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体外膜式氧合的临床应用

目的 总结体外膜式氧合（ECMO）在临床的应用经验，以提高对危重患者的治疗效果。 方法 2006年7月至2008年2月, 27例患者使用ECMO,其中非手术急性心肺功能衰竭8例，心脏手术后的心功能辅助4例，心脏不停跳冠状动脉旁路移植术中心脏功能辅助13例，体外循环与ECMO相互转换应用于心脏手术中和术后的心功能辅助2例。 结果 27例患者应用ECMO辅助时间为2～61 h，26例成功撤离ECMO，1例82岁患者成功撤离ECMO后24 h出现轻度二氧化碳潴留，患者家属要求出院；2例院内死亡；24例康复出院。 结论 ECMO是抢救心肺功能衰竭的有效方法，对非手术患者或高危患者行心脏不停跳冠状动脉旁路移植术以及心脏手术中、手术后的心脏功能辅助亦有明显的效果。

The Application of Exchange Between Cardiopulmonary Bypass and Closed Extracorporeal Circulation during Operation on Heart

Objective To introduce the method and effect of common cardiop ulmonary bypass(CPB) switched to closed extracorporeal circulation by medtronic extracorporeal membrane oxygenation(ECMO) package. Methods From Junuary 2007 to June 2008, common CPB switched to closed extracorporeal circulation by Medtronic ECMO package adding blood reservoir and artery microembolus filtrator was used to 15 patients with grave heart disease to provide CPB support during operation on heart and cardiac function support after operation. The circulation was built through femoral arteryfemoral veinsuperior vena cava intubation or aortaright auricle intubation. There were 10 male and 5 female aged from 6582 years (74.0±9.3 years) and weighed from 6389 kg (69.0±11.4 kg). There were 11 cases with old myocardial infarction, 1 case with acute myocardial infarction, 1 case with old myocardial infarction complicated with mitral stenosis and mitral incompetence, and 2 cases reopened and undergone double valve replacement. Results For all the 15 patients, the closed circulation time was 31112 min（77.3±21.5 min）. The CPB time was 51-84 min（69.7±9.8 min）. The ostoperative mechanical ventilation time was 414 h（8.3±2.9 h）. The 24 hchest drainage was 110-360 ml（227.3±80.4 ml）. All patients were cured and discharged successfully with cardiac function classification in grade ⅠⅡ. Thirteen cases were followed up. The followup time was 412 months. Their cardiac function recovered well and no complication occurred. Conclusion This method could provide effective support for heart and lung before operation，during operation and after operation. This method could save material cost. The heparin paintcoat could reduce inflammatory reaction and it is good for patients’ recovery.

体外膜式氧合在心脏不停跳冠状动脉旁路移植术中应用二例

妊娠合并心血管疾病的手术方法及文献复习

目的 介绍剖腹产术（CS）加同期体外循环（CPB）心脏手术方法，并探讨妊娠合并心血管疾病手术方法的选择。 方法 1例27岁、妊娠38周合并先天性心脏病患者出现亚急性细菌性心内膜炎、三尖瓣和右心室流出道有赘生物、心力衰竭、先兆早产、胎儿窘迫患者，在局部麻醉＋静脉麻醉下先行CS，再行CPB心脏手术，包括三尖瓣和右心室流出道赘生物摘除、室间隔缺损修补、房间隔缺损修补。 结果 CS中顺利取出一健康成活女婴。CPB时间87min，升主动脉阻断时间59min。手术后母婴平安、恢复顺利。随访11个月，患者心功能Ⅰ级，婴儿发育正常。 结论 在妊娠合并心血管疾病影响孕妇及胎儿生命安全的情况下,可以在施行CS后同期施行心内直视手术。但手术方法的选择应慎重。

Clinical Application of Cardiopulmonary Bypass through Intubation of Femoral Artery and Vein for Completely Video Assisted Cardiac Surgery

Objective To discuss the way and management of cardiopulmonary bypass （CPB） through intubation of femoral artery and femoral vein for completely video assisted cardiac operations, Methods CPB were set up through femoral artery and femoral vein in 85 patients on heart surgery by video assisted thoracotomy. Thirtyeight patients were diagnosed as atrial septal defect （ASD）, forty-three patients were diagnosed as ventricular septal defect （VSD）, and four patients were mitral valve stenosis and mitral incompetence （MS＋MI）,The video assisted thoracotomy was used to repair ASD, VSD and mitral valve replacement （MVR）. Results For all patients the durations of CPB and aortic cross-clamping time was 30-179 min（91.7±27.4 min）, 6-103 min（37.2±6. 1 min）. In one patient, the CPB was set up again for repairing of residual leak. The endothelium of femoral artery was lacerated during withdrawing the cannula in 2 patients. Conclusion The video assisted thoracic operation with CPB and by intubation of femoral artery and femoral vein to perform heart operation are feasible and safe. All patients are recovered well.

