微创心脏手术不同术式的插管特点及体外循环管理经验

Intubation Characteristics and Cardiopulmonary Bypass Management Experience of Different Surgical Procedures in Minimally Invasive Cardiac Surgery

目的 总结在微创心脏手术(MICS)中采用不同手术方式的插管特点及体外循环(CPB)的管理经验。方法 回顾性分析2020年10月至2022年2月阜外华中心血管病医院完成的MICS。总结人口学特征和手术病种;依据手术切口部位或插管方式进行分类汇总,阐述不同MICS术式的麻醉、手术和CPB管理特点;总结CPB的围手术期指标和不良事件发生情况。结果 共有195例患者纳入研究,其中男110例(56.4%),年龄12~83(45.73±15.11)岁,手术病种包括先天性心脏病(64例)、瓣膜手术(109例)、大血管手术(5例)、心脏肿瘤(17例)。外科切口部位包括右前外侧2~4肋间、胸骨中段“J”形切口及胸骨上段小切口。插管方式分为:股动脉和股静脉(FAV),股动脉、股静脉和右侧颈内静脉(FAV-RJV),股动脉、股静脉和上腔静脉(FAV-SVC),股动脉和右房(FA-RA)。所有病例均完成手术,CPB转流时间70~227(119.24±48.52)min,心脏停跳时间32~195(75.30±30.11)min,超滤量700~3 300(1 350.73±362.43)mL。36例(18.5%)患者围手术期未使用红细胞。所有手术均在心脏停跳下进行,其中89例(46.8%)自动复跳,112例(58.9%)安置临时起搏器,术后机械通气时间5~12(6.52±1.43)h,胸腔引流量30~570(174.72±36.91)mL,ICU停留时间8~55(15.13±6.74)h。11例(5.6%)由于手术矫正不满意经历二次CPB,2例(1.0%)因插管困难转为正中开胸,2例(1.0%)术后出现插管并发症接受骨筋膜室切开减压,4例(2.1%)因引流量多接受胸腔镜下二次开胸止血,无住院死亡。结论 在MICS中,应根据拟行手术方式、患者血管情况选择插管型号和方式,灌注医生应提前制定灌注预案,根据外科医生习惯制定不同的灌注策略,良好的沟通和多学科有效协作是保证手术成功的关键。

Objective To summarize the intubation characteristics and cardiopulmonary bypass(CPB) management experience of different surgical procedures in minimally invasive cardiac surgery(MICS).Methods Analyzed the MICS which were completed in Fuwai Central China Cardiovascular Hospital from October 2020 to February 2022 retrospectively.Summarized the demographic characteristics and surgical diseases.Classified these surgeries according to the surgical incision site or intubation method.Evaluated the characteristics of anesthesia,surgery and CPB management of different MICS procedures,and summarized the perioperative indicators and adverse events of CPB.Results A total of 195 patients were included in the study.Among them,110 cases(56.4%) were male and the age was 12-83(45.73±15.11) years old.The diseases include congenital heart disease(64 cases),valve surgery(109 cases),major vascular surgery(5 cases) and cardiac tumor(17 cases).Surgical incision sites include right anterolateral 2-4 intercostal space,mid-sternum “J” incision and small incision in the upper sternum.Intubation methods were divided into femoral artery and femoral vein(FAV),femoral artery,femoral vein and right internal jugular vein(FAV-RJV),femoral artery,femoral vein and superior vena cava(FAV-SVC),femoral artery and right atrium(FA-RA).Operation was completed in all cases.The CPB switching time was 70-227(119.24±48.52) minutes,the cardiac arrest time was 32-195(75.30±30.11) minutes,and the ultrafiltration volume was 700-3 300(1 350.73±362.43) mL.And 36 patients(18.5%) did not use erythrocytes during perioperative period.All patients accepted surgery under cardiac arrest,and 89 cases(46.8%) of which were auto-rebeat,and 112 patients(58.9%) who implanted with a temporary pacemaker.The postoperative mechanical ventilation time was 5-12(6.52±1.43) hours,and the chest drainage volume was 30-570(174.72±36.91) mL.The ICU stay time was 8-55(15.13±6.74) hours.Eleven patients(5.6%) underwent a re-CPB due to unsatisfactory surgical correction.Two cases(1.0%) were turned to median thoracotomy due to difficulty in intubation.Two cases(1.0%) had osteofaceial compartments syndrome and underwent compartment decompression.Four cases(2.1%) underwent secondary thoracotomy to stop bleeding due to drainage volume.There was no in-hospital deaths occurred.Conclusion In MICS,the type and mode of catheter should be selected according to the proposed surgical method and the patient’s vascular condition.Perfusionists should make plans in advance and develop different strategies according to the surgeon’s habits.Good communication and effective multidisciplinary collaboration are the key to a successful operation.