原位心脏移植术的围术期临床经验及效果

目的总结心脏移植围术期的心肌保护方法和经验。方法2003年3月至2005年11月为11例终末期心脏病患者实施了原位心脏移植,其中心-肺联合移植、心-肾联合移植各1例。采取标准法1例,双腔静脉法10例。结果全组热缺血时间8￣12min,冷缺血时间90￣292min,术中心肌自动复跳10例,1例电除颤复跳。术后1周超声心动图示各心腔大小、EF值均在正常范围。死亡3例:心-肺联合移植术后气管吻合口瘘合并重度感染1例,心-肾联合移植、单纯心脏移植术后急性肾功能衰竭各1例。随访1￣29个月,8例存活患者心功能均恢复至Ⅰ￣Ⅱ级。结论心脏移植术中除在供心的正确切取过程中注意供心的心肌保护外,还应在术中吻合、术后管理过程的整个围手术期都要重点加强心肌保护,这些均是手术成功的重要基础。     

60例风湿性心脏病双瓣膜置换术的临床治疗体会

目的总结风湿性心脏病、主动脉瓣及二尖瓣双瓣膜置换术的治疗经验，进一步降低手术并发症及死亡率。方法自1998年2月至2004年12月行风湿性心脏病、双瓣膜置换术60例，其中前16例采用4℃冷晶体停跳液间断灌注行心肌保护，后其余44例采用含甲基强地松龙、FDP冷血停跳液（10℃～15℃）加温血诱导停搏、复苏早期温血再灌注技术。结果前16例心脏自动复跳率为43，75％（7／16），3例术后发生低心排综合征。1例因心肌保护不佳，复跳后不能脱机死亡。1例术后第7天死于肺部感染、呼吸衰竭。后44例心脏停跳后心肌颜色红润、质地柔软、表面无出血点，自动复跳率为95.45％（42／44），术后呼吸机辅助通气时间较前明显缩短，应用血管活性药物剂量减小，部分病人可以不用升压药物，无早期死亡。本组死亡率为3.33％。结论加强术前处理、改善心功能及营养状况，不断改进和完善心肌保护方法，重视巨大左房及功能性三尖瓣关闭不全的处理，是降低手术死亡率提高手术疗效的关键。采用含甲基强的松龙、FDP冷血停跳液加温血诱导、复苏早期温血再灌注技术，对术前心功能差、多瓣膜病变、主动脉阻断时间较长的重症患者更为适合，可认为是目前最佳的心肌保护方法。     

不停跳冠状动脉旁路移植加左心室重建术治疗左室室壁瘤10例

目的总结10例不停跳冠状动脉旁路移植加左心室重建术治疗左室室壁瘤的手术经验。方法2002年12月至2006年6月,对术前心脏超声及左室造影未提示明显附壁血栓的10例心梗后左室室壁瘤患者,行不停跳冠状动脉旁路移植同期左心室重建术,左心室重建前行冠状动脉旁路移植,1例室壁瘤在非体外循环下行闭式缝合,其余在常温体外循环心脏不停跳下行心内膜荷包环缩或心内室壁瘤缝合。结果平均每例吻合冠脉(3.3±1.2)支,室壁瘤闭式缝合1例,心内膜荷包环缩6例,心内室壁瘤缝合3例。术后主动脉内囊反搏治疗1例。全组无死亡,术后心绞痛消失,心脏超声提示心功能指标改善,无中枢神经系统并发症、心梗及恶性心律失常发生。结论不停跳冠状动脉旁路移植加左心室重建术,治疗低血栓栓塞风险的心梗后左室室壁瘤,可减轻心肌缺血及再灌注损伤,心肌血运重建同时重建左室形态。     

长时间心肌血运阻断心脏手术的心肌保护临床经验

本文报告34例心肌血运阻断时间超过180分钟的心脏手术心肌保护的经验。升主动脉阻断时间180—346分钟,平均215分钟。本文介绍了术中心肌保护的方法。结果17例(50％)自动复跳,5例死亡,其中2例与心肌保护有关。作者认为用本文介绍的方法保护心肌,对心肌血运阻断3—4小时左右的手术是比较安全的。     

