全电视胸腔镜下心脏手术的体外循环管理经验

The experience of cardiopulmonary bypass management in patients undergoing total videothoracoscopic cardiac surgery

目的总结全电视胸腔镜下心脏手术的体外循环管理经验。方法回顾性分析2012年3月到2014年8月58例心脏病患者在电视胸腔镜下的体外循环管理经验。其中男17例,女41例,年龄7~62（35.19±14.51）岁,体重19~80（57.64±11.47）kg。房缺修补术28例（48.27%）,房缺修补加三尖瓣成型术12例（20.69%）,左房黏液瘤摘除术12例（20.69%）,右房肿物摘除1例（1.73%）,部分房室管畸形矫治术1例（1.73%）,房缺修补＋肺动脉瓣狭窄切开术3例（5.17%）,房缺修补＋无顶冠状静脉窦矫治术1例（1.72%）。采用股动静脉建立体外循环,转中采用中度低温、中流量灌注,4：1冷氧合血灌注进行心肌保护,其中心脏停跳56例,不停跳2例。结果体外循环转流时间65~178（108.83±24.73）min,升主动脉阻断时间0~78（52.46±17.29）min,开放升主动脉后有54例自动复跳,2例室颤,电除颤后复跳。4例患者静脉回流不够加插上腔静脉引流管,3例患者转机后股动脉灌注压高,灌注流量不够,加插右侧股动脉,1例股动脉拔出困难致血管撕裂,1例导丝刺破血管。呼吸机平均辅助时间（6.13±2.33）h,ICU平均停留时间（21.05±4.35）h,术后平均胸腔引流（142.07±52.07）ml。全部患者未出现术后相关并发症均治愈出院。结论选择合适的插管型号和插管方式,保证引流和灌注,加强手术团队的交流和配合,及时处理有关问题是保证腔镜体外循环手术成功的重要条件。

Objective To summarize the management of cardiopulmonary bypass（CPB） in patients undergoing surgery with to-tal video thoracoscope.Methods A retrospective analysis of 58 patients undergoing cardiac surgery with total video thoracoscope fromMarch 2012 to Auguat 2014 was conducted. 17 patients were male, 41 patients were female. The patient age was 35.19±14.51 yearsand weight was 57.64±11.47 kg. Twenty eight（48.27%）patients of atrial septal defect, 12（20.69%）patients of atrial septal defect andtricuspid valvuloplasty, 12（20.69%）patients of left atrial myxoma, 1（1.73%）patients of right atarial tumor, 1（1.73%）patient of par-tial atrioventricular canal defect, 3（5.17%）patients of atrial septal defect and pulmonary stenosis, 1（1.72%）patient of atrial septaldefect and unroofed coronary sinus received surgery. The arterial catheter was placed in the right femoral vein, the venous catheter wasplaced in the superior vena cava to set up CPB. Middle – hypothermia, middle-hemodilution, middle-high flow rate perfusion wereused during the CPB, the myocardium was protected by coronary perfusion with 4：1 cold oxygenated blood. Aortic corss-clamping wasperformed in 56 pantients and 2 patients had beating heart surgery.Results Cardiopulmonary bypass time ranged form 65 min to 178 min with a mean of 108.83±24.73（min）. Aortic cross-clamp time ranged from 20 min to 78 min with a mean of 52.46±17.29（min）.Fifty six patients had spontaneous cardiac rhythm recovery whereas 2 patients had ventricular fibrillation and recovery sinus rhythm byelectric defibrillation. Four patients experienced inadequate venous drainage, and superior vena cava（SVC） cannulation had to be per-formed to facilitate blood drainage.Three patients had excessively high femoral pressure and the left femoral artery cannula was required.Vascular injury happened in two cases from difficulty in removal of femoral artery cannulae fromone patient and piercing of the femoralartery by the guiding wire. The mechanical ventilation time was 6.13±2.33（h）andthe time of stay in ICU was 21.05±4.35（h）. The chest tube drainage was 142.07±52.07（mL）.No complications was noted and all patients were cured and discharged.Conclusion It isvery important to choose suitable cannula type and make sure they are put in the right way. Effective drainage and perfusion and goodcommunication between surgeons and perfusionistsare also very important for the successful management of CPB for total videothoraco-scopic cardiac surgery.