再次瓣膜置换术的体外循环管理

在体外循环下行再次瓣膜置换术96例，手术过程均顺利。认为充分的术前准备、膜式氧合器的应用、良好的心肌保护、抑肽酶术后止血、应用超滤或改良超滤是再次瓣膜置换术体外循环管理的关键。     

改良超滤联合常规超滤对重症瓣膜病患者瓣膜置换术后肺保护的作用

目的:探讨改良超滤联合常规超滤技术对体外循环瓣膜置换术后肺损伤的改善作用.方法:纳入102例行瓣膜置换术的重症瓣膜病患者,分为常规超滤组(CUF组)和常规超滤联合改良超滤组(CMUF组),两组在体外循环(CPB)中均进行常规超滤,CMUF组在转流结束后进行改良超滤直至机血全部回输体内.分别于诱导后(T1)、常规超滤开始...     

零平衡超滤对体外循环瓣膜置换术患者白细胞介素-6、白细胞介素-10和高敏C-反应蛋白的影响

目的探究体外循环(cardiopulmonary bypass,CPB)下零平衡超滤对心脏瓣膜置换术患者促炎因子白细胞介素(interleukin,IL)-6、IL-10和高敏C-反应蛋白(high sensitivity C-reactive protein,hs-CRP)浓度的影响。方法选取2015年1月至2017年1月梅州市人民医院收治的CPB心脏瓣膜置换术患者40例,按随机数字表法分为观察组(n=20,零平衡超滤组)和对照组(n=20,常规超滤组),分别于CPB前(T_1)、超滤毕即刻(T_2)、术后24 h(T_3)、48 h(T_4)、72 h(T_5)时间点采集动脉血标本,采用双抗体夹心酶联免疫吸附法(ELISA)法测定血浆中IL-6和IL-10浓度,免疫比浊法测定血浆hs-CRP浓度。收集患者术前和术后的临床资料。结果两组患者基线资料比较,差异无统计学意义(P0.05);两组患者术中的临床指标比较,差异无统计学意义(P0.05);两组患者术前IL-6、IL-10和hs-CRP浓度均在正常范围,组间比较差异无统计学意义(P0.05);两组患者的IL-6浓度于CPB开始后均有显著升高,术后24 h时均达到峰值,术后72 h仍高于术前,差异均有统计学意义(P0.01);且观察组在T_3、T_4、T_5时刻IL-6浓度均显著低于对照组,差异均有统计学意义(P0.05)。两组患者的IL-10浓度术后即刻均显著升高,术后24 h均达到峰值,术后72 h仍高于术前,差异均有统计学意义(P0.01);观察组的IL-10浓度在T_2、T_3、T_4、T_5时刻均低于对照组,但差异无统计学意义(P0.05)。两组患者的血浆hs-CRP浓度于CPB开始后均缓慢升高,术后48 h均达到峰值,术后72 h仍高于术前,差异均有统计学意义(P0.01);且观察组血浆hs-CRP浓度在T_3、T_4、T_5时刻均显著低于对照组,差异均有统计学意义(P0.05)。结论 CPB瓣膜置换术中患者血液IL-6、IL-10和hs-CRP浓度会产生明显变化。零平衡超滤能有效降低术后炎症反应,减少机体损伤,改善临床预后,值得临床推广应用。     

老年患者心脏瓣膜置换术后急性肾衰竭透析治疗的高危因素分析

目的探讨老年患者心脏瓣膜置换术后急性肾衰竭(ARF)透析治疗的高危因素。方法将年龄>65岁行心脏瓣膜置换术后发生ARF需要透析的43例患者作为透析组,另选年龄同上行心脏瓣膜置换术无需透析的86例患者作为对照组,应用logistic回归进行多因素分析,筛选出心脏瓣膜置换术后ARF需透析治疗的高危因素。结果透析组患者术前NYHA分级、LVEF、肌酐、尿素水平、体外循环时间、术后发生低心排综合征。24h内输入库血量与对照组比较,差异有统计学意义(P<0.05,P<0.01);其中术后发生低心排综合征、体外循环时间与术后ARF需要透析的关系最为密切。结论年龄不是老年患者心脏瓣膜置换术后ARF需透析治疗的高危因素,其发生与术后低心排综合征、体外循环时间关系最为密切,积极防范和应对可以减少这种严重并发症的发生。     