成分库血在婴幼儿体外循环预充中的应用

目的 探讨婴幼儿体外循环中减少库血用量的方法。方法 将小于3岁的先天性心脏病患者160例分成实验组（n＝80）和对照组（n＝80），实验组：在体外循环预充时加入浓缩红细胞，对照组：加入全血。结果 实验组患者在体外循环中应用浓缩红细胞量240±80ml，胶体（血定安）400±101ml；对照组患者在体外循环预充中应用库血量400±96ml，血浆190±57ml；实验组用血量明显减少，而两组患者术后的恢复情况无明显差别。结论 成分库血在体外循环预充中可明显提高红细胞压积，不影响患者术后恢复，并可以明显减少库血用量。

局限性缩窄性心包炎误诊为心室室壁瘤一例

The Combined Protective Effects of U50 488H and Hypothermia Preservation on Isolated Rabbit Hearts

Abstract: 　Objective　To observe the combined protective effects of U50 488H and hypothermia preservation on isolated rabbit hearts preconditioned. 　Methods　Forty rabbits were randomly divided into five groups, 8 rabbits in each group. The perfusion model of isolated rabbit hearts was established by the Langendorff device. In the control group: the isolated rabbit hearts were preserved with the University of Wissconsin solution (UW ) for six hours; groupI : the isolated rabbit hearts were preconditioned with St. ThomasII cardioplegic solution containing U50 488H (1. 6mmo l/L ) and then preserved with hypothermic preservation for four hours; groupII ; the precondition was the same as group II , hypothermic preservat ion fo r six hours; group III : the precondit ion was the same as group I , hypothermic preservation for eight hours; group IV : the precondit on was the same as group I , hypothermic preservation for ten hours. The cardiac function, myocardial sarcoplasmic reticulum calcium ion adenosine triphosphatase (SRCa2+ -ATPase) act ivity and calcium ion concentrations in mitochondria were determined at thirty minutes after reperfusion. 　Results　As the hypothermic preservation time increased from four to ten hours, the recovery rate of each index of cardiac function, coronary artery flow (Cf) and SRCa2+ -ATPase activity also decreased, but the calcium ion concentrations in the mitochondria increased. Cardiac function index recovery rates in group I and group II w ere higher than those in group III and groupIV respectively (P lt; 0. 05, 0. 01) ,meanwhile recovery rates of cardiac function index in group III were higher than that in group IV (P lt; 0. 05). Recovery rate of Cf in groupII ( 84. 56%±10. 38%)were higher than those in group III (79. 45%±9. 67% ) and group IV (68. 31%±6. 84% , P lt;0.01) , meanwhile the recovery rate of Cf in group III was higher than that in group IV (P lt; 0. 05). SRCa2+ -A Tpase activity in group II (4. 43±0. 41μmo l/m g?h)were higher than those in control group (3. 04±0. 22Lmo l/mg?h ) , group III (3. 26±0. 29Lmo l/m g?h) and group IV (2. 57±0. 63Lmo l/m g?h, P lt; 0. 05) , SRCa2+ -ATPase activity in group III was higher than that in group IV (P lt; 0. 01). The calcium ion concentrations in mitochondria in group II (38176±4. 30μmo l/g ?dw ) and in the control group (40. 23±3. 75μmol/g ?dw )were less than those in group III (43125±5116μmol/g?dw ) and groupIV (45. 78±3. 26μmol/g?dw , P lt; 0. 05, 0. 01) respect ively. Conclusion　The hypothermic preservation time for isolated dono r’s hearts p re-treated with St. Thomas II cardioplegic solution containing U 50 488H should the kep tunder 8h. The myocardial protection effects of both UW solution and U50 488H- containing St. Thomas II cardioplegic solution on isolated dono r’s hearts appear to be the same at 6 hours.

The Influence of Various Methods of Cerebral Protection duringDeep Hypothermic Circulatory Arrest on Expressionof S-100 Protein

Abstract: 　Objective 　To observe the influence of various methods of cerebral protection during deep hypothermic circulatory arrest (DHCA ) on S-100 protein. 　Methods　Eighteen dogs were randomly and equally divided into three groups: the deep hypothermic circulatory arrest (DHCA group ) , the DHCA with retrograde cerebral perfusion (DHCA + RCP group ) , and the DHCA with intermittent antegrade cerebral perfusion (DHCA + IACP group ). Upon interruption of cardiopulmonary bypass (CPB) , the nasopharyngeal temperature was slowly lowered to 18℃, before CPB was discontinued for 90 minutes, after 90 minutes, CPB was re-established and the body temperature was gradually restored to 36℃, then CPB was terminated. Before the circulatory arrest, 45min, 90min after the circulatory arrest and 15min, 30min after re-established of CPB, blood samples were drawn from the jugular veins fo r assay of S-100 protein. Upon completion of surgery, the dogs was sacrificed and the hippocampus was removed from the brain, properly processed for examination by transmission electron microscope for changes in the ultrastructure of the brain and nerve cells. 　Results　There was no significant difference in the content of S-100 protein before circulatory arrest among all three groups (P gt; 0.05). After circulatory arrest, DHCA and DHCA +RCP group showed an significant increase in the content of S-100 protein (P lt; 0.01). There was no significant difference in the content of S-100 protein after circulatory arrest in DHCA + IACP group. 　Conclusion 　Cerebral ischemic injuries would occur if the period of DHCA is prolonged. RCP during DHCA would provide protection for the brain to some extent, but it is more likely to cause dropsy in the brain and nerve cells. On the other hand IACP during DHCA appears to provide better brain protection.