全心脏原位移植(附4例报告)

目的总结4例全心脏原位移植的经验。方法我院于2005年4月至2006年12月对4例扩张型心肌病患者施行了全心脏原位移植手术,其中男性2例,女性2例,年龄32～57岁。供体均为急性脑死亡者。供心心肌保护3例为UW,1例为HTK液。全心脏移植吻合次序依次左肺静脉、右肺静脉、下腔静脉、上腔静脉、肺动脉及主动脉,其中2例由于受体全心脏扩大,按常规保留的受体上、下腔静脉长度无法与供体腔静脉吻合,为此,截取一段长4cm的供体肺动脉,一端与受体下腔静脉吻合,另一端与供体下腔静脉吻合。吻合时间78～104min,主动脉阻断时间136～197min,体外循环时间202～261min。主动脉开放后,1例电击复跳,3例自动复跳,均为窦性心律,未安置心脏临时起搏器。结果患者术后3～6h神志清楚,14～19h拔除气管插管,6d拔除所有侵入性监测管道,两周后从ICU迁至普通病房,1例术后52d出现急性排异反应,经处理得到控制,均痊愈出院。术后随访心功能均为I级,窦性心律,2例有轻度三尖瓣反流,2例已经恢复工作。结论全心脏原位移植法不仅保存左右心房解剖上完整性,有利于心功能恢复,减少移植后血栓的发生率,而且使房、室间隔传导系统的完整性免遭破坏,降低了心律失常的发生率,这是一种值得推荐的心脏移植方法。     

猪心保存24小时及复跳后各期的超微结构

本文应用单纯低温法联合低温持续灌注法保存成年猪心24h(共10例)。利用人工心肺机灌注稀释血建立离体心脏工作模型,所有保存的心脏均能复跳。取保存末及复跳后15min～2h的心肌活检,心脏保存24h后,心肌水肿显著,线粒体等均有损害;上述病变在心脏恢复氧合血灌注复跳后各期明显减轻,说明用本法保存心脏保存期出现的超微结构改变是可逆的。     

儿童心脏瓣膜置换术的体外循环管理

目的 总结15岁以下儿童心脏瓣膜置换术中体外循环的特点，探讨最佳的体外循环方法。方法 回顾性分析2006年01月- 2016年01月上海交通大学医学院附属新华医院15岁以下61例行瓣膜置换患者临床资料。其中男39例，女性22例，年龄1-15岁。病因中先天性瓣膜发育异常36例，感染性心内膜炎9例，先天性心脏病术后13例，瓣膜成形术后3例；所有手术均使用进口中空纤维膜式氧合器。浅或中低温中高流量灌注。采用4:1冷氧合血灌注进行心肌保护。全组病人术中使用常规超滤，部分患儿术后使用改良超滤。结果 患者CPB时间（115.5±57.1） min，主动脉阻断时间（65.5±39.4） min。术中灌注压30-60mmHg，转流过程平稳，尿量满意，心脏自动复跳率96%，全部顺利脱机。全组院内死亡1例（1.6%），术后出现并发症6例(9.8% )。结论 儿童瓣膜置换手术的体外循环，合理的预充和血液稀释，良好的心肌保护，充分的组织灌注；超滤技术的应用等是降低儿童瓣膜手术后并发症，提高体外循环质量的重要方法。     

