Lichtenstein S V, Abel J G, Slutsky A S
Department of Surgery, St. Michael's Hospital, University of Toronto, Ontario, Canada.
J Thorac Cardiovasc Surg. 1992 Aug;104(2):374-80.
Hypothermia is believed to be the most important aspect of successful myocardial protection with retrograde coronary sinus cardioplegia. Because nutritive capillary flow to the right ventricle and septum is thought to be diminished with retrograde perfusion, these areas of the myocardium are considered at higher risk for intraoperative deterioration without the added protection of hypothermia. Recently we introduced warm aerobic arrest as an alternative to conventional methods of myocardial protection. We present our clinical results in 37 patients with mitral valve disease (+/- aortic valve, aortic root, or coronary artery disease) who underwent various cardiac procedures for which warm blood cardioplegic solution was delivered continuously via the coronary sinus after antegrade arrest. Thirty-five of the patients were in New York Heart Association class III or IV, and 19 patients had grade 3 or grade 4 left ventricular function. Sixteen patients had pulmonary hypertension, three with suprasystemic pressures, and marked right ventricular hypertrophy. Two patients had associated left ventricular hypertrophy. Nearly all patients returned to normal sinus rhythm shortly after removal of the aortic crossclamp, and they were easily discontinued from cardiopulmonary bypass even with crossclamp times of 3 hours. The 30-day hospital mortality rate was 2.7%. The perioperative myocardial infarction rate was 5.4%, and the prevalence of low-output syndrome was 10.8%. The results suggest that retrograde coronary sinus perfusion of blood cardioplegic solution at 37 degrees C is an effective method of myocardial protection even in patients with pulmonary hypertension at high risk for right ventricular failure. Its efficacy in this circumstance does not reside in its ability to deliver hypothermia.
低温被认为是逆行冠状静脉窦停搏法成功进行心肌保护的最重要方面。由于逆行灌注时右心室和室间隔的营养性毛细血管血流被认为会减少，因此在没有低温额外保护的情况下，这些心肌区域被认为在术中恶化的风险更高。最近，我们引入了温血有氧停搏作为传统心肌保护方法的替代方案。我们报告了37例二尖瓣疾病（±主动脉瓣、主动脉根部或冠状动脉疾病）患者的临床结果，这些患者接受了各种心脏手术，在顺行停搏后通过冠状静脉窦持续输注温血心脏停搏液。其中35例患者为纽约心脏协会III或IV级，19例患者左心室功能为3级或4级。16例患者有肺动脉高压，3例为系统性高血压，并有明显的右心室肥厚。2例患者伴有左心室肥厚。几乎所有患者在移除主动脉阻断钳后不久即恢复正常窦性心律，即使阻断钳夹闭时间长达3小时，他们也能很容易地脱离体外循环。30天住院死亡率为2.7%。围手术期心肌梗死发生率为5.4%，低心排血量综合征发生率为10.8%。结果表明，37℃的温血心脏停搏液逆行冠状静脉窦灌注是一种有效的心肌保护方法，即使对于有右心室衰竭高风险的肺动脉高压患者也是如此。其在这种情况下的有效性并不在于其产生低温的能力。
