二尖瓣置换术中同期行房颤射频消融术的麻醉和围术期管理

摘要

OBJECTIVE To review the anesthetic and perioperative management methods on mitral valve replacement surgery plus concomitant atrial fibrillation radiofrequency ablation. METHODS From October 2008 to July 2009, 68 consecutive patients,including 25 males and 43 females, with mitral valve disease and atrial fibrillation underwent the procedure of mitral valve replacement plus concomitant radiofrequency ablation. The mean age of patients was 54 ± 11 years, mean body surface area was 1.68 ± 0.18 m2 and the mean time of fibrillation atrial before surgery was 32 ± 22 months. Propofol, midazolam, fentanyl, isoflurane and pipecuronium were used to induce and maintain anesthesia level. During the operation, transesophagus echocardiography was used routinely. Cell Saver was also routinely used for blood conservation. RESULTS A total of 68 cases underwent mitral valve replacement, 22 cases underwent aortic valve replacement meanwhile and 32 cases underwent tricuspid valvoplasty meanwhile. Radiofrequency time was ( 20 ±6 ) minutes, cardiopulmonary bypass time was ( 113 ±44 ) minutes and cross clamp time was ( 81 ± 35 ) minutes. Postoperative mechanical ventilation time was ( 18.8 ± 8.8 ) hours, the length of intensive care unit stay was ( 50 ±51 ) hours. There was no death and renal failure. Two patients were re - exploration for bleeding after the surgery. Three patients implanted permanent pace maker because of complete atrioventricular block postoperatively. 35 ( 55％ ) patients were recovery to sinus rhythm in hospital. CONCLUSION Understanding the methods and mechanism of radiofrequency, using proper anti - arrhythmia medicine, and applying intensive rhythm control strategies and blood conservation methods are the key issues during perioperative management.%目的 回顾性分析、总结二尖瓣置换术中同期行房颤射频消融术的麻醉和围术期管理重点.方法 我院从2008年10月至2009年7月连续进行该类手术68例,68例患者均诊断为二尖瓣狭窄和/或关闭不全合并房颤.其中男性25例、女性43例,年龄(54±11)岁,体表面积(1.68±0.18)m2,术前房颤的持续时间为(32±22)个月.手术在静吸复合全身麻醉及体外循环下进行,在瓣膜置换的同时直视下行射频消融术.术中常规行食道超声检查,并应用洗血球机(cell saver)行自体血液回收.术后如无禁忌,常规应用胺碘酮防止房颤复发.结果 全组68例患者均行二尖瓣置换术,其中22例同时行主动脉瓣置换术,32例同时行三尖瓣成形术.术中射频消融时间(20±6)min,体外循环时间(113±44)min,主动脉阻断时间(81±35)min.术后机械呼吸时间(18.8±8.8)h、ICU停留时间(50±51)h、24 h胸管引流量(570±312)ml.术后放置主动脉内球囊反搏(IABP)辅助1例,意识障碍1例,III度房室传导阻滞放置永久起搏器3例,心包填塞二次开胸止血2例,全组无肾功能衰竭、无死亡.出院前有35例(55%)患者恢复窦性心律.结论 掌握射频消融的方法和原理,正确使用抗心律失常药物,加强心律(率)的管理和血液保护,是麻醉和围术期管理的关键.