应用中低温停循环联合单侧脑灌注行急诊弓部置换手术的早中期结果

Early-and mid-term results of emergent aortic arch replacement using moderate hypothermic circulatory arrest and unilateral selective antegrade cerebral perfusion

目的研究中低温停循环(MHCA)联合单侧顺行性脑灌注(UACP)应用于急诊主动脉弓部置换手术的疗效。方法回顾性分析2008年1月至2018年6月我院146例急诊应用MHCA+UACP方法行主动脉弓部置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。按手术方式不同将患者分为全弓置换组(n=104)和半弓置换组(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),脑灌注压力50~60 mm Hg。结果全组体外循环时间(235.0±42.0)min,主动脉阻断时间(154.0±29.0)min,停循环时间(48.1±13.0)min。全弓置换组体外循环时间、停循环时间长于半弓置换组。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发生率为4.1%,延迟拔管发生率21.9%。两组死亡率和并发症发生率差异无统计学意义。平均随访(63.0±33.1)个月,术后5年生存率全弓置换组72.6%、半弓置换组85.5%,两组差异无统计学意义。结论应用MHCA+UACP方法行急诊主动脉弓部置换手术疗效满意。

Objective To investigate the results of emergent aortic arch replacement using moderate hypothermic circulatory arrest and unilateral 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 approaches, 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 ℃ with the flow of 5-10 ml/(kg·min). Flow was adjusted to maintain cerebral perfusion pressure of50–60 mm Hg. Results CPB time was 235.0±42.0 min. Aortic clamp time was 154.0±29.0 min. Circulatory arrest(CA)time was 48.1±13.0 min. The CPB time and CA time of the TAR group were longer than those of SAR group. Overall mortality rate was 9.6%. Complications included permanent neurological dysfunction(PND), temporary neurological dysfunction(TND), acute kidney injury(AKI) requiring dialysis and delayed extubation(mechanical ventilation time72 hours). Overall incidence of PND and TND was 2.7% and 6.8%, respectively. The incidence of AKI requiring dialysis was 4.1%. The incidence of delayed extubation was 21.9%. No difference of mortality rate or incidence of complications was found between the two groups. The average follow-up was 63.0±33.1 months. The 5-year survival rate was 72.6% in the TAR group and 85.5% in the SAR group. Conclusion Emergent aortic arch replacement using MHCA+UACP can be accomplished with excellent results.