康斯特保护液与含血冷停搏液在机器人心脏瓣膜手术中的比较

目的对比康斯特保护液(HTK液)和4:1含血冷停搏液(St.Thomas液)在全机器人心脏瓣膜直视手术中的心肌保护效果及其对手术的影响。方法 2007年3月至2012年8月使用达芬奇(da Vinci.S)机器人手术系统在周围体外循环(PECC)下完成心脏瓣膜直视手术111例,其中二尖瓣成形79例,二尖瓣置换32例。在食道超声(TEE)引导下,经右侧股动脉、股静脉及颈内静脉插管建立PECC。心肌保护分别采用HTK液(n=46)和4∶1含血冷停搏液(n=65)灌注,使用BD14G静脉穿刺针作为停搏液灌注针,经胸壁穿刺进入胸腔后插入升主动脉,TEE评估停搏液灌注针插入的深度、位置及停搏液灌注效果。HTK液经升主动脉一次性灌注1 300～3 000 ml(25～30 ml/kg),灌注时间4～6 min,灌注压力200～250 mm Hg;使用4∶1含血冷停搏液者,首次灌注剂量1 000～1 500 ml(20 ml/kg),灌注压力300～380 mm Hg,灌注流量250～350 ml/min,以后每20～30 min半量复灌。结果两组患者体外循环时间、升主动脉阻断时间、心脏自动复苏率均无显著性差异(P>0.05),术后心肌酶CK、多巴胺用量、呼吸机辅助时间及胸腔引流量等亦无显著差异(P>0.05);HTK液组停搏液用量明显多于含血停搏液组(P<0.01);术中钠离子明显降低(P<0.05);液体总量显著增加(P<0.05)。结论 HTK液和含血冷停搏液在机器人心脏瓣膜手术中均能获得相同的心肌保护效果,HTK液不影响手术进程,较为实用,但易导致血液过度稀释及低钠血症,需积极处理。

Comparative study of the effect of HTK solution vs blood cardioplegic solution in robotic heart valve surgery

Objective To compare the effect of HTK solution vs cold blood cardioplegic solution on myocardial protection and the impact on surgical procedures in totally robotic heart valve surgery. Methods From Mar. 2007 to Aug. 2012, a total of 111 patients underwent heart valve surgery using da vinci robotic surgical system, including 79 undergoing mitral valve plasty （MVP）, 32 un- dergoing mitral valve replacement （MVR）. Peripheral extracorporeal circulation （PECC） was established through the right femoral ar- terial eannula, right femoral venous cannula and right internal jugular venous cannula with the transesophageal echocardiography （TEE）. Myocardial protection was managed with 4：1 blood cardioplegic solution （n =65） or HTK solution （n =46）, using BD14G venous puncture needle as the cardioplegia perfusion cannula. The cardioplegia cannula was inserted into the ascending aorta after tho- racentesis. TEE was performed to document the depth and the exact location of canuula, evaluating the efficiency of the perfusion pro- cedure. Results The ECC time, aortic -cross clamping time, cardiac resuscitation rate had no significant difference （ P 〉 0.05） be- tween cold blood cardioplegia group and HTK cardioplegia group. The cardioplegia volume of HTK group was more than cold blood cardio- plegia group （ P 〈 0.01）. Intraoperative blood sodium decreased significantly and total volume increased significantly （ P 〈 0.05） in HTK group. The postoperative dopamine dosage, mechanical ventilation time and drainage volume had no significant difference （ P 〉 0.05）. Conclusion HTK solution or cold blood cardioplegic solutio can provide comparative myocardial protective effects in robotic heart surgery. HTK solution does not affect the surgical process and is more practical, but it is easy to cause excessive blood dilution and hyponatremic, which need to be actively management.