Jegger D, Tevaearai H T, Horisberger J, Mueller X M, Boone Y, Pierrel N, Seigneul I, von Segesser L K
Department of Cardiovascular Surgery, University Hospital (CHUV), Lausanne, Switzerland.
Eur J Cardiothorac Surg. 1999 Sep;16(3):312-6. doi: 10.1016/s1010-7940(99)00228-6.
Minimally invasive open heart surgery involves limited intrathoracic cannulation sites necessitating cardiopulmonary bypass to be initiated via peripheral access using percutaneous cannulae with the tip placed into the right atrial cavity. However, surgery involving the opening of the right heart obliges the surgeon to maintain the end of the cannulae into the vena cavae. The impeded venous return due to the smaller diameter may be alleviated by inserting a centrifugal pump in the venous line.
Right anterior mini-thoracotomy and exposure of the femoral site were performed before the patient was heparinized. Cannulation of the femoral artery, the inferior vena cava via the femoral vein and the superior vena cava through the mini-thoracotomy was performed and cardiopulmonary bypass was initiated. Venous drainage was augmented with the centrifugal pump. Cardiac arrest was provoked and both vena cavae were snared before performing the intracardiac procedure.
Twenty consecutive patients were operated on using this technique (15 males/five females; age: 44.8 +/- 14.3 years; bodyweight: 73.5 +/- 15.1 kg; body surface area: 1.8 +/- 0.2 m2; theoretical blood flow rate: 4.4 +/- 0.5 l/min). The cannula sizes were 21.9 +/- 2.2 Fr for the femoral artery, 26.5 +/- 1.7 Fr for the inferior vena cava and 23.8 +/- 2.5 Fr for the superior vena cava. Venous drainage through the single inferior vena cava cannula was 2.1 +/- 0.6 l/min (48.8 +/- 13.3% of the theoretical flow). Adding the superior vena cava cannula increased the venous flow to 3.1 +/- 0.4 l/min (70.7 +/- 9.6% of the theoretical value, P < 0.005). The use of the centrifugal pump increased the flow to 4.1 +/- 0.6 l/min (93.4 +/- 8.9% of the theoretical flow, P < 0.001) with a mean inlet negative pressure of -69 +/- 10.2 mmHg. The mean bypass time was 64.0 +/- 24.6 min for a mean operative time of 226.3 +/- 61.0 min. Minimum venous saturation was 69.4 +/- 8.5%.
Despite the smaller diameter of the vena cavae compared to the right atrium, and a smaller internal diameter of percutaneous cardiopulmonary bypass cannulae compared to classic ones; the centrifugal pump improves the venous drainage significantly so that minimally invasive open heart procedures can be performed under optimal and safe perfusion conditions.
微创心脏手术涉及有限的胸内插管部位，需要通过外周通路使用经皮插管将尖端置于右心房腔来启动体外循环。然而，涉及右心开放的手术要求外科医生将插管末端维持在腔静脉内。通过在静脉管路中插入离心泵，可缓解因管径较小导致的静脉回流受阻。
在患者肝素化前进行右前小切口开胸并暴露股部部位。进行股动脉、经股静脉的下腔静脉以及通过小切口的上腔静脉插管，并启动体外循环。使用离心泵增加静脉引流。诱发心脏停搏并在进行心内手术前结扎双侧腔静脉。
连续20例患者采用该技术进行手术（15例男性/5例女性；年龄：44.8±14.3岁；体重：73.5±15.1kg；体表面积：1.8±0.2m²；理论血流速度：4.4±0.5l/min）。股动脉插管尺寸为21.9±2.2Fr，下腔静脉插管尺寸为26.5±1.7Fr，上腔静脉插管尺寸为23.8±2.5Fr。通过单一的下腔静脉插管的静脉引流为2.1±0.6l/min（理论流量的48.8±13.3%）。增加上腔静脉插管后，静脉流量增加至3.1±0.4l/min（理论值的70.7±9.6%，P<0.005）。使用离心泵后，流量增加至4.1±0.6l/min（理论流量的93.4±8.9%，P<0.001），平均入口负压为-69±10.2mmHg。平均体外循环时间为64.0±24.6min，平均手术时间为226.3±61.0min。最低静脉血氧饱和度为69.4±8.5%。
尽管腔静脉的直径比右心房小，且经皮体外循环插管的内径比传统插管小；但离心泵显著改善了静脉引流，从而可以在最佳且安全的灌注条件下进行微创心脏手术。
