122例右胸前外侧小切口微创心脏手术的体外循环应用

目的探讨微创心脏手术中体外循环管理策略,总结新型手术中体外循环的初步经验。方法 2010年1月-2012年8月122例病人实施微创心脏手术,其中男性54例,女性68例,年龄14-65（36.7±14.5）岁,体质量31-76（57.3±10.6）kg。61例采用常温非停跳心内直视手术（非停跳组）,其余病例于浅或中低温体外循环停跳下行心内直视术（停跳组）。术式包括房间隔缺损修补术,室间隔缺损修补术,主动脉瓣置换术,二尖瓣置换/成形术,三尖瓣成形术,部分型肺静脉异位引流矫治术,左房黏液瘤摘除术。小切口主动脉瓣置换术的病例采用股动脉插管、二级股静脉插管建立循环回路,必要时加用上腔静脉插管引流。其余病例均采取股动脉插管、同侧股静脉插管及上腔静脉插管建立体外循环回路。停跳组阻断升主动脉后,顺行灌注4∶1冷血停搏液,行浅或中低温高流量灌注。必要时配合超滤。结果体外循环时间20-161（72.4±27.9）min,最低鼻温27.7-35.4（33.0±1.9）℃,最低肛温31-35.7（34.1±1.3）℃。停跳组61例病例中,升主动脉阻断时间17-107（49.9±21.0）min,其中36例病人心脏自动复跳,自动复跳率为58.9%。转中常规超滤3例,超滤液量1 500-3 000ml;平衡超滤8例,超滤液量2 000-7 000ml;常规超滤±平衡超滤6例,超滤液量3 800-6 500ml。122例患者均安返监护室,术后呼吸机辅助时间为4-18（6.5±2.5）h。监护室停留时间为13-37（19.0±4.8）h,术后胸腔引流量50-420（150±203）ml。术后住院时间为6-21（7.2±2.0）天。治愈出院121例,死亡1例,死亡率为0.8%。结论综合而全面的进行体外循环管理对微创心脏手术是有效而必要的,同时还应注重与术者及麻醉师等相关手术人员的有效配合与沟通。

The Application of Cardiopulmonary Bypass in Minimally Invasive Cardio Surgery Through Right Ministernotomy with 122 Cases

Objective To discuss the management strategy and the preliminary experience of cardiopulmonary by- pass （CPB） in minimally invasive cardio surgery （MICS）. Methods From January 2010 to August 2012,122 patients with 14-65（36.7±14.5）years old,31-76（57.3±10.6）kg,were performed with MICS,54 cases of male,68 female. Six- ty-one patients with beating heart surgery（the group with beating heart） ,the＇rest were treated with open heart surgery by stopping heartbeat with CPB in light or middle hypothermic（the group with heartbeat stopped） , including repair of atrial septal defect （ASD）,repair of ventricular septal defect （VSD）,aortic valve replacement （AVR）,mitral valve re- placement （MVR） or valve plasty （MVP）, tricuspid valvoplasty （TVP）,left atrial myxoma extirpation, respectively. For patients with AVR in MICS,CPB with femoral artery intubation and two-grade femoral artery intubation. Superior vena cava cannula was applied when it was necessary. For others,CPB with femoral artery intubation, femoral vein intu- bation and superior vena cava cannula. After aortic cross clamp （ACC） in the group with heartbeat stopped~ antegrade perfusion of 4 ： 1 cold blood cardioplegia with high flow in mild or moderate low temperature. Ultrafiltration was used if it was important. Results The CPB time was 20-161（72.4＋--27.9） min. The lowest nasopharynx temperature was 27.7-35.4（33.0＋1. 9） ℃ and the lowest rectal temperature was 31-35.7 （34.1±1.3） ℃ during CPB. In the group with heartbeat stopped,including 61 patients,the aortic cross-clamp time was 17-107 （49.9±21.0）min and 36 of them with the heartbeat recovered spontaneously. The rate of automatic beating was 58.9 %. The volume of 3 cases of conventional ultrafiltration （CUF） was 1500-3000 mlthe volume of 8 cases of balance ultrafiltration （BUF） was 2000-7000 ml;the volume of 6 cases of CUF combined with BUF was 3800-6500 ml during CPB. All patients returned to intensive care u- nit （ICU） safely. The time of assisted respiration with respirator was 4-18（6.5±2.5） h after MICS. The retention time in ICU was 13-37（19.0±4.8） h. The volume of chest drainage of patients was 50-420（150±203）ml. The length of hospital stay was 6-21（7.3±2.0） days after MICS. One patient died after surgery,the mortality rate of 0.8%. Others were cured. Conclusion The management of CPB in MICS was comprehensive and all-around and to pay attention to the effective cooperation and communication with others,such as surgeon and analgesist.