微创技术在体外循环心脏手术中的应用104例临床分析

Application of Minimally Invasive Technique in Cardiopulmonary Bypass Surgery: Report of 104 Cases

目的观察微创技术在体外循环心脏手术中的应用.方法从2012年9月至2014年8月,共选择104例心脏外科手术患者,包括:房间隔缺损修补14例、房间隔缺损修补+三尖瓣成形25例、二尖瓣修复8例、二尖瓣置换44例、主动脉瓣置换11例、二尖瓣+主动脉瓣置换2例.房间隔缺损及二尖瓣病变采用右胸小切口、外周体外循环、胸腔镜辅助完成心内操作;主动脉瓣置换8例采用右胸骨旁小切口和3例采用胸骨上段小切口中心体外循环完成.除3例胸骨上段小切口用传统方式建立体外循环外,其余101例均采用外周体外循环,经股动脉及股静脉插管建立CPB,25例采用颈内静脉插管.CPB采用浅低温、中流量灌注,应用VAVD(负压控制在(-30^-60 mm H),连续血气监测及超滤.Chitwoodg阻闭钳阻闭升主动脉阻断循环,升主动脉根部灌注心肌停跳保护液.心内操作使用微创器械完成与常规手术相同的步骤.结果 104例患者CPB时间46~209(118.1±25.6)min,升主动脉阻断时间29~145(55.7±22.8)min,术后呼吸机辅助时间4~17(11.1±4.3)h,术后24 h引流量50~680(232.6±194.5)m L.术后ICU时间3~56(12.3±8.33)h,术后住院时间4~16(12.1±4.5)d.术后早期心胸比率,左心房内径,左心室内径,左室射血分数与术前相比均有不同程度改善,心功能Ⅰ级49例,Ⅱ级53例,Ⅲ级2例,明显好于术前.1例髂静脉损伤予修补,2例胸膜严重粘连无法分离转正中开胸,1例再次开胸止血,全组术后均恢复顺利,无死亡.随访1~23月,随访率98%(102/104),无远期死亡,症状心功能均明显改善,生活满意度高.结论微创技术在体外循环心脏手术中的应用,具有切口小、创伤小、安全性高、恢复快和不影响美观等特点,在特定的病例中可获得良好的手术效果.

Objective To observe the application of minimally invasive technique in cardiopulmonary bypass surgery. Methods From September 2012 to August 2014, 104 cardiac surgery patients were selected, including 14 cases of atrial septal defect repair, 25 cases of atrial septal defect repair ＋ tricuspid, 8 cases of mitral valve repair, 44 cases of mitral valve replacement, 11 cases of aortic valve replacement, and 2 cases of mitral and aortic valve replacement. Atrial septal defect and mitral valve disease were treated using right chest incision, peripheral cardiopulmonary bypass and thoracoscope assisted operation. Aortic valve replacement were completed using small incision cardiopulmonary bypass in right next to sternum for 8 cases and on the center section of sternum for 3 cases. Cardiopulmonary bypass for 3 cases of sternal segment small incision were established using traditional way, other 101 cases using the outer peripheral cardiopulmonary bypass through the femoral artery and femoral vein cannulation to establish CPB, of which 25 cases were internal jugular vein catheterization. CPB was established using mild hypothermia, the flow perfusion, application VAVD （negative control range from 30 to 60 mmHg） , continuous blood gas monitoring and uhrafihration. Chitwood occlusion clamp was used to close aortic circulation, and aortic root was perfused with myocardial protection solution. Cardiac arrest operation was completed using the same procedure as conventional minimally invasive operation. Ftosults For all cases, CPB time was 46-209 （118.1 ± 25.6） min, aortic clamping time was 29-145 （55.7± 22.8） min, postoperative ventilation time was 4-17 （11.1 ± 4.3） h, volume of drainage after 24 h was 50-680 （232.6 ± 194.5） mL, postoperative ICU time was 3-56 （12.3 ± 8.33） h, and postoperative hospital stay was 4-16 （12.1 ± 4.5） d. Cardiothoracic ratio, left atrial diameter, left ventricular diameter, left ventricular ejection of early post-operation were improved with different degrees compared with those of pre-operation. There were 49 cases with cardiac function grade Ⅰ , 43 cases with grade Ⅱ and 2 cases with grade Ⅲ, which were significantly better than pre-operation. 1 case of iliac vein injury was repaired, 2 cases of severe pleural adhesions were performed with thoracotomy. All cases had smooth recovery after operation, and no deaths occurred. Followed up 1-23 months, and the follow-up rate was 98% （102/104） . No long-term deaths occurred. The symptom and cardiac function were significantly improved with high life satisfaction. Conclusion Minimally invasive technique in open heart surgery has the advantages of small incision, less trauma, safe, rapid recovery, and meeting the requirements of aesthetics, which can obtain good operative effects in certain cases.