缺血预适应对先天性心脏病者体外循环的心电图影响

目的　观察单用冷停搏液与缺血预适应 (IPC)加冷停搏液联合应用对先天性心脏病 (CHD)心内直视手术者心电图的影响。方法　CHD者 2 0例 ,随机分为缺血预适应组 (IPC组 )和对照组。IPC组阻断升主动脉前实施 3min缺血～ 5min再灌注的IPC ,然后阻断升主动脉 ,灌注冷 (4C)StThomas停搏液 ,心脏完全停跳后开始心内手术。对照组不进行IPC方案。 2组于并行循环前、开放升主动脉复跳后及IPC期间观察心电图变化 ,同时记录血流动力学指标。结果　IPC组阻断升主动脉期间ST段降低 (阻断 30s时发生 ) ,开放升主动脉后ST段在 15s内完全恢复。IPC期间 ,4例出现窦性心动过缓 ,开放升主动脉后 4例自动复跳 ,3例除颤后复跳者出现一过性室性早搏 ,心脏复跳后 6 0min未发现ST -T改变。对照组 2例自动复跳 ,6例除颤后复跳者出现频发室性早搏 (药物干预后终止 ) ,5例患者心脏复跳后出现T波倒置或双向 ,3例伴ST段水平或下斜型降低 ,复跳后 6 0min仍有 2例ST -T改变未恢复。 2组血流动力学维持平稳 ,对照组有 3例转后单次应用多巴胺 ,心脏复跳后 6 0min时IPC组心率明显低于对照组 ,而平均动脉压则高于对照组 (P <0 0 5 )。结论　IPC可显著改善心肌对缺血耐受能力 ,具有良好的心肌保护效果     

冠状动脉傍路移植术后尸体解剖的研究

作者对60例傍路移植术后死亡和145例冠心病死亡患者进行了病理学研究,为了解吻合口、移植静脉、冠状动脉、心肌输出血管、未手术的冠状动脉、以及侧枝循环的情况,60例中44例尸解研究的第一步是作选择性冠状动脉电影摄影,后改用动物胶与造影剂混合物灌注冠状动脉,切开心脏,平铺固定后作X线全面及定点拍片,然后将心脏横切成切片再摄片。冠状动脉亦从心肌游离后     

原位心脏移植5例初步经验

目的总结原位心脏移植成功的初步经验。方法2000年9月至2004年9月为5例扩张型心肌病患者行原位心脏移植术,其中标准原位心脏移植手术2例,双腔静脉吻合法3例。结果本组5例无手术死亡,2例术后因右心衰竭和真菌感染致肾功衰竭分别于术后第14天和第76天死亡,其余3例至今(2005年5月)存活,最长生存时间近5年,生活质量良好,心功能0～I级。结论合适的受体选择,良好的心肌保护,术后并发症的有效防治和合理的免疫治疗,是心脏移植成功的重要因素。     

先心病心脏不停跳下心内直视手术(附555例报告)

目的 :介绍浅低温体外循环心脏不停跳心内直视手术治疗先天性心脏病心内畸形的应用体会。方法 :5 5 5例先心病患者采用该手术 ,常规建立体外循环 ,置左心房引流管 ,降温至 32± 1℃并维持 ,仅阻断上下腔静脉 ,不阻断主动脉 ,维持灌注压在 6 0mmHg左右 ,心脏跳动下施行畸形矫正 ,方法同停跳手术。结果 :死亡 11例 (死亡率 2 .0 % ) ,其余均痊愈出院 ,随访 1～ 13个月 ,恢复良好。结论 :浅低温心脏不停跳心内直视手术 ,是一种有效的心肌保护方法 ,能减少并发症的发生 ,缩短体外循环时间。     

Intraoperative cardiac troponin T release and lactate metabolism during coronary artery surgery: comparison of beating heart with conventional coronary artery surgery with cardiopulmonary bypass