糖尿病患者体外循环心脏手术后早期脑损伤的临床研究

目的　探讨糖尿病患者行体外循环心脏手术后早期脑损伤的情况。方法　随机选择行瓣膜置换术的糖尿病患者 16例为实验组 ,非糖尿病患者 2 0例为对照组。在体外循环结束后 5小时抽血 ,采用 EL ISA法检测血清 S10 0 B蛋白浓度 ,以判断脑损伤的发生。结果　实验组和对照组的术后早期脑损伤发生率分别为 94 %和6 5 % ,有显著性差异 (P<0 .0 5 )。结论　糖尿病患者在体外循环术后脑损伤的发生率明显高于非糖尿病患者。为减少糖尿病患者术后脑损伤的发生 ,术前必须严格控制血糖 ,术中严密观察血糖变化 ,术中和术后及时应用胰岛素控制血糖。     

改良超滤在重症瓣膜病体外循环中的临床应用

目的总结重症心脏瓣膜病体外循环中使用改良超滤的临床经验,探讨提高早期生存率的措施。方法自2005年6月至2008年7月,对78例重症心脏瓣膜病行瓣膜置换术体外循环中加用改良超滤,其中单纯二尖瓣置换12例,二尖瓣置换十三尖瓣成形22例,单纯主动脉瓣置换8例,二尖瓣＋主动脉瓣置换＋三尖瓣成形35例,二尖瓣置换＋冠状动脉旁路移植术1例。复温开始超滤,在血液动力学基本稳定时,开始改良超滤,超滤时间和超滤量以红细胞压积来决定,根据患者的血容量、胶体渗透压、红细胞压积,选择超滤速度和滤出量。结果死亡6例,其中术后并发低心排血量5例,心室颤动治疗无效死亡1例,死亡率7．69％。随访53例,平均随访2．5年,死亡5例。结论改良超滤能高效超滤多余水分减少机体水肿和滤出炎症介质减少炎性反应,提高了左心室收缩功能及舒张顺应性,明显提高术后心指数、左室每搏功指数和每搏指数,减少术后早期尿量,缩短呼吸机辅助通气时间和重症监护时间,重症瓣膜病手术患者应用改良超滤会有效提高术后早期的预后。     

超滤与改良超滤在婴幼儿体外循环手术的应用

目的探讨超滤与改良超滤法对婴幼儿心内直视手术的影响.方法1999年1月至2004年1月行婴幼儿心内直视手术60例,分为两组,治疗组采用超滤和改良超滤,对两组患者体外循环时间、呼吸机使用时间、术后出血及输血等进行了比较.结果术后呼吸机辅助时间、术后出血两组差异有统计学意义(t=2.66,3.49,P＜0.05,0.01).结论超滤与改良超滤在体外循环中可快速有效的脱水,减少体外循环后的出血,有利于患者的术后恢复和呼吸机的脱离.     

温、冷血停搏液间断灌注在瓣膜置换术中的心肌保护作用

目的比较体外循环下温血停搏液间断灌注与冷血停搏液间断灌注在瓣膜置换术中的心肌保护作用.方法36例心脏瓣膜置换术患者被随机分为温血间断灌注组(n=18)和冷血间断灌注组(n=18),分别于体外循环前,主动脉开放后30分钟、6小时、24小时采集动脉血,测血清心肌肌钙蛋白Ⅰ(cTnI)浓度.二尖瓣置换患者在主动脉开放时从冠状静脉窦抽取静脉血,检测乳酸浓度.部分患者于主动脉阻断前,开放后30分钟分别取右心房组织,透射电镜观察心肌超微结构.结果瓣膜置换术中温血停搏液间断灌注的心肌保护作用与冷血停搏液间断灌注近似,具有临床应用价值.两组各时间点血清cTnI浓度组间差异无显著性,温血间断灌注组冠状静脉窦血乳酸浓度高于冷血间断灌注组(P＜0.05),两组心肌超微结构变化近似.结论瓣膜置换术中温血停搏液间断灌注的心肌保护作用与冷血停搏液间断灌注近似,具有临床应用价值.     

