不同温度下停循环选择性脑灌注在急性Ⅰ型StandfordA主动脉夹层中的应用

Application of circulatory arrest and selective cerebral perfusion under different temperature in acute Standford type A aortic dissection

目的：评价急性Ⅰ型 Standford A 主动脉夹层手术在不同温度下停循环选择性脑灌注技术中的临床效果。方法50例行主动脉全弓置换者按照开始停循环的最低温度分为5组：A 组（10例,鼻咽温16～18℃）、B 组（10例,18～20℃）、C 组（10例,20～22℃）、D 组（10例,22～24℃）、E 组（10例,24～26℃）。观察5组患者手术及临床预后情况。结果术后患者出现1例永久性神经功能障碍（PND）患者放弃治疗,5例短暂性神经系统功能障碍（TND）,4例一过性肾功能障碍,手术中无死亡,术后无严重低心排出量综合征和多脏器功能衰竭,治愈出院。50例患者中,49例痊愈出院,1例自动出院。各组开始选择性脑灌注鼻咽温和直肠温度如下：A 组（17．1±1．8）℃、（20．5±1．2）℃；B 组（18．9±3．1）℃、（22．4±1．2）℃； C 组（21．2±1．1）℃、（24．4±1．9）℃；D 组（23±1．2）℃、（26．2±1．8）℃； E 组（25±1．1）℃、（27．2±1．7）℃。5组患者复温时间比较：体外循环时间差异均有统计学意义（F =6．572,P ＜0．05）,5组患者术后1例 PND 发生率为2%,TND 发生率为10%,差异无统计学意义（F =1．283,P ＞0．05）。术后呼吸机辅助时间、肾功能衰竭发生率、监护室停留时间、住院时间差异无统计学意义（F =0．935,P ＞0．05）。结论急性 Standford A 型主动脉夹层在不同温度下,停循环选择性脑灌注技术用于手术,可以明确减少体外循环转机时间,并未增加患者术后神经系统并发症,在中低温下行停循环加选择性脑灌注在主动脉夹层中的应用更加安全可靠。

Objective To evaluate the clinical effect of circulatory arrest and selective cerebral perfusion under dif-ferent temperature on acute Standford type A aortic dissection. Methods 50 cases of all aortic arch replacement were carried out during January 2008 to November 2014. According to the lowest nasopharyngeal temperature at the beginning of stop cycle, all the cases were divided into the following groups：group A （10 cases, 16 ～ 18 ℃） , group B （10 cases, 18 ～ 20 ℃）, group C （10 cases, 20 ～ 22 ℃） , group D （10 cases, 22 ～ 24 ℃）, group E （10 cases, 24 ～ 26 ℃）. The surgery and clinical prognosis of all the patients were observed. Results After the operation, one patient appeared permanent neurologic disorders and gave up treatment. Five patients appeared to transient neurological dysfunction. Four cases turned to transient renal dysfunction. All the patients survived with-out postoperative low cardiac and multiple organ failure. Among 50 cases, 49 cases were recovered and discharged, 1 case discharged automatically. At the beginning of selective cerebral reperfusion, nasopharyngeal temperature and rectal temperature were as the following respectively：group A （17. 1 ± 1. 8） ℃ and （20. 5 ± 1. 2） ℃, group B （18. 9 ± 3. 1） ℃ and （22. 4 ± 1. 2） ℃, group C （21. 2 ± 1. 1） ℃ and （24. 4 ± 1. 9） ℃, group D （23 ± 1. 2）℃ and （26. 2 ± 1. 8） ℃ ,group E （25 ± 1. 1） ℃ and （27. 2 ± 1. 7） ℃. Compared the temperature rewarming time of five groups, extracorporeal circulation time difference had statistical significance（F = 6. 572, P 〈 0. 05）. 1 case of permanent neurological complications postoperatively in five groups （ PND unit）：the incidence rate was 2% ; temporary neurological complications incidence （TND）：10% , there was no statistically significant difference （F = 1. 283,P 〉 0. 05）. There was no statistically significant difference in postoperative respiratory machine auxil-iary time, incidence of renal failure, residence time of care unit, as well as the period of hospitalization. Conclu-sion The selective cerebral perfusion technique under different temperature for acute Standford type A aortic dis-section surgery could reduce the CPB time clearly. At the same time, it could not increase the incidence of postop-erative neurological complications. It is safer and more reliable to use circulatory arrest under low-middle tempera-ture and selective cerebral reperfusion in the operation of aortic dissection.