瓣膜病同时合并冠心病体外循环中的心肌保护

目的探讨瓣膜病合并冠心病患者同时行瓣膜手术及冠状动脉旁路移植术(CABG)体外循环(ECC)中的心肌保护策略。方法总结2000年1月-2009年12月我院96例瓣膜病合并冠心病患者实施瓣膜手术及CABG ECC中的心肌保护经验。ECC中及时的心脏减压,维持适当的灌注压,并根据患者病情采用顺行灌注(顺灌)、冠状静脉窦逆行灌注(逆灌)、左右冠状动脉窦直视灌注(直视灌)、血管桥灌注(桥灌)多种方法结合,4∶1冷血(15~20℃)停搏液灌注-冷血(10~15℃)半钾停搏液维持-开放主动脉前温血(30~32℃)灌注的方式进行心肌保护。96例患者中单纯二尖瓣成形(MVP)+CABG 2例;二尖瓣置换(MVR)+CABG 18例(同期行血栓清除5例);MVR合并三尖瓣成形(TVP)+CABG 20例(同期行左房血栓、右房血栓清除各1例);主动脉瓣置换(AVR)+CABG 24例(同期行瓦氏窦瘤修补1例,行室壁瘤切除1例);二尖瓣合并主动脉瓣置换(DVR)+CABG 20例(同期行左房血栓清除3例);双瓣膜置换合并三尖瓣成形(DVR+TVP)+CABG 8例(同期行左房血栓清除3例);双瓣膜置换合并三尖瓣置换(DVR+TVR)+CABG 1例;马凡氏综合征行Bentall术+CABG3例。结果 ECC时间101~360 min,阻断主动脉时间67~241 min。全组96例患者自动复跳58例,自动复跳率60.4%。死亡5例,死亡率5.21%。其余患者均康复出院。结论 ECC中及时心脏减压,维持适当的灌注压;针对手术方式,选择多种灌注方法可以较好的保护心肌,提高自动复跳率,增加手术成功率。

Myocardial protection strategy on the patients of valve disease combined with coronary artery disease in the cardiopulmonary bypass

OBJECTIVE This paper reported the myocardial protection strategy on 96 patients underwent valve surgery and coronary artery bypass grafting（CABG） with cardiopulmonary bypass（CPB） from January 2000 to December 2009 in the xinqiao hospital of the Third Military Medical University.METHODS During the CPB depressed the heart immediately to prevent excessive expansion of the heart,maintained adequate mean arterial pressure（MAP）.Then we chose antegrade cardioplegia perfusion or retrograde coronary sinus cardioplegia perfusion or coronary arterial graft cardioplegia perfusion as the integrated way for myocardial protection with 4 parts blood to 1 part St.Thomas＇s.First,cold-blood（15-20℃） cardioplegia（potassium 22 mmol/L） was perfused.Then,cold-blood（10-15℃） cardioplegia（potassium 10 mmol/L） was perfused continuously.Warm blood（30-32℃） was administered for 3 to 5 minutes to the ascending aorta before unclamping the aorta.All patients suffered from complicated heart valve disease and coronary artery disease which included mitral valvuloplasty（MVP）＋CABG（2 cases）,mitral valve replacement（MVR）＋CABG（18 cases）,MVR＋tricuspid valvuloplasty（TVP）＋CABG（20 cases）,aortic valve replacement（AVR）＋CABG（24 cases）,double valve replacement（DVR）＋CABG（20 cases）,DVR＋TVP＋CABG（8 cases）,DVR＋TVR＋CABG（1 case）,Bentall＋CABG（3 cases）.RESULTS The CPB time of patients was 101-360 minutesand the cross clamp time was 67-241 minutes.The cardiac spontaneous resuscitation was 60.4%,5 patients died and mortality was 5.21%.CONCLUSION Cold-blood with high potassium induction,cold-blood with low potassium continuous perfusion and terminal warm-blood perfusion provide good myocardial protection to the patients.It will increase the spontaneous resuscitation and the success rate of valve surgery and CABG.