OBJECTIVE: To compare cardiac troponin T release and lactate metabolism in coronary sinus and arterial blood during uncomplicated coronary grafting on the beating heart with conventional coronary grafting using cardiopulmonary bypass. DESIGN: A prospective observational study with simultaneous sampling of coronary sinus and arterial blood: before and 1, 4, 10, and 20 minutes after reperfusion for analysis of cardiac troponin T and lactate. Cardiac troponin T was also analysed in venous samples taken 3, 6, 24, 48, and 72 hours after surgery. SETTING: Cardiac surgical unit in a tertiary referral centre. PATIENTS: 18 patients undergoing coronary grafting on the beating heart (10 single vessel and eight two-vessel grafting) and eight undergoing two-vessel grafting with cardiopulmonary bypass. RESULTS: Cardiac troponin T was detected in coronary sinus blood in all patients by 20 minutes after beating heart coronary artery surgery before arterial concentrations were consistently increased. Peak arterial and coronary sinus cardiac troponin T values on the beating heart during single (0.03 (0 to 0. 05) and 0.09 (0.07 to 0.16 microg/l, respectively) and two-vessel grafting (0.1 (0.07 to 0.11) and 0.19 (0.14 to 0.25) microg/l) were lower than the values obtained during cardiopulmonary bypass (0.64 (0.52 to 0.72) and 1.4 (0.9 to 2.0) microg/l) (p < 0.05). The area under the curve of venous cardiac troponin T over 72 hours for two-vessel grafting on the beating heart was less than with cardiopulmonary bypass (13 (10 to 16) v 68 (26 to 102) microg.h/l) (p < 0.001). Lactate extraction began within one minute of snare release during beating heart coronary surgery while lactate was still being produced 20 minutes after cross clamp release following cardiopulmonary bypass. CONCLUSIONS: Lower intraoperative and serial venous cardiac troponin T concentrations suggest a lesser degree of myocyte injury during beating heart coronary artery surgery than during cardiopulmonary bypass. Oxidative metabolism also recovers more rapidly with beating heart coronary artery surgery than with conventional coronary grafting. Coronary sinus cardiac troponin T concentrations increased earlier and were greater than arterial concentrations during beating heart surgery, suggesting that this may be a more sensitive method of intraoperative assessment of myocardial injury.     

Redo mitral valve operation via right minithoracotomy--"no touch" technique

Five patients who had had previous cardiac operations underwent minimally invasive beating heart mitral valve operations via a right minithoracotomy between November 2006 and February 2009. The mean age was 64 ± 10 years and 4 were female. Under general anesthesia with single-lumen ventilation, cardiopulmonary bypass was established using the right femoral artery and vein. Through right minithoracotomy, the left atrium was opened without dissection of pericardial adhesion. The aorta was not cannulated or clamped, using a so-called "No Touch" technique. Four patients had mitral valve replacement and one had mitral ring annuloplasty with the heart beating. Mean cardiopulmonary bypass time was 118 ± 38 minutes. There was no early mortality or confirmed stroke. One patient who underwent mitral ring annuloplasty for ischemic mitral regurgitation died 3 months after surgery due to renal failure. At follow-up, New York Heart Association functional class had improved in 3 patients. In conclusion, in our initial series, minimally invasive beating heart redo mitral valve surgery through right minithoracotomy was safely performed with no early mortality.     

Effects of aortic balloon pumping during cardiopulmonary bypass on myocardial perfusion, metabolism, and contractility.

This study was undertaken to determine if the production of pulsatile flow by the intra-aortic balloon pump during cardiopulmonary bypass has any beneficial effect on coronary flow, regional myocardial flow, myocardial metabolism, and left ventricular function. Thirty-six conditioned dogs were subjected to one hour of total normothermic cardiopulmonary bypass. They were divided into the following five groups: (1) controls, beating heart and femoral inflow; (2) balloon, beating heart, and femoral inflow; (3) balloon, beating heart, and aortic inflow; (4) control, fibrillating heart and femoral inflow; and (5) balloon, fibrillating heart, and femoral inflow. Total coronary flow, left ventricular flow, coronary sinus flow, and the endocardial-to-epicardial flow ratio increased in group 3. This increase in flow may have been in part due to increased resistance to flow in the descending aorta by the balloon. No differences in flow were noted in the other groups, all of which were perfused via the femoral artery. No significant differences in myocardial metabolism or left ventricular contractility could be demonstrated between balloon-treated and control groups in these normal hearts.     

新型肺动脉带瓣管道移植动物实验与血流动力学评价

目的:对我们与佰仁公司共同研制的肺动脉带瓣管道进行犬移植实验并进行血流动力学评价。方法:肺动脉带瓣管道在体外循环辅助心脏不停跳下对犬行肺动脉瓣置换术,术后持续监测生命体征,术中及术后观察瓣膜血流动力学变化。结果:8条犬6条存活,且存活均超过1个月,存活个体状态良好。死亡的犬中1条由于呼吸机故障,1条可能与瓣膜不匹配有关。手术前后无明显血流动力学变化,手术后右室-肺动脉无明显压差。结论:新型改良肺动脉带瓣管道植入实验犬是适合的。新型肺动脉带瓣管道已显示出优良的血流动力学优势。     

Mitral valve replacement on a beating heart

We report the case of a patient who needed mitral valve replacement but was at a high risk of myocardial injury with the conventional technique (cardioplegic arrest on cardiopulmonary bypass). Valve replacement was carried out on a beating heart on cardiopulmonary bypass by perfusing the heart continuously with oxygenated noncardioplegic normothermic blood via the coronary sinus.     

