心脏瓣膜置换同期行射频消融治疗房颤的术中护理(1)
[摘要] 目的 探讨心脏瓣膜置换同期行射频消融治疗房颤的术中配合和护理要点。 方法 回顾分析33例接受心脏瓣膜置换手术的患者，同期行射频消融治疗房颤的术中配合和护理过程。 结果 33例患者手术顺利，术后均安返重症监护室，无死亡病例，术后一年房颤转复率为83.3%。 结论 认真做好术前常规物品及射频消融仪器的准备，对患者病情进行充分的评估，熟悉手术步骤，掌握特殊仪器的使用方法，及时准确传递手术器械，协助体外循环转流医生及麻醉医生密切观察患者术中生命体征及体温监测，安全用药，是保证手术顺利完成的关键。
[关键词] 瓣膜置换；房颤；射频消融；术中护理
[中图分类号] R654.2 [文献标识码] B [文章编号] 2095-0616(2015)20-95-04
Intraoperative nursing of cardiac valve replacement combined with radiofrequency ablation in treatment with atrial fibrillation
, 百拇医药
DU Meilan
Operating Room，the First Affiliated Hospital of Suzhou University，Suzhou 215006，China
[Abstract] Objective To explore cooperation in operation and nursing points of cardiac valve replacement combined with radiofrequency ablation in treatment with atrial fibrillation. Methods Cooperation in operation and nursing process of 33 patients who were treated with cardiac valve replacement combined with radiofrequency ablation in treatment with atrial fibrillation were retrospectively analyzed. Results 33 patients all had successful operations and they were returned to intensive care unit after operation.There was no death case.The success rate of reversing atrial fibrillation of one year after operation was 83.3%. Conclusion Keys to a successful operation were to make careful preparations of preoperative conventional goods and radiofrequency ablation instrument，sufficiently evaluate patients' conditions，grasp using methods of special instruments，transfer surgical instrument promptly and accurately，assist doctors of cardiopulmonary bypass and anesthesia to closely observe intraoperative vital signs and temperature monitoring of patients as well was safe medication.
, 百拇医药
[Key words] Valve replacement；Atrial fibrillation；Radiofrequency ablation；Intraoperative nursing
心房颤动(简称房颤)为临床常见的心律失常[1]，持续的房颤会增加脑中风的发生率[2]，严重影响患者的生活质量。房颤的发病率成人在0.5%～0.95%，心脏瓣膜病伴有心房扩大的患者中，发病率可达50%以上[3]。对于这类患者，单纯瓣膜置换手术仅可改善临床症状及心功能，不能解决房颤对其的影响，其可能导致的血栓将对患者生命构成威胁[4]。在瓣膜置换手术同期通过射频消融的方法治疗房颤，是近几年来外科治疗心脏瓣膜病合并房颤的有效方法[5-7]。我院心血管外科自2014年1月～2015年4月，对33例合并房颤的瓣膜病患者，在瓣膜手术同时通过冲洗式单极射频消融系统进行房颤消融，取得了满意的效果，现将术中护理总结如下。
1 资料与方法
, http://www.100md.com
1.1 一般资料
本组患者共33例，男15例，女18例，平均年龄(57.0±10.2)岁，风湿性心脏瓣膜病24例，其中单纯二尖瓣狭窄6例，二尖瓣狭窄伴关闭不全9例，二尖瓣及主动脉瓣联合瓣膜病变9例；退行性瓣膜病8例，均有不同程度的二尖瓣关闭不全，2例合并有主动脉瓣关闭不全。13例患者合并有三尖瓣关闭不全。术前心功能(NYHA)Ⅰ～Ⅱ级19例，Ⅲ级14例，持续性房颤27例，阵发性房颤6例。
1.2 手术方法
静吸复合全身麻醉后，气管插管，胸骨正中切口，全身肝素化，体外循环转流后，降至中度低温，阻断主动脉，经主动脉根部或直接切开主动脉灌注冠脉冷停跳液，待心电活动停止后，阻断上下腔静脉。纵切右房，取房间隔切口，检查左房、左室内有无附壁血栓，如有血栓形成，予行血栓清除术。继以冲洗式单极射频消融系统(CardioblateTM，Medtronic，USA)行心内膜消融，消融路径按如下路线进行：右上、右下肺静脉开口周线，左上、左下肺静脉开口周线，左心耳根部周线，左右上、下肺静脉连线，左上肺静脉至左心耳连线，左下肺静脉至二尖瓣后叶瓣环连线[8]，射频消融选择能量25W，生理盐水冲洗速度5mL/min，观察心内膜组织明显发白隆起并轻微皱缩为度。射频消融完成后，再行二尖瓣、主动脉瓣及三尖瓣置换或成形术。常规缝扎左心耳，切断Marshell韧带，左房大者(左房最大径>60mm)行左房成形术，以缩小左心房容量。复温，排气，关闭房间隔及右心房，开放升主动脉。术中常规于右心室心外膜缝合起搏导线两根，连接临时起搏器备用。, 百拇医药(杜美兰)