平衡超滤加改良超滤对婴幼儿体外循环术后血清炎症介质水平的影响

目的观察平衡超滤加改良超滤对低体重婴幼儿体外循环术后血清炎症介质水平的影响。方法40例低体重先天性心脏病患儿,随机分为观察组和对照组,各20例。观察组在体外循环术中施行平衡超滤加改良超滤技术,对照组未应用超滤技术。测定两组患儿术前、体外循环术后即刻及3、6、24h血清肿瘤坏死因子（TNF）-α及白细胞介素（IL）-6、8水平。结果体外循环后各时点观察组患儿血清TNF—α、IL-6、IL-8水平均显著低于对照组。结论平衡超滤加改良超滤技术可显著降低体外循环术后患儿血清TNF—α、IL-6、IL-8的水平。     

65岁以上老年患者心脏瓣膜手术中的体外循环管理

目的总结65岁以上老年人心脏瓣膜置换术的体外循环管理方法。方法回顾性分析2006年1月至2008年12月老年人心脏瓣膜置换术232例患者的临床资料,着重分析体外循环方法和手术方法。全部患者采用气管插管、静吸复合麻醉,中度血液稀释、中度低温、中高流量,冷含血停跳液进行心肌保护,全部应用超滤器。结果体外循环时间（87.2±32.7）min;主动脉阻断时间（58.3±27.5）min。转流中平均动脉压维持在60～90mm Hg（1mm Hg=0.133kPa）,超滤量为800～8300mL,心脏自动复跳率86%,本组早期死亡10例（4.3%）。结论体外循环中加强心肌保护;控制血液稀释度,使用血液超滤技术维持机体内环境的稳定;有效的组织灌注以及良好的保护等综合性措施,有助于脑、肾、肺等重要脏器的保护,有利于提高老年患者心脏瓣膜置换术中体外循环的质量,并确保手术安全。     

Atrial natriuretic factor release in postoperative cardiothoracic surgical patients

Immunoreactive atrial natriuretic factor (ANF) levels were measured preoperatively and for 5 days postoperatively in 22 patients undergoing cardiothoracic surgery. They were studied in 4 groups according to surgical procedure (mitral valve replacement, aortic valve replacement, coronary artery bypass grafting, and lung resection). The highest preoperative ANF levels were observed in the aortic valve group (mean 40.9 pmol/L) which were 2.5 (95% CI: 0.7 to 8.6) to 3.5 (95% CI: 0.9 to 13.9) times higher than the other groups. Values tended to peak on the 3rd and 4th postoperative days in all groups, although significantly elevated postoperative ANF concentrations occurred only in the coronary artery bypass group where the levels increased by a factor of 3.2 (95% CI: 1.3 to 7.5). As a separate part of the study, measurement of ANF release before, during, and after cardiopulmonary bypass in 6 patients tended to show a fall in ANF levels when on bypass, with a return to baseline levels on cessation of bypass.     

Intraoperative contrast echocardiography to evaluate mitral valve operations

Intraoperative two-dimensional contrast echocardiography was performed on 29 patients undergoing open heart surgery to determine the presence of mitral regurgitation before and immediately after the operative procedure: 14 patients had predominant mitral stenosis, 9 had severe mitral regurgitation and 6 had no mitral valve disease (control subjects). Two-dimensional echocardiography was performed by applying a 5 MHz transducer directly on the heart during injection of saline solution through an apical ventricular sump or transseptal needle, generating contrast microbubbles, with imaging in two planes. Baseline studies were performed after thoracotomy and pericardiotomy before cardiopulmonary bypass, and a second study was done after the operative procedure, with the patient off cardiopulmonary bypass with hemodynamic stabilization before chest closure. No control subject had contrast evidence of mitral regurgitation before or after cardiopulmonary bypass. Two of three patients with mitral valvuloplasty and two of five with commissurotomy required a second operative procedure before chest closure because of persistent mitral regurgitation detected by intraoperative two-dimensional contrast echocardiography. Thirteen of the 15 patients with valve replacement had no mitral regurgitation after cardiopulmonary bypass. Intraoperative two-dimensional echocardiographic findings correlated with data from postoperative clinical examinations and two-dimensional echocardiography-Doppler studies. It is concluded that two-dimensional echocardiography with contrast is an important intraoperative tool for assessing the presence and relative severity of mitral regurgitation after mitral commissurotomy, valvuloplasty or valve replacement. This technique may allow surgeons to be more aggressive in combining reparative operative procedures (that is, commissurotomy and valvuloplasty) in an attempt to retain native valves.     