Anaesthetic considerations for noncoronary surgery on a perfused beating heart under cardiopulmonary bypass

Myocardial revascularisation on a beating heart with or without cardiopulmonary bypass has significantly reduced the incidence of cardioplegic myocardial injury. With this advantage in view, noncoronary open heart surgery was performed on a beating heart under cardiopulmonary bypass. We discuss the anaesthetic management of such cases. Thirty-three patients aged 14-56 years underwent open heart surgery on a perfused beating heart. Eleven of them underwent open mitral valvotomy, eighteen underwent mitral valve replacement, repair of atrial septal defect was performed in 3 patients and one had removal of left atrial myxoma. Cardiopulmonary bypass was instituted with aortic and bicaval cannulation. At normothermia, aorta was cross-clamped and continuous coronary perfusion was maintained through an aortic root needle at a rate of 4-6 mL/Kg/minute facilitating a beating heart. Trans-oesophageal echocardiography was routinely deployed. Anaesthetic considerations were focused towards the maintenance of the beating state of the heart, that included, strict control of electrolyte balance, maintenance of adequate perfusion pressure and ST segment monitoring. All the patients could be weaned off cardiopulmonary bypass without defibrillation or significant inotropic support. There was no operative mortality. Open heart surgery on a beating heart for non-coronary cardiac conditions appears to be a good and reproducible option to protect the myocardium from deleterious effects of cardioplegic arrest.     

Coronary-coronary bypass using vein graft on a beating heart in a patient with porcelain aorta

There is increased risk of systemic embolism during cardiopulmonary bypass in patients with a severely atherosclerotic ascending aorta. We report a coronary-coronary bypass in a 74-year-old man with a porcelain aorta. He underwent a proximal right coronary-distal right coronary artery bypass with a saphenous vein graft, combined with a pedicled arterial graft (left internal mammary artery) to the left anterior descending artery, in the presence of a beating heart without cardiopulmonary bypass. The patient survived without evidence of perioperative myocardial infarction or cerebrovascular accident. One year later, follow-up angiography showed graft patency with good distal run-off. Coronary-coronary bypass on a beating heart without cardiopulmonary bypass can be performed safely in a patient with porcelain aorta.     

心脏停跳与不停跳先心病矫治术患者围术期cTnⅠ及心肌酶水平变化

目的探讨心脏停跳与不停跳先天性心脏病（先心病）矫治术对心肌的损伤程度,并寻找敏感性评价指标。方法将40例同期拟行先心病矫治术的患者随机分为对照组和观察组各20例,分别于心脏停跳与不停跳下手术,两组麻醉及体外循环（CPB）方法相同。分别于围术期检测血清心肌肌钙蛋白Ⅰ（cTnⅠ）、肌酸激酶同工酶（CK-MB）、乳酸脱氢酶（LDH）、肌酸激酶（CK）、AST、α-羟丁酸脱氢酶（HBDH）,同时观察心电图及心脏超声指标改变。结果两组围术期心电图及心脏超声指标均无明显异常,但术中、术后血清cTnⅠ及CK、CK—MB、LDH水平均明显升高,对照组显著高于观察组;其中血清cTnⅠ水平升高出现早、恢复慢（术后72h时仍显著高于术前水平）。结论心脏不停跳先心病矫治术对心肌的损伤小于心脏停跳手术;cTnⅠ是评价心脏手术围术期心肌损伤敏感的特异指标．     

主动脉手术体外循环的初步体会

10例主动脉手术在体外循环下进行。降主动脉手术4例,升主动脉手术5例,主动脉弓离断(B型)手术1例。根据不同手术分别采用低温体外循环,深低温停循环或左心转流。本组死亡3例。本文讨论了左心转流的方法,深低温停循环的安全时限,B型主动脉弓离断手术的体外循环管理,及防止人工血管渗血的问题。