股动静脉及右颈内静脉插管建立体外循环在机器人心脏手术中的应用

摘要

目的 总结股动、静脉及右侧颈内静脉插管建立体外循环在机器人微创心脏手术中的应用.方法 2007年1月至2011年6月,400例患者接受机器人("达芬奇 S")微创心脏手术,其中体外循环下214例,术式包括房间隔或室间隔缺损修补105例,二尖瓣成形或置换76例,心房黏液瘤切除33例.术中食道超声引导下右侧股、动静脉及右侧颈内静脉插管建立体外循环.除心脏不停跳术式外,升主动脉顺行灌注含血冷停搏液或康斯特保护液(HTK液)进行心肌保护,Chitwood钳经胸阻断升主动脉.体外循环采用浅低温、中流量灌注,灌注中采用负压辅助静脉引流及连续动脉血气监测.体外循环停止后,股动脉插管处重建,颈内静脉压迫止血.结果 体外循环时间45～206(104±39.7)min,升主动脉阻断时间21～117(67.8±32.3)min.股动脉插管直径(15～20)Fr,股静脉插管直径(19～23)Fr,颈内静脉插管直径(15或17)Fr.术后髂静脉及股总静脉栓塞3例,股动脉栓塞2例,经华法林或Fogarty导管取栓后治愈.结论 机器人微创心脏术中,右侧股动、静脉及右侧颈内静脉插管建立体外循环安全、可行.%OBJECTIVE To evaluate the efficiency and safety of cardiopulmonary bypass ( CPB ) establishment through femoral artery, vein and internal jugular vein cannulation for totally robotic heart surgery. METHODS A total of 400 selective patients have underwent robotic ( davincis ) minimally invasive heart surgery from January 2007 to June 2011, including 214 cases with CPB. 117 patients accepted atrial or ventricular septal defect repair, 76 patients accepted mitral valve repair or replacement and 33 patients accepted atrial myxoma resection. CPB was established through cannulation of right femoral artery, vein and right internal jugular venous under the guidance of transesophageal echo ( TEE ). The myocardial protection was performed with cold blood cardioplegic solution or HTK solution and the transthoracic Chitwood clamp was used to occlusion the ascending aorta. Mild hypothermia, moderate flow the vacuum - assist venous drainage ( VAVD ) and continuous blood gas monitoring were used during CPB. The femoral artery was reconstructed after extubation. The internal jugular vein was pressed hard to stop bleeding. RESULTS The mean CPB time and aortic cross clamp time was 45 - 206 ( 104 ± 39.7 ) min and 21 - 117 ( 67.8 ± 32.3 ) min respectively. 15 - 20 Fr cannula was applied for femoral artery, 19 -23 Fr cannula for femoral vein and 15 or 17 Fr cannula for right internal jugular vein. 3 cases of femoral vein thrombus and 2 cases of femoral arterial thrombus were observed after the surgery. All the complications were cured using warfarin or embolectomy. CONCLUSION The cannulation of femoral artery, vein and internal jugular vein for CPB establishment in totally robotic heart surgery was feasible and safe.