电针预处理对心脏外科手术患者早期认知功能障碍的影响

目的: 观察术前给予电针预处理对全麻体外循环下行冠状动脉搭桥术和心脏瓣膜置换术的患者早期认知功能障碍（POCD）发生率的影响。方法: 选择择期在全麻体外循环下行冠状动脉搭桥术和心脏瓣膜置换术的患者106（男49,女57）例,随机将其分为电针预处理组和对照组两组。电针预处理组在术前连续5 d给予电针预处理,取患者双侧“内关”(PC6)、“列缺”(LU7)、“云门”(LU2)穴给予电针预处理（“华佗”牌SDZ-Ⅱ型电子针疗仪,苏州医疗用品有限公司）,30 min/d。分别在术前、术后7 d及术后14 d对所有患者进行神经心理学评估,采用简易智力量表、数字符号测试、数字广度测试、循环连线测试和小故事记忆测试5项测试。结果: 因各种原因实际参与完整评估的患者共75例,其中电针预处理组38例,对照组37例。两组患者的年龄、性别、身高、体质量、受教育年限等等一般资料及手术时间和麻醉药物总量差异均无统计学意义。电针预处理组与对照组术后7 d POCD发生率分别为26％和24％,术后14 d POCD的发生率分别为10％和14％,两组间差异无统计学意义。结论: 术前给予电针预处理对全麻体外循环下行冠状动脉搭桥术和心脏瓣膜置换术的患者早期认知功能障碍发生率无显著影响。     

改良超滤在成人心脏瓣膜置换术中的应用

目的:总结改良超滤在成人心脏瓣膜置换手术的应用,并评价其减少围术期出血的效果及库血应用情况。方法:将100例体外循环(CPB)下心脏瓣膜置换术成人患者,随机分成改良超滤组(MUF组,n=50)及常规超滤组(CUF组,n=50)。检测两组红细胞压积(Hct)和血小板(Plt)在各时段的变化;并对围术期输血量、出血量,呼吸机辅助通气时间和ICU监护时间进行比较。结果:对照组因出血死亡2例,余98例患者痊愈出院,两组患者Hct和血小板在各时段比较无明显异常,MUF组未输入库血率明显高于CUF组[(29/50)与(14/5),P<0.01)]、输库血量及出血量较CUF组明显减少[(2.7±1.2)vs.(4.2±2.2),P<0.05];[(577±281)vs.(901±591)mL,P<0.05)]、MUF组呼吸机辅助通气时间(12.5±4.4)h、ICU监护时间(16.8±6.7)h和CUF组呼吸机辅助通气时间(17±6.9)h、ICU监护时间(22.0±11.1)h比较,明显缩短(P<0.05)。结论:心脏手术体外循环后采取改良超滤,可迅速回输心肺机管道系统的余血,排出体内多余水分,能迅速浓缩血液成分,减少库血的应用及输入量。     

Impact of intraoperative echocardiography on surgical management of congenital heart disease

Intraoperative echocardiography was performed by epicardial, 2-dimensional, low- and high-pulsed repetition frequency, continuous-wave Doppler and color flow mapping in 50 patients. Forty studies were performed before and 44 studies after cardiopulmonary bypass. Studies before cardiopulmonary bypass agreed with preoperative evaluation. After cardiopulmonary bypass, studies revealed that 11 of 25 patients who underwent repair of ventricular septal defects had residual ventricular septal defects, and 1 of 25 patients who underwent atrial septal repair had 1 residual atrial communication. One patient with a "Swiss cheese" ventricular septum underwent repeat cardiopulmonary bypass to close residual ventricular septal defects. The patient with a residual atrial communication required immediate reoperation because of a right to left shunt after a modified Fontan procedure. Eight of 10 remaining residual ventricular septal defects spontaneously closed 1 to 41 days after operation. Assessment of postcardiopulmonary bypass and postoperative valvular regurgitation in 21 valves revealed good correlation (p less than 0.01). However, 1 patient required reoperation for mitral valve replacement on the sixth postoperative day. The correlation was fair between postcardiopulmonary bypass and postoperative residual stenotic pressure gradients in 12 surgically repaired stenotic lesions. This study shows that little additional information is added to a comprehensive preoperative evaluation by precardiopulmonary bypass intraoperative echocardiography. Postcardiopulmonary bypass intraoperative echocardiography is useful in identifying residual shunts. Assessment of stenotic gradients and valvular regurgitation must be interpreted in light of a changing hemodynamic state.     

