| Backgroud:Delirium is an acute syndrome of cerebral nervous system,characterized by disturbances of consciousness and cognitive function.Most patients of delirium can heal by themselves in 2~3 days,and rarely extend to seventh days.By now,the risk factors and pathogenesis is still not clear.Also,there are no effective methods for diagnosis and treatment.Therefore,more attention has been paid to postoperative delirium about its influence on the prognosis of the patients.Due to the unique factors,such as great surgical trauma,high surgical stress response and cardiopulmonary bypass,the incidence of postoperative delirium for cardiac surgery is quite high.With the development of cardiac surgery,transition from standard median sternotomy to a minimally invasive incision in cardiac surgery is very important.Recently,minimally invasive surgery has been used in cardiac surgery.In our department,the minimally invasive cardiac surgery technique “right vertical infra-axillary mini-incision”(RVAI)approach has been applied for several years,and its safety and cosmetic efficacy has also been demonstrated.However,the limitation of operation view is a crucial defect of this technique.Fortunately,thoracoscope assistance offers a straight and direct view,thereby compensating for the defects of the RVAI approach.The thoracoscope has been used in cardiac surgery for several decades,and its use has progressively increased with minimally invasive cardiac surgery.Therefore,the combination of the RVAI and the thoracoscopic technique via the TARVAI approach can be expected to improve the efficacy of cardiac surgery.In our center,TARVAI approach has been employed in both pediatric and adult patients with simple congenital heart diseases and mitral valve disease.The TARVAI approach has several unique advantages.First of all,compared with the right anterolateral minithoractomy and partial sternotomy techniques,TARVAI approach has cosmetically superior result,which could reduce the complications of thoracic deformity,asymmetrical development of the breast and unsightly scar potentially.In the present study,the incision located on the right midaxillary line was small and could be hidden by the resting arm.And no asymmetrical development of the breast,thoracic deformity,or scoliosis was found during follow-up.And all the patients felt that they had an aesthetically pleasing scar,and would choose the same procedure again if they had to undergo redo surgery during the follow-up.Furthermore,the TARVAI approach permits a straight and direct view of the operation.TARVAI of mitral valve replacement approach(TARVAI-MVR)has been widely used,with good effect.However,there is no research for the incidence,risk factors and pathogenesis of TARVAI-MVR.Part one The study about the incidence,risk factors of TARVAI-MVRObjective: to observe the incidence,risk factors of TARVAI-MVR.Method: 1.One hundred and thirty-four patients who undergone TARVAI-MVR surgery were enrolled.2.Neurocognitive testing of MMSE was performed before surgery.And delirium testing was performed with the CAM-ICU on 1,2 and 3day after the operation.According to the result of delirium,the patients were divided into two groups(POD group and NPOD group).Besides,A standard Visual Analogue Scale(VAS)method and RASS were used to assess pain and sedation depth respectively during ICU.Results:1.The postoperative delirium was observed in 48 patients,and the incidence of Postoperative delirium was 35.8%.2.Single factor analysis showed that,in the POD group,the indexes of age(t=-3.741,P<0.001),Proportion of hard-drinking(? 2=17.556,p<0.001),preoperative MMSE score(t=8.659,P=<0.001),educational level(?2=27.652,p<0.001),the time of CPB(Z=-8.61,P<0.001)aortic clamp closing time(Z=-8.267,P<0.001),operative time(Z=-4.604,P<0.001)and intraoperative hypotension occurred rate(?2=24.703,p=0.000),intraoperative incidence of hypoxemia(?2=28.598,p=0.000),drainage after operation(Z=-2.135,P<0.001),ventilator time(Z=-6.617,P<0.001),ICU stay(Z=-7.794,P<0.001),the depth of sedation(?2=30.443,p=0.000),the degree of pain(?2=28.711,p=0.000)were significantly different from these in the NPOD group.And the indexes of sex(?2=2.718,p=0.099),body weight(t=-0.465,P=0.642),preoperative hemoglobin concentration(t=-0.322,P=0.748),postoperative first day of albumin(t=0.483,P=0.63),and creatinine(Z=-1.715,P=0.086)were similar between the two groups.Logistic regression analysis showed that,the indexes of age,proportion of hard-drinking,educational level,the time of CPB,intraoperative hypotension occurred rate,ICU stay,the depth of sedation and the degree of pain were the important risk factors for postoperative delirium of TARVAI-MVR surgery.Conclusion: 1.the incidence of postoperative delirium of TARVAI-MVR surgery was35.8%.2.the index of age,Proportion of hard-drinking,educational level,the time of CPB,intraoperative hypotension occurred rate,ICU stay,the depth of sedation and the degree of pain may be the important risk factor of postoperative delirium of TARVAI-MVR surgery.Part two The study about the pathogenesis of TARVAI-MVRObjective: to explore the pathogenesis of TARVAI-MVR.Method: 1.One hundred and thirty-four patients who undergone TARVAI-MVR surgery were enrolled.Neurocognitive testing of MMSE was performed before surgery.And delirium testing was performed with the CAM-ICU on 1,2 and 3day after the operation.According to the result of delirium,the patients were divided into two groups(POD group and NPOD group).2.Blood samples were taken and immediately sent for centrifugation at 3000 r.p.m for 10 before surgery,24 h,48h,72 h after surgery.The method of ELISA was used to measure the level of CRP,IL-6 and TNF-.Then,the levels of the three inflammatory factors were compared between the POD group and NPOD group.Results: 1.The postoperative delirium was observed in 48 patients,and the incidence of postoperative delirium was 35.8%.2.Compared to the NPOD group,both of the level of TNF-α(21.44±10.34 pg/ml vs 13.58±9.94 pg/ml,P<0.05;23.21±13.70 pg/ml vs12.94±4.15 pg/ml,P<0.05)and CRP(200.96±50.21 mg/Lvs 117.21±38.36 mg/L,P<0.05;122.96 ± 61.65 mg/L vs 56.34 ± 26.30 mg/L,P<0.05)were significantly higher on the 48 h and 72 h after surgery;and both were similar on other time points(Ps>0.05).The level of IL-6 in the POD group was obviously higher than that in the NPOD group on all time points(Ps<0.05)except before surgery(P>0.05).Conclusion: 1.the incidence of postoperative delirium of TARVAI-MVR surgery was35.8%.2.The higher level of CRP,IL-6 and TNF-α may be play important role in the Pathogenesis of postoperative delirium of TARVAI-MVR. |
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