2018 年第 12 期 第 13 卷

肥厚型梗阻性心肌病外科治疗的麻醉管理

Anesthesia management of surgical treatment for hypertrophic obstructive cardiomyopathy

作者：迟慧卿恩明来永强马骏

英文作者：

单位：100029首都医科大学附属北京安贞医院麻醉中心

英文单位：

关键词：肥厚型梗阻性心肌病；外科治疗；左心室流出道疏通术；麻醉管理

英文关键词：

• 摘要：

• 【摘要】目的    总结外科治疗肥厚型梗阻性心肌病（HOCM）患者的麻醉管理经验。方法    回顾性分析2007年1月至2017年6月首都医科大学附属北京安贞医院150例HOCM行体外循环下左心室流出道疏通术部分联合二尖瓣置换或成形术患者的麻醉管理资料。所有患者均采用静脉复合麻醉，麻醉诱导及维持采用咪达唑仑、丙泊酚、七氟烷、舒芬太尼和顺式阿曲库铵，术中监测并记录不同时段心率、平均动脉压、肺毛细血管楔压、心输出量、心脏排血指数、外周血管阻力、肺血管阻力以及左心室流出道压差。结果    全组患者均顺利完成手术，术中血流动力学平稳，无严重心律失常发生。心脏复跳后，经食管超声心动图示二尖瓣前叶收缩期前向运动现象（SAM征）改善或消失，左心室腔增大。流出道疏通后左心室流出道压差较疏通前明显下降［（22±11）mmHg(1 mmHg＝0.133 kPa)比（74±31）mmHg］（P＜0.01），其他监测指标无明显改变（均P＞0.05）。结论    对HOCM外科治疗患者的麻醉管理关键在于维持适度的麻醉深度以避免增加心肌收缩力，维持正常的心率、血压及心脏前后负荷，避免使用扩张血管和增强心肌收缩力的药物。

• 【Abstract】Objective    To review the anesthesia management experience of surgical treatment for hypertrophic obstructive cardiomyopathy（HOCM）. Methods    Anesthesia data of 150 HOCM patients who had on-pump left ventricular outflow septal myectomy with or without mitral valve replacement/angioplasty in Beijing Anzhen Hospital, Capital Medical University from January 2007 to June 2017 were retrospectively analyzed. All patients had intravenous anesthesia using midazolam, propofol, sevoflurane, sulfentanyl and cisatracurium. Heart rate, mean arterial pressure, pulmonary capillary wedge pressure, cardiac output, cardiac index, systemic vascular resistance, pulmonary vascular resistance and left ventricular outflow tract pressure gradient（ΔPLVOT） were monitored during operation. Results    Hemodynamics were stable and there was no serious arrhythmia occurred during operation. Transesophageal echocardiography showed that SAM signs were improved or disappeared and left ventricular cavity enlarged after operation. ΔPLVOT after outflow tract dredging significantly decreased compared to that before operation［（22±11）mmHg vs （74±31）mmHg］（P＜0.01）; other indicators showed no significant changes（P＞0.05）. Conclusion    Anesthesia management should focus on reducing myocardial contractility with: adequate deep anesthesia, heart rate, blood pressure, sufficient cardiac preload and afterload, avoiding the use of vasodilators and positive inotropics.