116例微创心脏外科手术的体外循环管理

The management of cardiopulmonary bypass in 116 minimally invasive cardiac surgeries

目的探讨微创心脏外科手术体外循环管理方法和经验。方法自2013年7月至2014年12月间，我院心胸外科共开展116例右胸前外侧小切口微创心脏手术，其中男性71例、女性45例，年龄13～-72（40．6±14．2）岁，体重35～85（50．5±10．8）kg。手术方式包括房间隔缺损修补术、室间隔缺损修补术、二尖瓣成形／置换术、主动脉瓣置换术、三尖瓣成形术、左房／右房黏液瘤摘除术。所有患者均为右胸前外侧小切口进行手术，采用股动脉插管灌注，食管超声引导下的二极股静脉进行插管引流，如有必要可加用上腔静脉插管。其他病例则采用同侧股动脉、股静脉、上腔静脉或右侧颈内静脉插管建立体外循环。除心脏不停跳的术式外，升主动脉顺行灌注4：1冷含血停搏液进行心肌保护。浅低温，中高流量灌注。全组病例都应用负压辅助静脉引流装置（VAVD）和常规超滤。体外循环结束后，股动脉插管处重建，颈内静脉压迫止血。结果全组病例均顺利完成手术，体外循环转流时间31～158（82．3±31．7）min，主动脉阻断时间16～96（48．1±19．8）min，超滤量1100～3500ml。除47例不停跳手术外，其余患者中56例心脏自动复跳，自动复跳率81．2％。术后呼吸机辅助时间3～16（4．5±1．4）h，胸腔引流量90～550（160±65）ml，术后住院时间6～21（9．1±2．7）d。88例患者（75．9％）住院期间未输血。115例痊愈出院，1例死于术后感染引起的多脏器功能衰竭，死亡率0．86％。结论各种外周插管建立的体外循环、VAVD技术的应用、适宜的灌注流量和灌注压力、良好的心肌保护、综合全面的体外循环管理为微创心脏手术提供了坚实的保障，实用性强，值得临床上推广和应用。

Objective To summary the management and experience of cardiopulmonary bypass in mini- mally invasive cardiac surgery. Methods One hundred and sixteen minimally invasive cardiac surgeries using min- imal right anterolateral thoracotomy were performed in our institute from July 2013 to December 2014. There are 71 males and 45 females. The age was from 13 to 72 years old, with mean of 40.6±14.2. The body weight ranges from 35 to 85 kilograms, with mean of 50.5±10.8. The operations include atrial septal defect repair, ventricular septal defect repair, mitral valve repair/replacement, aortic valve replacement, tricuspid valve repair, and atrial myxoma resection. All the operations underwent right anterolateral thoracotomy. In aortic valve replacement surgeries, the arterial cannla was inserted in the femoral artery, and the venous cannula was placed in the femoral vein with a bipolar cannula. A second superior vena cava cannula was placed if needed. In all the other cases, unilateral femoral artery and vein were used, and either a right jugular vein or a superior vena cava cannula was used. The antegrade cardioplegia was given for the myocardium protection with 4：1 warm blood plegia. Mild hypothermia and high flow strategy were used during the cardiopulmonary bypass. After the surgery, the femoral vessels were recon- structed, and the internal jugular vein was compressed for hemostasis. Vacuum-assist venous drainage（VAVD ） and ultra-filtration were used in all the surgeries. Results All the patients completed the surgeries uneventfully. The cardiopulmonary bypass time was 31 - 158 （ 82.3±31.7 ） min, and the aortic cross clamp time was 16-96 （ 48.1 ± 19.8 ）min. The volume of the ultra-filtration was 1100-3500 ml. Forty-seven patients had surgeries without aortic cross clamp. Fifty-six （56/69, 81.2%） had spontaneous heart recovery after removal of aortic cross clamp. The ventila- tion time was 3-16（4.5±1.4）hours, and the chest drainage was 90-550（ 160±65）ml. The post-operative hospital stay time was 6-21（9.1±2.7）days. Eighty-eight（75.9%） patients did not receive transfusion. There was one post- operative death （0.86%） because of multiple organ failure secondary to infection. Conclusion The management of cardiopulmonary bypass for minimally invasive cardiac surgery includes appropriate peripheral cannulation, vacu- um-assist venous drainage, adequate perfusion flow and pressure, and cautious myocardium protection. This man- agement improves safety of the surgery.