中低温停循环联合顺行性脑灌注在大体重成人主动脉弓部手术中的临床应用

The clinical practice of moderate hypothermic circulatory and unilateral antegrade cerebral perfusion during aortic arch surgery in overweight patients

目的:评价不同程度中低温停循环联合顺行性脑灌注技术用于超重(BMI≥24kg/m^2)成人主动脉弓部手术的临床效果。方法:选取2009年1月至2015年12月,于北京安贞医院,在中低温停循环选择性脑灌注下行主动脉弓手术超重患者997例,按停循环开始时鼻咽温不同,分低温组(LM组,20.1~24.0℃,n=662)和高温组(HM组,24.1~28.0℃,n=335)。比较其临床预后,并分析相关风险因素。结果:62例(6.2%)住院死亡,42例(4.3%)严重神经系统损伤。与低温组患者相比较,高温组患者行半弓置换术比率较高(23.0%vs.11.0%),而行孙氏手术操作比率较低(75.2%vs.87.2%),差异均具有统计学意义(P<0.01)。经1∶1匹配后,两组患者临床资料可比性较好。两组患者住院病死率(4.3%vs.7.6%,P=0.19)、术后永久性神经系统并发症(6.5%vs.5.5%,P=0.67)及术后其他并发症发生率差异无统计学意义(P>0.05)。回归分析结果未见高温是住院死亡及术后并发症的风险因素。结论:中低温停循环联合选择性脑灌注用于主动脉弓部手术时,较高的鼻咽温能够安全用于超重患者。

Objective： To analyze clinical outcomes of overweight(BMI ≥24 kg/m^2） patients who underwent aortic arch surgery with unilateral antegrade cerebral perfusion(UACP） using different temperature ranges for moderate hypothermic circulatory arrest. Methods： From 2009 to 2015,a total of 997 overweight patients underwent aortic arch surgery with MHCA and UACP. Circulatory arrest was initiated at a nasopharyngeal temperature of 20. 1-24. 0℃ in the lower-temperature group(LM group,n = 662） and at 24. 1-28. 0℃ in the higher-temperature group(HM group,n = 335）. The different clinical outcomes in two groups were compared by a propensity score-matched analysis. We used multivariate logistic regression analysis to validate the result of matched analysis and identify risk factors of clinical outcomes. Results： The in-hospital mortality rate was6. 2%(n = 62） and the incidence of permanent neurologic dysfunction(PND） was 4. 3%(n = 42）. The differences in the distribution of patient baseline data were too great in HM and LM groups,such as the proportion of hemiarch replacement(23. 0% vs. 11. 0%,P〈0. 01） and Sun＇s procedure(75. 2% vs. 87. 2%,P〈0. 01）. After the 1∶ 1 propensity score matching,the pro-and intraoperative data in the two groups was comparable. For the matched patients,in-hospital mortality(4. 3% vs. 7. 6%,P = 0. 19）,the incidence of PND(6. 5% vs. 5. 5%,P = 0. 67） and other postoperative complications in the HM and LM groups have no statistical difference(P〉0. 19）. Multivariable analysis did not show that undergoing higher-degree MHCA was an independent protective factor for in-hospital mortality and postoperative complications. Conclusion： Our study showed that using higher-degree moderate hypothermia(24. 1-28. 0℃） during aortic arch surgery in overweight patients is safe and efficient.