中低温停循环双侧脑灌注下行全主动脉弓替换治疗急性Stanford A型主动脉夹层

The application of moderate hypothermia circulatory arrest and bilateral selective antegrade cerebral perfusion in total arch replacement for acute Stanford type A aortic dissection

目的评估中低温停循环(moderate hypothermia circulatory arrest,MHCA)结合双侧顺行性脑灌注(bilateral selective antegrade cerebral perfusion,bSACP)在全弓替换及支架型人工血管置入术治疗急性Stanford A型主动脉夹层(type Stanford A aortic dissection,TAAD)中的应用。方法回顾性分析北京安贞医院主动脉疾病诊疗中心2019年7月至2020年1月在MHCA(29℃)及bSACP辅助下治疗的15例急性TAAD病例(改良组),采用同期在MHCA(25℃)及单侧选择性脑灌注(unilateral selective antegrade cerebral perfusion,uSACP)辅助下治疗的26例急性TAAD患者作为对照(传统组)。全组患者均为复杂A型主动脉夹层,平均年龄49岁,男性32例(78%),高血压病36例(87.8%)。根部操作包括窦部成型13例(31.7%),升主动脉替换29例(70.7%),Bentall 12例(29.3%)。弓部操作均为全主动脉弓替换+支架型人工血管置入术。结果全组住院死亡2例(4.9%),脑梗塞3例(7.3%),短暂性神经功能障碍5例(12.2%),截瘫2例(4.9%)。传统组与改良组上述不良事件发生率差异无统计学意义,分别为[2例(7.7%)对0例,P=0.524]、[3例(11.5%)对0例,P=0.287]、[4例(15.4%)对1例(6.7%),P=0.636]、[1例(3.8%)对1例(6.7%),P=1.000]。改良组术后主要不良事件为短暂性神经功能障碍及迟发性截瘫各1例。改良组的手术、体外循环、阻断、停循环、顺行性低流量脑灌注、呼吸机辅助、ICU滞留时间及术后48 h引流量均小于传统组。组间新发急性肾衰行持续性肾脏替代治疗和再次开胸探查率差异无统计学意义。结论在MHCA(29℃)及bSACP辅助下采用全弓替换及支架型人工血管置入术治疗急性TAAD早期结果良好。与传统组相较,改良组的呼吸机辅助、ICU滞留时间及术后48 h引流量显著减少。

Objective To evaluate the application of moderate hypothermia circulatory arrest(MHCA)with a higher temperature(29℃)and bilateral selective antegrade cerebral perfusion(bSACP)in acute Stanford type A aortic dissection(TAAD)treated by total arch replacement with stented elephant trunk implantation.Methods From July 2019 to January 2020,fifteen patients of acute TAAD undergoing emergent operations via MHCA with a core temperature of 29℃and bSACP were analyzed retrospectively(modified group),and 26 patients treated by MHCA(25℃)and unilateral selective antegrade cerebral perfusion(uSACP)during the same period were defined as the traditional group.All cases were complicated type A dissection.The mean age in this cohort was 49 years,and 32 patients(78%)were male.Thirty six patients(87.8%)suffered from arterial hypertension.The proximal manipulations included:aortic sinus repair in 13 cases(31.7%),ascending aortic replacement in 29(70.7%),Bentall in 12(29.3%).Total arch replacement with stented elephant trunk implantation was performed in all cases.Results The in-hospital death occurred in 2(4.9%),and cerebral infarction in 3(7.3%),transient neurologic deficit in 5(12.2%),paraplegia in 2(4.9%).The ratios of above-mentioned adverse events in the traditional and modified group were[2(7.7%)vs.0,P=0.524],[3(11.5%)vs.0,P=0.287],[4(15.4%)vs.1(6.7%),P=0.636],[1(3.8%)vs.1(6.7%),P=1.000]respectively.The major adverse events in the modified group were transient neurologic deficit and paraplegia in 1 each.Compared with the traditional group,the time of operation,CPB,cardiac arrest,circulatory arrest of the lower part,anterograde low flow cerebral perfusion,mechanical ventilation and ICU stay was shorter.The drainage of 48 hours after surgery was less also.The differences in new acute renal failure requiring CRRT and re-sternotomy for bleeding between groups were not statistical significance.Conclusion The early results of MHCA(29℃)and bSACP applied in total arch replacement with stented elephant trunk implantation for acute TAAD were satisfactory.The time of mechanical ventilation and ICU stay was shorter in the modified group,and the drainage of 48 hours after surgery was less also.