中国胸心血管外科临床杂志

中国胸心血管外科临床杂志

应用中低温停循环联合单侧脑灌注行急诊弓部替换手术的早中期结果

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目的 研究中低温停循环联合单侧顺行性脑灌注应用于急诊主动脉弓部替换手术的疗效。 方法 回顾性分析 2008 年 1 月至 2018 年 6 月 146 例急诊应用中低温停循环(MHCA)联合单侧顺行性脑灌注(UACP)方法行主动脉弓部替换手术患者的临床资料,其中男 111 例、女 35 例,平均年龄(60.3±7.2)岁,按手术方式不同分全弓替换组(n=104)和半弓替换组(n=42)。右侧腋动脉插灌注管,停循环温度(23.4±1.4)℃,单侧顺行性脑灌注,灌注液温度 18℃~22℃、流量 5~10 ml/(kg·min),脑灌压力 50~60 mm Hg。 结果 体外循环时间(CPBT)(235±42)min,主动脉阻断时间(AACT)(154±29)min,停循环时间(CAT)(48.1±13.0)min。全弓组 CPBT、CAT 大于半弓组。手术死亡率 9.6%。术后并发症包括永久性神经功能障碍(PND)、一过性神经功能障碍(TND)、需要透析的急性肾损伤(AKI)和延迟拔管(机械通气时间>72 h)。PND、TND 发生率分别是 2.7% 和 6.8%,需要透析的 AKI 发生率 4.1%,延迟拔管发生率 21.9%。死亡率和并发症发生率两组无差异。平均随访 63 个月,术后 5 年生存率全弓组 72.6%、半弓组 85.5%,两组无差异。 结论 应用 MHCA+UACP 方法行急诊主动脉弓部替换手术疗效满意。

Objective To investigate the results of emergent aortic arch replacement using moderate hypothermic circulatory arrest and unilateral selective antegrade cerebral perfusion (MHCA+UACP). Methods We retrospectively analyzed the clinical data of 146 patients who underwent emergent aortic arch replacement using MHCA+UACP in our institution from January 2008 to June 2018. There were 111 males and 35 females aged 60.3±7.2 years. According to different surgical approach, patients were divided into two groups, a total arch replacement (TAR) group (n=104) and a semi arch replacement (SAR) group (n=42). Right axillary artery was cannulated for cardiopulmonary bypass (CPB) and cerebral perfusion. Core temperature at the onset of MHCA was 23.4℃±1.4℃. UACP was initiated at 18℃–22℃ at 5–10 ml/(kg·min). Flow was adjusted to maintain cerebral perfusion pressure of 50–60 mm Hg. Results CPB time was 235±42 min. Aortic clamp time was 154±29 min. Circulatory arrest (CA) time was 48.1±13.0 min. The CPB and CA time of TAR group were longer than that of SAR group. Overall mortality rate was 9.6%. Complications included permanent neurological disfunction (PND), temporary neurological disfunction (TND), acute kidney injury (AKI) requiring dialysis and delayed extubatio n (mechanical ventilation time >72 hours). Overall incidence of PND and TND was 2.7% and 6.8%. The incidence of AKI requiring dialysis was 4.1%. The incidence of delayed extubation was 21.9%. No difference of mortality rate and incidence of complications was found between two groups. Conclusion Emergent aortic arch replacement using MHCA+UACP can be accomplished with excellent results.

关键词: 主动脉弓替换; 低温停循环; 顺行性脑灌注

Key words: Aortic arch replacement; hypothermic circulatory arrest; antegrade cerebral perfusion

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