体外循环心脏术后死亡危险因素分析

目的 探讨体外循环心脏术后死亡可能的危险因素.方法 回顾性分析江苏省苏北人民医院从2005年3月至2006年6月体外循环心脏手术36例患者的临床资料.死亡组入选标准:(1)体外循环心脏手术患者;(2)术前心功能Ⅰ-Ⅲ级;(3)术前无其它脏器功能不全;(4)术后28 d内患者死亡;其中死亡组6人,存活组30例.调查内容包括:(1)术前因素:性别,年龄,术前诊断,术前NYHA分级,APACHEⅡ评分,左室舒张末内径.(2)术中因素:手术时间,主动脉阻断时间.(3)术后因素:出血量,机械通气时间,以及术后6h血流动力学及氧代谢指标:心率(HR),中心静脉压(CVP),肺动脉嵌顿压(PAWP),心输出量指数(CI),动脉血乳酸,动脉氧分压(PaO2),混合静脉血氧饱和度(SvO2),氧输送指数(DO2I),氧耗指数(VO2I),全身氧提取率(O2ext).所有数据应用SPSS10.0 for windows统计学软件包进行统计学分析.首先应用单因素相关分析,筛选出两组有显著差异的参数,然后再对这些参数进行多元回归分析,从中找出体外循环心脏术后死亡的独立危险因素.结果 单因素相关分析显示两组间APACHEⅡ评分,左室舒张末内径,主动脉阻断时间,机械通气时间,动脉血乳酸,SvO2等差异有统计学意义(P＜0.05).多元回归分析显示左室舒张末期内径,动脉血乳酸是体外循环心脏术后死亡的两个独立危险因素(P＜0.05).结论 左室舒张末期内径和动脉血乳酸可以作为评价体外循环心脏术后预后的重要指标.     

Biventricular Bypass with Oxygenation for Postcardiotomy Ventricular Failure

Abstract: Between January 1984 and March 1995, biventricular bypass (BVB) with oxygenation was used in 17 patients for postcardiotomy ventricular failure at the Heart Institute of Japan, Tokyo Women's Medical College. Of the 17 patients, 12 (70.6%) were weaned from the circulatory support, and 8 (47.1%) were discharged from the hospital. The time interval from the end of cardiopulmonary bypass to the start of BVB was significantly shorter in weaned patients than in unweaned patients. The duration on support also has been shortened significantly in the last 6 years, compared with the earlier 6 years. Causes of death were severe heart failure or ventricular arrhythmia in 6 patients and multiple organ failure in 3 patients. These results suggest that early application and timely weaning from biventricular bypass with oxygenation might be the effective circulatory support of choice for treatment of postcardiotomy ventricular failure.     

Clinical Experience with BioMedicus Centrifugal Ventricular Support in 172 Patients

Abstract: One hundred and seventy-two patients at The Methodist Hospital in Houston, Texas, were placed on BioMedicus centrifugal ventricular support. One hundred thirty-nine patients were male and 33 were female with a mean age of 59.7 years. Reasons for support were post-cardiotomy cardiac failure (129 patients), cardiac allograft failure (17 patients), bridge to transplantation (10 patients), resuscitation (7 patients), postpercutaneous trans-luminal coronary angioplasty emergent (2 patients), and other (7 patients). Support was by left ventricular assist device in 108 patients, right ventricular assist device in 20 patients, and biventricular assist device in 44 patients. Eighty-four patients (48.8%) were weaned from the ventricular assist device, and 88 patients (51.2%) were not weaned. Thirty-four patients (20.0%) were discharged from the hospital. Complications included coagulopathy, renal insufficiency/failure, respiratory insufficiency/ failure, neurological deficits, sepsis, arrhythmias, and device-related complications. Overall causes of death were ventricular failure (55.1%), triage (13.0%), arrhythmias (9.4%), graft failure (5.9%), coagulopathy (4.3%), sepsis syndrome (2.9%), device-related (0.7%), and other (0.7%). BioMedicus centrifugal ventricular support can be implemented rapidly and easily. Device-related complications are few (1.2%), and it is relatively inexpensive when compared with other ventricular assist systems. This series demonstrates that a substantial number of patients may benefit from temporary centrifugal ventricular support.     