[关键词] 瓣膜置换；房颤；射频消融；术中护理
[中图分类号] R654.2 [文献标识码] B [文章编号] 2095-0616(2015)20-95-04
Intraoperative nursing of cardiac valve replacement combined with radiofrequency ablation in treatment with atrial fibrillation
, 百拇医药
DU Meilan
Operating Room，the First Affiliated Hospital of Suzhou University，Suzhou 215006，China
[Abstract] Objective To explore cooperation in operation and nursing points of cardiac valve replacement combined with radiofrequency ablation in treatment with atrial fibrillation. Methods Cooperation in operation and nursing process of 33 patients who were treated with cardiac valve replacement combined with radiofrequency ablation in treatment with atrial fibrillation were retrospectively analyzed. Results 33 patients all had successful operations and they were returned to intensive care unit after operation.There was no death case.The success rate of reversing atrial fibrillation of one year after operation was 83.3%. Conclusion Keys to a successful operation were to make careful preparations of preoperative conventional goods and radiofrequency ablation instrument，sufficiently evaluate patients' conditions，grasp using methods of special instruments，transfer surgical instrument promptly and accurately，assist doctors of cardiopulmonary bypass and anesthesia to closely observe intraoperative vital signs and temperature monitoring of patients as well was safe medication.
, 百拇医药
[Key words] Valve replacement；Atrial fibrillation；Radiofrequency ablation；Intraoperative nursing
心房颤动(简称房颤)为临床常见的心律失常[1]，持续的房颤会增加脑中风的发生率[2]，严重影响患者的生活质量。房颤的发病率成人在0.5%～0.95%，心脏瓣膜病伴有心房扩大的患者中，发病率可达50%以上[3]。对于这类患者，单纯瓣膜置换手术仅可改善临床症状及心功能，不能解决房颤对其的影响，其可能导致的血栓将对患者生命构成威胁[4]。在瓣膜置换手术同期通过射频消融的方法治疗房颤，是近几年来外科治疗心脏瓣膜病合并房颤的有效方法[5-7]。我院心血管外科自2014年1月～2015年4月，对33例合并房颤的瓣膜病患者，在瓣膜手术同时通过冲洗式单极射频消融系统进行房颤消融，取得了满意的效果，现将术中护理总结如下。
1 资料与方法
, http://www.100md.com
1.1 一般资料
本组患者共33例，男15例，女18例，平均年龄(57.0±10.2)岁，风湿性心脏瓣膜病24例，其中单纯二尖瓣狭窄6例，二尖瓣狭窄伴关闭不全9例，二尖瓣及主动脉瓣联合瓣膜病变9例；退行性瓣膜病8例，均有不同程度的二尖瓣关闭不全，2例合并有主动脉瓣关闭不全。13例患者合并有三尖瓣关闭不全。术前心功能(NYHA)Ⅰ～Ⅱ级19例，Ⅲ级14例，持续性房颤27例，阵发性房颤6例。
1.2 手术方法
静吸复合全身麻醉后，气管插管，胸骨正中切口，全身肝素化，体外循环转流后，降至中度低温，阻断主动脉，经主动脉根部或直接切开主动脉灌注冠脉冷停跳液，待心电活动停止后，阻断上下腔静脉。纵切右房，取房间隔切口，检查左房、左室内有无附壁血栓，如有血栓形成，予行血栓清除术。继以冲洗式单极射频消融系统(CardioblateTM，Medtronic，USA)行心内膜消融，消融路径按如下路线进行：右上、右下肺静脉开口周线，左上、左下肺静脉开口周线，左心耳根部周线，左右上、下肺静脉连线，左上肺静脉至左心耳连线，左下肺静脉至二尖瓣后叶瓣环连线[8]，射频消融选择能量25W，生理盐水冲洗速度5mL/min，观察心内膜组织明显发白隆起并轻微皱缩为度。射频消融完成后，再行二尖瓣、主动脉瓣及三尖瓣置换或成形术。常规缝扎左心耳，切断Marshell韧带，左房大者(左房最大径>60mm)行左房成形术，以缩小左心房容量。复温，排气，关闭房间隔及右心房，开放升主动脉。术中常规于右心室心外膜缝合起搏导线两根，连接临时起搏器备用。, 百拇医药(杜美兰)