食管超声多普勒应用于体外循环下主动脉瓣膜置换术的左心功能评价

Transesophageal Doppler monitoring for fluid therapy and left ventricular myocardial function in patients undergoing aortic valve replacement after cardiopulmonary bypass

目的食管超声多普勒技术已广泛用于一些大手术中的补液指导,而在心脏瓣膜置换术中应用较少。文中旨在评价食管超声多普勒技术在体外循环下主动脉瓣膜置换术中指导液体治疗,血管活性药物使用后血流动力学参数的变化和心功能的恢复。方法选择2014年3月至2015年6月安徽医科大学附属安徽省立医院心脏外科收治的行体外循环下心脏主动脉瓣膜置换术患者40例,按随机数字表法分为多普勒组和对照组,每组20例。多普勒组根据食管多普勒监测血流动力学参数指导术中(停体外循环至术毕)输液和药物使用,对照组采用中心静脉压、平均动脉压和心率监测指导,进行经验性治疗。观察2组术中胶体液、晶体液、尿量、失血量和恢复情况及术中、后血流动力学参数、乳酸值的变化。结果与对照组胶体液量[(303±60)m L]、晶体液量[(533±87)m L]、体外循环后尿量[(274±95)m L]比较,多普勒组[(373±65)、(596±83)、(338±84)m L]均明显升高(P<0.05);红细胞、血浆、术后拔管时间、多巴胺用量、多巴酚丁胺用量及住院时间均明显降低(P<0.05)。手术结束时,多普勒组心率和峰流速变量较对照组明显降低[(114±11)次/min vs(107±10)次/min,(13.7±3.0)%vs(11.6±2.7)%],差异有统计学意义(P﹤0.05);多普勒组平均外脉压、每搏量、心脏指数、平均加速度和校正血流时间较对照组显著增加(P﹤0.05);术后6 h,多普勒组较对照组心率降低、MAP升高[(112±13)次/min vs(104±11)次/min,(71±10)mm Hg vs(78±8)mm Hg],差异有统计学意义(P﹤0.05)。手术结束和术后6 h的对照组乳酸值为[(3.56±0.76)、(2.34±0.37)mmo L/L],而多普勒组[(2.99±0.61)、(2.03±0.40)mmo L/L]显著降低(P﹤0.05)。与体外循环结束时乳酸值比较,手术结束和术后24 h对照组和多普勒组组内比较差异均有统计学意义(P﹤0.05)。结论在主动脉瓣膜置换术中,采用食管超声多普勒技术可以及时准确地反映血流动力学的变化和左心功能,更精确地指导临床医师进行最合适的治疗,确保机体微循环的灌注,是快速康复外科治疗的一种有效措施。

Objective Transesophageal Doppler monitoring（ TDM） has been widely applied to fluid therapy in some major operations but rarely used in aortic valve replacement. The purpose of this study was to assess the value of TDM in fluid therapy,vasoactive drugs use,and left ventricular function in patients undergoing aorta valve replacement after cardiopulmonary bypass. Methods This study included 40 patients undergoing aotic valve replacement after cardiopulmonary bypass in Anhui Provincial Hospital from March 2014 to June 2015,which were randomly assigned to a TDM and a control group of equal number. TDM was used for the guidance of fluid infusion and vasoactive drug administration for the patients in the former group,while central venous pressure,mean arterial pressure,and heart rate were employed for those in the latter. The fluid volume infused,urine volume,blood loss,hemodynamics,arterial blood lactate,and outcomes were compared between the two groups. Results Compared with the control, the TDM group showed significantly increases in the colloidal fluid volume（ [303 ± 60] vs [373 ± 65]mL,P〈0. 05）,crystal fluid volume（ [533 ± 87] vs [596 ± 83]mL,P〈0. 05）,and urine volume（ [274 ± 95] vs [338 ± 84]mL,P〈0. 05）,but remarkable decreases in the red blood cell count,blood plasma volume,postoperative extubation time,doses of dopamine and dobutamine,and length of hospital stay（ all P〈0. 05）. The hemodynamics were more stable and arterial blood lactate was lower in the TDM group than in the control（ P〈0. 05）. Conclusion Transesophageal Doppler monitoring can timely and exactly manifest the hemodynamic changes and left ventricular function of the patient undergoing aotic valve replacement and provide precise guidance for fluid therapy and vasoactive drug administration.