成人心脏术后心包胸骨后固定后的出血患者70例临床分析

目的研究心脏手术关胸时渗血严重病例,用心包胸骨后固定方法,观察术后出血情况,了解此方法是否能够减少术后出血。方法选择同期心脏手术后渗血严重心包完整病例,对比心包胸骨后固定后出血量、术后感染、胸腔积液、心包填塞、呼吸机使用时间及血流动力学改变是否有明显差别。结果心包胸骨后固定在心脏手术后渗血严重心包完整病例中,能有效减少术后出血量,减少用血量,减少医疗费用,证明心包胸骨后固定不失为减少术后出血的一个办法。结论对比心脏手术心包完整创面渗血严重病例,关胸时,将心包胸骨后固定,以此将前纵隔和心包腔分隔开,心包紧贴于胸骨后,以此达到压迫止血目的。对比类似常规关胸病例,出血明显减少,证明心包胸骨后固定能够有效减少术后出血,减少术后用血量,降低医疗费用。     

无创双水平正压通气在心脏手术后急性呼吸衰竭的应用与护理

目的：观察无刨双水平正压通气（Bi-level Positive Airway Pressure）在心脏手术后急性呼吸衰竭的应用与护理。方法：观察20例心脏手术后急性呼吸衰竭患者应用无创双水平正压通气（BIPAP）治疗前、后血气分析及生命指征的变化。结果：18例患者BIPAP治疗后血气分析指标和生命指征得到明显改善。治疗后的PaO2、氧合指数明显提高;呼吸频率、收缩压、心率及PaCO2水平明显下降。2例患者不适应面罩吸氧、加压通气行二次气管插管治疗。结论：早期应用无创双水平正压通气能有效治疗心脏手术后急性呼吸衰竭,快速提高PaO2,降低PaCO2,缓解气促、紫绀、呼吸困难等症状。     

The Short-term Pulsatile Ventricular Assist Device for Postcardiotomy Cardiogenic Shock: A Clinical Trial in China

Abstract:  Despite the recent advances in myocardial protection, surgical techniques, intra-aortic balloon therapy, and maximal pharmacological support, postoperative ventricular dysfunction continues to occur in 0.5–1.0% of all patients undergoing cardiac surgery. Ventricular assist device (VAD) is an important therapeutic adjunct in treating patients with profound ventricular dysfunction with postcardiotomy cardiogenic shock. The purpose of this report was to describe the clinical results with the China-made Luo-Ye VAD as a short-term circulatory support. From May 1998 to December 2006, 17 patients with postcardiotomy cardiogenic shock were supported by the Luo-Ye VAD. Of these patients, 10 were males and seven were females with a mean age of 49.6 years (range 36–68 years). All cases were supported by left VAD (LVAD). Mean duration of support was 46.3 h (range 13–113 h). A criteria of insertion was established to standardize implantation criteria. Among the 17 patients treated with LVAD, eight (47.1%) patients were weaned from support and seven (41.2%) patients were discharged from hospital. Ten (58.8%) patients died while on LVAD support (nine cases) or shortly after weaning (one case). The causes of death in the entire group were cardiac (40%), renal failure (20%), neurologic (10%), sepsis (10%), and multiple organ system failure (20%). The complications were represented by bleeding, renal failure, neurologic event, infection, ventricular arrhythmias, etc. The Luo-Ye VAD functioned well and proved to be useful in patients with postcardiotomy cardiogenic shock. It carries a less-postoperative anticoagulant and a low incidence of VAD-related complications. The survival rate was encouraging in our small cohort of patients.     

