squeezed to close each time. In the control group, there were 120 patients including 64 males and 56 females with their average age of 61,85±11.97 years. Patients in the control group received routine procedures of CPB except nitroglycerin perfu- sion before heart re-beating. Automatic heart re-beating rate, CPB supporting time after heart re-beating, postoperative usage of inotropic drugs, mechanical ventilation time, perioperative morbidity and length of hospital stay were compared between the 2 groups, and patients were followed up and further evaluated. Results There was no in-hospital death. CPB supporting time after heart re-beating （ 12.32 ± 9.76 min vs. 23.43 ± 10.33 min, t=-1.233, P=-0.000）, dopamine usage C3.45±2.33 Ixg/（kg,min）vs. 5.67±3.12 μg/（kg,min）, t=-0.943, P=0.0341 and epinephrine usage 10.026±0.013 μg/ （kg.min） vs. 0.0564-0.021 μg/（kg .rain）, t=--0.822, P=0.027] of the nitroglycerin group were significantly shorter or lower than those of the control group. Automatic heart re-beating rate of the nitroglycerin group was significantly higher than that of the control group 197.01% vs. 66.67 %, Z2=-2. l 15, P=0.000 ]. A total of 121 patients in the nitroglycerin group were followed up for 2-36 months, and 13 patients were lost during follow-up. There was no death during follow-up. Conclusion For patients undergoing heart valve replacement, some myocardial protection strategies including nitroglycerin perfusion via the aortic root before heart re-beating, use of norepinephrine, and aortic root squeezing in high frequency by hand can significantly increase the automatic heart re-beating rate, shorten the CPB supporting time after heart re-beating, and improve postoperative clinical outcomes.