感染性心内膜炎瓣膜置换术体外循环管理及分析.docVIP

感染性心内膜炎瓣膜置换术体外循环管理及分析 　 作者：廖祥丽，范士志，陈建明，李志平，何勇，胡义杰，雷钧 【摘要】 目的 本文回顾性总结我院自1996年8月至2008年3月间施行的16例感染性心内膜炎(IE)行瓣膜置换术的体外循环(CPB)管理体会。 方法 采用中度低温(26℃～30℃)，中高流量[2.4～3.0 L/(min·m2)]灌注。心肌保护采用4℃冷晶体停搏液或7℃～10℃ 4∶1稀释血停搏液顺灌或持续逆灌。主动脉瓣膜置换术(AVR)、主动脉瓣和二尖瓣置换术(DVR)均采用冠状静脉窦逆灌。结果 本组CPB总时间99～224 min，主动脉阻断时间62～141 min，16例均顺利脱离CPB。14例痊愈出院，术后早期死亡2例，死亡原因均为颅内出血。结论 良好的设备、控制胶/晶比值、积极应用超滤器、加强ACT和凝血功能的监测，以及注重围术期抗生素的应用对患者的治疗和恢复至关重要。 【关键词】 感染性心内膜炎;体外循环;瓣膜置换 　　Abstract: OBJECTIVE To summarize retrospectively the experience of management of cardiopulmonary bypass(CPB) during valve replacement for infective endocarditis in 16 cases.METHODS Valve replacement with CPB was performed in 16 cases of infective endocarditis in our hospital between August 1996 and March 2008. CPB was performed with mid-low temperature(26℃-30℃) and moderate or high flow rate (2.4-3.0 L/(min·m2). Cardioplegia with 4℃ cold crystalloid or 7℃-10℃ 4∶1 (blood∶crystalloid ) was performed by antegrade or retrograde coronary sinus perfusion for myocardial protection. Only retrograde coronary sinus perfusion was performed during AVR and DVR. RESULTS The duration of CPB ranged from 99 to 224 min, and aorta cross-clamp time(ACC) from 62 to 141 min. All 16 cases were weaned from CPB successfully. 2 cases died early postoperatively due to intracranial hemorrhage, the others recovered completely.CONCLUSION The key factors for successful treatment are the use membrane oxygenator and ultrafiltration, control of colloid volume, monitor of ACT and coagulation function and use of antibiotic in the patient with infective endocarditis during CPB. 　　Key words： Endocarditis;Cardiopulmonary bypass;Valve replacement 　　本文回顾性总结我院自1996年8月至2008年3月间施行的16例感染性心内膜炎(infective endocarditis IE)行瓣膜置换术的体外循环(cardiopulmonary bypass, CPB)管理体会，对ACT监测、预充液的选择、灌注方法及抗生素的应用以及术后颅内出血等原因进行了分析。现将经验总结报告如下。 　　1 资料与方法 　　1.1 临床资料 本组患者16例，男性12例，女性4例，年龄13～62岁，体重31～65 kg。均有反复间断发热感染病史。入院时心功能(NYHA)Ⅲ级13例，Ⅳ级3例;彩色多普勒提示：瓣膜赘生物形成及穿孔11例，其中1例主动脉瓣三叶及二尖瓣后瓣均有赘生物形成，瓣周穿孔，主动脉瓣及二尖瓣重度关闭不全，少量心包积液并伴有左侧肱动脉栓塞;2