Extracorporeal Life Support: A Simple and Effective Weapon for Postcardiotomy Right Ventricular Failure

Postcardiotomy right ventricular (RV) failure develops during the perioperative period following pulmonary hypertensive crisis or acute myocardial infarction. This study reports our institutional experience in treating these patients with extracorporeal life support (ECLS). Between June 2002 and July 2005, 46 adults were treated with ECLS for postcardiotomy shock. Acute RV failure was the cause of support in 14 (30%). Patient mean age was 55.7 ± 15.4 years. Cardiac pathologies were valvular ( n  = 7), coronary ( n  = 1), combined coronary and valvular disease ( n  = 2), complex congenital heart ( n  = 2), aortic aneurysm ( n  = 1), and cardiomyopathy post heart transplant ( n  = 1). The triggers of RV failure were pulmonary hypertension ( n  = 6), RV infarction ( n  = 4), and not defined ( n  = 4). Patients were supported on ECLS for a mean duration of 71 ± 52 h (range, 10–183 h). Major complications included acute renal failure requiring hemodialysis ( n  = 4), reexploration for bleeding ( n  = 2), and acute subdural hematoma ( n  = 1). Nine (64%) patients were successfully weaned from ECLS, and seven (50%) survived to discharge. Preexisting pulmonary hypertension had a favorable tendency for weaning, and acute renal failure requiring hemodialysis correlated with in-hospital mortality. ECLS is beneficial for treating postcardiotomy RV failure when conventional therapy is exhausted. As it can be deployed rapidly and does not require resternotomy for weaning, ECLS could be regarded as the first choice of mechanical support for postcardiotomy RV failure.     

Postcardiotomy centrifugal assist: a single surgeon's experience

Because of the infrequent application of cardiac assist devices for postcardiotomy heart failure, most published reports include the results of learning curves from multiple surgeons. Between October 1986 and June 2001, a single surgeon used 35 Sarns Centrifugal Pumps as ventricular assist devices in 21 patients with severe hemodynamic compromise after open heart surgery (0.88% incidence). Patients' ages ranged from 39 to 77 (mean, 59.6 years). Three patients required right ventricular assist devices, 4 left ventricular assist devices, and 14 had biventricular assist devices. For all, the indication for application was inability to wean from cardiopulmonary bypass despite multiple inotropes and intraaortic balloon pumping. All were expected to be intraoperative deaths without further mechanical assistance. Patients were assisted from 2 to 434 h (median, 48 h). Fifteen patients (71.4%) were weaned from device(s), and 11 patients (52.4%) were hospital survivors. Actuarial survival in those dismissed from the hospital was 78% at 5 years and 39% at 10 years. Patients facing certain demise after cardiac surgery can be salvaged with temporary centrifugal mechanical assist. Results are competitive with that achieved with more sophisticated devices. Hospital survivors enjoy reasonable longevity.     

Clinical evaluation of centrifugal pump in left heart bypass for patients with postcardiotomy shock

Clinical experience with the use of the centrifugal pump for left heart bypass was reviewed in patients with postcardiotomy shock in an attempt to improve survival. Twenty-one patients who could not be weaned from cardiopulmonary bypass were reviewed. All patients with postcardiotomy heart failure were supported with a centrifugal pump as left heart bypass. The mean duration of support was 102±66 h. Nine patients (43%) needed right heart bypass through the same median sternotomy because of right heart failure. The weaning rate was 67% and the survival rate was 43%. Twelve patients died. Seven patients were not weaned from the device and died of multiple organ failure, including major bleeding in five patients. The other five patients were weaned from the device but died of low cardiac output syndrome (three patients), infection (one patient), and brain death (one patient). The complications related to the device included bleeding in seven patients (33%), of which only one patients survived. Four patients had stroke (19%), and two of them survived. These data demonstrated that postoperative bleeding and stroke were the major factors affecting survival in patients with postcardiotomy heart failure with a centrifugal pump used as left heart bypass.