改良灌注策略在主动脉缩窄合并心内畸形一期矫治术中的应用

Usefulness of modified perfusion strategy during one-stage repair of aorta coarctation combined with intracardiac malformations

目的探讨以浅、中度低温，区域性脑灌注同期心脏灌注行主动脉缩窄（CoA）矫治的改良灌注策略，在婴幼儿主动脉缩窄合并心内畸形一期矫治中的应用及手术结果。方法2010年9月至2012年12月，59例CoA合并心内畸形患儿手术，男37例，女22例；年龄2～46（8．2±6．3）个月，体质量4．0—18．0（6．6±2．2）kg-1。采用改良灌注策略组29例，改良的灌注策略要点包括：降温至鼻咽温26℃～35℃，直肠温29℃～35℃，分别在无名动脉一左颈总动脉间和缩窄段远端放置阻断钳，不改变动脉插管位置，心脏跳动下以40—60ml·kg-1·min-1灌注流量行区域性脑灌注兼心脏灌注，下半身停循环下以端端吻合或扩大端端吻合法矫治CoA，CoA矫治完成后，行升主动脉阻断，心脏灌停，矫治心内畸形。传统灌注策略组30例患儿作为对照，采用常规的心脏停跳、全身深低温、单纯区域性脑灌注的灌注策略矫治CoA，其余操作与前述相同。结果两组均无手术死亡，术后肺部感染12例，气胸3例，尿少行腹膜透析3例，伤口感染行二次清创缝合1例。改良手术策略组与传统灌注策略组相比，心脏阻断时间[（35．3±10．2）min对（58．4±19．8）min]、循环辅助时间[（16．8±4．0）min对（31．6±12．1）min]更短，术毕血管活性药物用量[多巴胺（4．5±0．8）μg·kg-1·min-1对（6．3±1．3）μg·kg-1·min-1更少。所有患儿出院前超声心动图检查均显示主动脉弓降部缩窄解除，吻合口通畅，流速正常或轻度增快。59例患儿随访3～26个月，无死亡和近、中期并发症。结论改良灌注策略与传统灌注策略相比较，可减轻心肌损伤，显著缩短心脏阻断、循环辅助及变温时间，缩短手术总时长，近期结果满意。

Objective To investigate the application and surgical results of the modified perfusion strategy,that means, mild/moderate hypothermia, regional cerebral perfusion combined with cardiac perfusion, in the surgical correction of coareta- tion of the aorta（CoA） in infants and young children of CoA with intracardiac malformations. Methods From September 2010 to December 2012, 59 patients of CoA combined with intracardiac malformation were enrolled in the study ,37 males and 22 females.. Among them, modifed purfusion strategy were performed in 29 patients, whereas ＂Traditional surgical strategy＂ were applied in 30 randomly selected cases as control. The age of the whole group ranged from 2 to 46 （ 8.2 ± 6.3 ） months and the body weight was from 4.0 -18 （6.58 ＋ 2.15 ） kg. The key points of the ＂Modified purfusion strategy＂ include： Cooling to a nasopharyngeal temperature of 26℃ -35 ℃, rectal temperature of 29℃ -35℃, Occlusion clamp was placed between the in- nominate artery-the left common carotid artery and the distal end of CoA. By keeping the position of asending arotic catheteriza- tion unchanged and keeping the heart beating, regional cerebral perfusion combined with heart perfusion were realised at 40 - 60 ml · kg-1 · min-1 flow rate. With lower body circulatory arrest, CoA were corrected by the approach of end-to-end or extentive end-to-end anastomosis. After the CoA correction is completed, clamping the asending aortic, cardiac arrest, correction Of cardiac anomalies. Traditional perfusion strategy group using conventional cardiac arrest, deep hypothermia, regional cerebral perfusion approch to correct COA, the rest of the operation is the same as described above. Results There was no operative death, postoperative pulmonary infection occurred in 12 cases, 3 cases occured pneumothorax, 1 case suffered wound in fection and underwent secondary debridement, 3 cases encountered postoperative oliguria and were treated with peritoneal dialy- sis. All patients received echocardiography examination before discharge and showed aortic arch coarctation has released, anas- tomotic stoma is patent, flow rate is normal or slightly fast. All patients were followed up for 3 - 26 months, no late death or complications oecours. Modified perfusion strategy group was significantly superiors to the traditional persufion strategy group in the aspects of cardiac arrest time[ （35.3 ± 10.2 ） min vs. （ 58.4 ± 19.8 ） min ] , auxiliary CPB time [ （ 16.8 ± 4.0 ） rain vs. （ 31.6 ± 12. 1 ） min ] and the vasoactive drug dosage [ dopamine ： （4.5 ± 0. 8 ） μg·kg-1·min-1 vs. （6.3 ± 1.3 ） μg·kg-1·min-1 ] after surgery. Conclusion Modified perfusion strategy can reduce myocardial injury, significantly reduce cardiac arrset,circulatory support and temperature adjusting time and shorten the total duralion of surgery compared with conventional perfusion strategy, the early result is satisfactory and has broad application prospects.