Effect of coronary bypass surgery and valve replacement on left ventricular function: assessment by intraoperative two-dimensional echocardiography

Intraoperative two-dimensional echocardiography (2DE) was performed in 15 patients during coronary artery bypass grafting (CABG) and in 14 patients during aortic (AVR) or mitral valve replacement (MVR) before and immediately after cardiopulmonary bypass by means of a 3.5 MHz transducer. Left ventricular ejection fraction (LVEF), end-diastolic (LVEDV) and end-systolic (LVESV) volumes were measured by a light pen system and biplane Simpson's rule from short-axis and apical two-chamber views. In seven patients with CABG and new abnormal Q waves or greater than 5% MB to total CPK ratio postoperatively, the mean LVEF decreased significantly (from 52 +/- 10 to 43 +/- 12%, p = 0.005). Patients undergoing MVR for mitral regurgitation showed, a significant decrease in LVEF (from 63 +/- 10 to 42 +/- 23%, p less than 0.025) and LVEDV (from 166 +/- 34 to 147 +/- 44 ml, p less than 0.05). Mean LVEF also decreased after AVR for aortic regurgitation (from 46 +/- 16 to 26 +/- 15%, p less than 0.05). Six patients with valve replacement and postoperative hypotension had the greatest decrease in intraoperative LVEF (from 50 +/- 12 to 24 +/- 10%, p less than 0.005). It is concluded that: Intraoperative 2DE can be used to assess immediate changes in left ventricular function after CABG or valve replacement. LVEF decreases significantly immediately after AVR for aortic regurgitation and MVR for mitral regurgitation. Intraoperative 2DE may identify those patients who can benefit from inotropic support in the immediate postoperative period after valve replacement.     

Late results of combined mitral valve replacement and coronary bypass surgery

The incremental risk of coronary bypass surgery was analyzed in 718 patients undergoing mitral valve replacement between 1971 and 1983. Ninety-eight patients (14%) had significant coronary artery disease requiring coronary bypass surgery. In 70 of these patients, the origin of the mitral valve disease was nonischemic, whereas 28 patients had ischemic mitral regurgitation unsuitable for conservative valve surgery. There were six operative deaths (9%) and four perioperative myocardial infarctions (6%) after mitral valve replacement and coronary bypass surgery for nonischemic mitral valve disease. Operative mortality was related to low output cardiac failure before operation or perioperative myocardial infarction. Actuarial curves predict survival (+/- standard error) of 55 +/- 7% at 5 years and 43 +/- 8% at 10 years. Preoperative functional class was the only significant predictor of long-term survival in this group (p less than 0.05). The actuarial survival of the 620 patients without coronary artery disease who underwent mitral valve replacement alone was 63 +/- 3% at 10 years. This was significantly better than that of the 70 patients who underwent mitral valve replacement and coronary bypass surgery for nonischemic mitral valve disease (p less than 0.001). Conversely, 5 year survival of the 28 patients with ischemic mitral regurgitation was 43 +/- 10%. This confirms the negative detrimental effect of an ischemic origin of mitral valve disease on survival after mitral valve replacement and coronary bypass surgery (p less than 0.0001).     

Evaluation of cloxacillin concentrations in plasma and muscle tissue during cardiopulmonary bypass.

Concentrations of cloxacillin in plasma and deep thoracic muscle tissue were measured in 10 patients who underwent elective coronary bypass surgery or valve replacement. One g of cloxacillin was administered after the induction of anaesthesia and 1 g cloxacillin was added to the oxygenator pump priming fluid before the start of the procedure. Blood and tissue samples were obtained before, during and after cardiopulmonary bypass. The relation between unbound plasma concentrations and total tissue contents of the drug was calculated. It was shown that measurement of the free plasma concentration may provide fairly reliable information on the free concentrations of cloxacillin in the tissues, and that determination of tissue contents may therefore not be necessary. Due to the administration of the second dose of cloxacillin at the start of cardiopulmonary bypass free tissue contents were just adequate in most patients. However, to obtain adequate tissue concentrations after bypass it is recommended that a third dose of the antibiotic be administered before the end of the operation.     

Effects of cardiopulmonary bypass on thyroid function

Alterations in serum concentration of thyroid hormones occur even in euthyroid patients undergoing cardiopulmonary bypass. The purpose of our prospective study was to define the effects of cardiopulmonary bypass on thyroid hormones. Twenty euthyroid patients for mitral valve replacement were included in this study. Heparinised arterial sample for thyroid function tests were obtained before cardiopulmonary bypass (CPB), 30 and 60 minutes after initiation of CPB, immediate post-CPB and 24 hours after termination of CPB. T3, T4 and thyroid stimulating hormone (TSH) were estimated using radioimmunoassay method. There was more than 50% decrease in T3 levels after initiation of CPB and it remained persistently below the physiological range until 24 hours after termination of CPB. T4 and TSH remained within normal limits throughout the study period. These results indicate that CPB simulates the euthyroid sick syndrome as seen in critically ill and burn patients. Whether routine administration of intravenous tri-iodo thyronine is beneficial in the prevention of low cardiac output syndrome seen after CPB remains to be elucidated in future.