机器人心脏外科手术中周围体外循环的灌注管理

目的 探讨机器人心脏外科手术中周围体外循环（peripheral extracorporeal circulation,PECC）的建立方法与灌注管理策略.方法 本院2007年1月-2014年1月使用达芬奇机器人外科手术系统（da Vinci.S）在PECC下完成心脏直视手术375例,其中房间隔缺损修补169例,室间隔缺损修补22例,二尖瓣成形96例,二尖瓣置换38例,左心房黏液瘤切除44例,右心房黏液瘤切除6例.在食管超声心动图（transesophageal echocardiography,TEE）引导下,体外循环（extracorporeal circulation,ECC）经右侧股动脉、股静脉及颈内静脉分别插管建立,手术通过右侧胸壁3个0.8 cm器械臂孔和一个2 cm工作孔完成.ECC转流中使用负压辅助静脉引流（vacuum-assist venous drainage,VAVD）,连续血气监测（CDITM 500）及超滤.除心脏不停跳术式外,其余手术均采用经胸阻断升主动脉,经主动脉停搏液灌注针顺行灌注含血冷停搏液或康斯特液（HTK液）进行心肌保护.结果 无手术死亡及术式转化.ECC时间24 ～ 219（94.9±38.8） min,升主动脉阻断时间18～166（66.7±29.0） min,转流中尿量30～2 100（593.1±459.4） ml,超滤液量800～6 700（3 005.6±1 245.2） ml.299例患者ECC液体出入量为负平衡（80％）,负平衡量50 ～3 100（856.7±563.8） ml.255例手术在心脏停跳下完成,术后心脏自动复苏率81％（207/255）.呼吸机辅助时间4～ 12（6.3±1.6）h,24 h胸腔引流量10 ～ 350（111.5±59.5） ml.术后发生股静脉栓塞3例,股动脉栓塞2例,经华法林钠或导管取栓后治愈.结论 PECC技术是保证机器人心脏手术开展的前提条件.使用VAVD和连续血气监测、选择合理的心肌保护方法是ECC管理的核心内容.

Perfusion management of peripheral extracorporeal circulation during robotic heart surgery

Objective To discuss the establishment and perfusion management strategies of peripheral extracorporeal circulation （PECC） during robotic heart surgery. Methods Of the 375 patients who underwent robotic heart surgery using ＂da Vinci S＂ surgical system from January 2007 to January 2014, 169 cases underwent repair of atrial septal defect, 22 cases underwent repair of ventricular septal defect, 96 cases underwent mitral valvuloplasty, 38 cases underwent mitral valve replacement, 44 cases underwent resection of left atrial myxoma and 6 cases underwent resection of right atrial myxoma. Surgery approach was achieved through three 0.8 cm trocar incision in the right side of the chest and a 2 cm working port. Extracorporeal circulation （ECC） was established through the femoral artery, femoral vein and right internal jugular vein cannulation with the guidance of transeophageal echocardiography （TEE）. Vacuum-assisted venous drainage （VAVD）, CDITM 500 continuous blood gas monitoring and ultra filtration were used during ECC procedures. The aortic occlusion was performed with a Chitwood crossclamp and antegrade cardioplegia was delivered directly via chest with cold blood cardioplegic solution or HTK solution for myocardial protection. Results All procedures were successfully performed with no operative death and conversion to a median sternotomy. ECC time and aortic cross-clamp time were 24-219 （94.9 ±38.8） min and 18-166 （66.7± 29.0） min respectively. During ECC, the urine volume were 30-2100 （593.1± 459.4） ml, ultra filtration volume was 800-6 700 （3 005.6± 1 245.2） ml, and the total fluid balance was subzero-balanced in 299 （80%） patients with subzero-balanced volume of 50-3 I00 （856.7± 563.8） ml. 255 patients underwent surgery with arrested heart and the cardiac autoresuscitation rate was 81% （207/255）. Postoperative intubation time was 4-12 （6.3 ± 1.6） h and drainage volume within 24 h postoperatively was 10-350 （111.5±59.5） ml. 3 cases of femoral vein thro