Bottio Tomaso, Bisleri Gianluigi, Piccoli Paolo, Negri Alberto, Manzato Aldo, Muneretto Claudio
Departments of Cardiovascular Surgery, University of Brescia Medical School, Brescia, Italy.
J Heart Valve Dis. 2007 Mar;16(2):187-94.
Heart valve surgery in high-risk patients is associated with considerable morbidity and mortality. Epidural anesthesia without mechanical ventilation has been proposed to reduce invasiveness. An analysis was conducted in very high-risk heart valve patients of mid-term survival free from complications, and patient satisfaction of regional anesthesia use, without mechanical ventilation.
A prospective follow up study was conducted in 50 patients (24 females, 26 males; mean age 74 +/- 10 years; range: 43-89 years) who underwent heart valve surgery with epidural anesthesia without endotracheal intubation. Preoperatively, all patients were in NYHA class III or IV; eight patients (16%) had undergone a previous cardiac procedure. The median Additive and Logistic EuroSCORE were 14.5 and 52%, respectively. Twenty-seven patients underwent aortic valve replacement, 10 mitral valve replacement, 10 mitral valve repair, two double valve replacement, and one patient ascending aorta replacement. Associated surgical procedures included coronary artery bypass grafting in 12 patients (24%), ascending aorta replacement in three (6%), and left ventricle reshaping in two (4%). Radiofrequency ablation to treat chronic atrial fibrillation (AF) was performed in 15 patients (30%). All patients were prospectively followed up, and a six-month quality of life assessment was performed in all survivors.
Procedures were performed without mechanical ventilation in completely awake and conscious patients. There were two in-hospital and two long-term deaths (8%). Three patients had had previous cardiac surgery (two double valve replacements, two complex mitral valve surgery). Among survivors, 34 (71%) had an uneventful postoperative outcome, except for AF in nine cases. Eight patients required revision for bleeding; two of these were redo cases. The most consistent postoperative complication was acute renal failure in 16 patients, five of whom had previous chronic renal failure. Three patients required mechanical ventilatory support, and none had a cerebrovascular accident. Patients were discharged home after a mean of 10 +/- 5 days (including ICU stay; median 9 h). At follow up, all patients were in NYHA class I/II, and all survivors expressed their satisfaction with epidural anesthesia.
Heart valve surgery while on cardiopulmonary bypass is feasible and safe using epidural anesthesia. By maintaining autonomic ventilation, a low mid-term morbidity and mortality was observed in patients in whom there was an unacceptable operative risk.
高危患者进行心脏瓣膜手术会伴有较高的发病率和死亡率。有人提出采用硬膜外麻醉且不进行机械通气可降低侵袭性。本研究对极高危心脏瓣膜患者进行了分析，观察其无并发症的中期生存率以及使用区域麻醉且不进行机械通气时患者的满意度。
对50例患者（24例女性，26例男性；平均年龄74±10岁；范围：43 - 89岁）进行了一项前瞻性随访研究，这些患者接受了硬膜外麻醉且未行气管插管的心脏瓣膜手术。术前，所有患者均为纽约心脏协会（NYHA）心功能Ⅲ级或Ⅳ级；8例患者（16%）曾接受过心脏手术。欧洲心脏手术风险评估系统（EuroSCORE）的相加评分和逻辑评分中位数分别为14.5和52%。27例患者接受主动脉瓣置换术，10例接受二尖瓣置换术，10例接受二尖瓣修复术，2例接受双瓣膜置换术，1例接受升主动脉置换术。相关手术操作包括12例患者（24%）进行冠状动脉旁路移植术，3例（6%）进行升主动脉置换术，2例（4%）进行左心室重塑术。15例患者（30%）进行了射频消融治疗慢性心房颤动（AF）。对所有患者进行前瞻性随访，并对所有幸存者进行了为期6个月的生活质量评估。
手术在完全清醒且有意识的患者身上进行，无需机械通气。有2例患者在住院期间死亡，2例患者长期死亡（8%）。3例患者曾接受过心脏手术（2例双瓣膜置换术，2例复杂二尖瓣手术）。在幸存者中，34例（71%）术后恢复顺利，9例除外房颤。8例患者因出血需要再次手术；其中2例为再次手术病例。最常见的术后并发症是16例患者出现急性肾衰竭，其中5例患者术前患有慢性肾衰竭。3例患者需要机械通气支持，无一例发生脑血管意外。患者平均在10±5天（包括入住重症监护病房时间；中位数9小时）后出院回家。随访时，所有患者均为NYHA心功能Ⅰ/Ⅱ级，所有幸存者均对硬膜外麻醉表示满意。
在体外循环下进行心脏瓣膜手术时，使用硬膜外麻醉是可行且安全的。通过维持自主通气，在手术风险不可接受的患者中观察到中期发病率和死亡率较低。
