Department of Perfusion, University Hospital Ghent, Ghent, Belgium.
Department of Anesthesia, University Hospital Ghent, Ghent, Belgium.
Interact Cardiovasc Thorac Surg. 2020 Jul 1;31(1):48-55. doi: 10.1093/icvts/ivaa052.
Research concerning cardiopulmonary bypass (CPB) management during minimally invasive cardiac surgery (MICS) is scarce. We investigated the effect of CPB parameters such as pump flow, haemoglobin concentration and oxygen delivery on clinical outcome and renal function in a propensity matched comparison between MICS and median sternotomy (MS) for atrioventricular valve surgery.
A total of 356 patients undergoing MICS or MS for atrioventricular valve surgery between 2006 and 2017 were analysed retrospectively. Propensity score analysis matched 90 patients in the MS group with 143 in the MICS group. Logistic regression analysis was performed to investigate independent predictors of cardiac surgery-associated acute kidney injury in patients having MICS.
In MICS, CPB (142.9 ± 39.4 vs 101.0 ± 38.3 min; P < 0.001) and aortic cross-clamp duration (89.9 ± 30.6 vs 63.5 ± 23.0 min; P < 0.001) were significantly prolonged although no differences in clinical outcomes were detected. The pump flow index was lower [2.2 ± 0.2 vs 2.4 ± 0.1 l⋅(min⋅m2)-1; P < 0.001] whereas intraoperative haemoglobin levels were higher (9.25 ± 1.1 vs 8.8 ± 1.2; P = 0.004) and the nadir oxygen delivery was lower [260.8 ± 43.5 vs 273.7 ± 43.7 ml⋅(min⋅m2)-1; P = 0.029] during MICS. Regression analysis revealed that the nadir haemoglobin concentration during CPB was the sole independent predictor of cardiac surgery-associated acute kidney injury (odds ratio 0.67, 95% confidence interval 0.46-0.96; P = 0.029) in MICS but not in MS.
Specific cannulation-related issues lead to CPB management during MICS being confronted with flow restrictions because an average pump flow index ≤2.2 l/min/m2 is achieved in 40% of patients who have MICS compared to those who have a conventional MS. This study showed that increasing the haemoglobin level might be helpful to reduce the incidence of cardiac surgery-associated acute kidney injury after minimally invasive mitral valve surgery.
微创心脏手术（MICS）期间体外循环（CPB）管理的相关研究较少。我们通过倾向性匹配比较分析，研究了 CPB 参数（如泵流量、血红蛋白浓度和氧输送）对 MICS 和正中胸骨切开术（MS）行房室瓣手术患者临床结局和肾功能的影响。
回顾性分析了 2006 年至 2017 年间接受 MICS 或 MS 行房室瓣手术的 356 例患者。采用倾向性评分分析将 MS 组 90 例患者与 MICS 组 143 例患者匹配。采用逻辑回归分析探讨 MICS 患者心脏手术后发生急性肾损伤的独立预测因素。
在 MICS 中，CPB（142.9±39.4 比 101.0±38.3 分钟；P<0.001）和主动脉阻断时间（89.9±30.6 比 63.5±23.0 分钟；P<0.001）明显延长，但临床结局无差异。泵流量指数较低[2.2±0.2 比 2.4±0.1 l·（min·m2）-1；P<0.001]，术中血红蛋白水平较高（9.25±1.1 比 8.8±1.2；P=0.004），最低氧输送量较低[260.8±43.5 比 273.7±43.7 ml·（min·m2）-1；P=0.029]。回归分析显示，CPB 期间最低血红蛋白浓度是 MICS 患者心脏手术后发生急性肾损伤的唯一独立预测因素（比值比 0.67，95%置信区间 0.46-0.96；P=0.029），而不是 MS 患者。
特定的插管相关问题导致 MICS 期间 CPB 管理面临流量限制，因为在接受 MICS 的患者中，有 40%的患者平均泵流量指数≤2.2 l/min/m2，而接受传统 MS 的患者则没有。本研究表明，增加血红蛋白水平可能有助于减少微创二尖瓣手术后心脏手术后急性肾损伤的发生率。
