Is More than One Hour of Selective Antegrade Cerebral Perfusion in Moderate-to-Mild Systemic Hypothermic Circulatory Arrest for Surgery of Acute Type A Aortic Dissection Safe?
Is More than One Hour of Selective Antegrade Cerebral Perfusion in Moderate-to-Mild Systemic Hypothermic Circulatory Arrest for Surgery of Acute Type A Aortic Dissection Safe?
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DOI：
10.1055/s-0037-1604451
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发表时间：
2018-04-01
影响因子：
1.5
通讯作者：
Zierer, Andreas
中科院分区：
文献类型：
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作者：
Ahmad, Ali El-Sayed;Papadopoulos, Nestoras;Zierer, Andreas
目的 急性 A 型主动脉夹层 (AAD) 手术仍然是一项手术挑战，具有相当大的发病率和死亡率风险。顺行脑灌注（ACP）已得到普及，在复杂的主动脉弓修复过程中提供了一种更符合生理学的脑灌注方法，这在 AAD 的情况下通常是必需的。这种方法在中度至轻度全身低温停循环（28 摄氏度）下的安全限度尚未确定。因此，本研究调查了选择性ACP且中度至轻度低温（28℃）体循环停止时间为60分钟的AAD患者手术治疗后的临床结果。方法2000年1月至2016年4月，连续63例患者在中度至轻度低温（28℃）下接受选择性ACP手术治疗，延长ACP和循环停止时间。患者的平均年龄为 5915 岁，其中 39 名患者 (62%) 为男性。分别有 13 名 (21%) 和 50 名 (79%) 患者进行了半弓置换术和全弓置换术。分别对 9 名（14%）、6 名（10%）和 3 名（5%）患者进行了冷冻象鼻术、拱灯术和象鼻术。临床数据前瞻性地输入我们的机构数据库。平均晚期随访时间为 64 年，完成率为 98%。 结果 心肺转流时间为 245 +/- 81 分钟，心肌缺血时间为 140 +/- 43 分钟。 ACP 的平均持续时间为 74 +/- 12 分钟。平均最低核心温度为 28.9 +/- 0.8 摄氏度。44 名患者 (70%) 进行了单侧 ACP；其余 19 名患者 (30%) 使用双侧 ACP。重症监护室住院时间达到 6 +/- 5 天。 8% 的患者出现新发急性肾功能衰竭，需要进行血液滤过（n = 5）。 5 名患者 (8%) 发现术后新出现的永久性神经功能缺损，6 名患者 (10%) 发现短暂性神经功能缺损。其中有1例截瘫。 30 天死亡率和院内死亡率分别为 8% ( n = 5) 和 11% ( n = 7)。 5 年总生存率为 76 +/- 9%。 结论 我们的初步数据表明，即使在 AAD 的情况下，在中度至轻度全身低温停循环（28 摄氏度）期间选择性 ACP 也可以安全应用 1 小时以上。
Objectives Surgery for acute type A aortic dissection (AAD) remains a surgical challenge with considerable risk of morbidity and mortality. Antegrade cerebral perfusion (ACP) has been popularized, offering a more physiologic method of brain perfusion during complex aortic arch repair, often necessary in setting of AAD. The safe limits of this approach under moderate-to-mild systemic hypothermic circulatory arrest ( 28 degrees C) are yet to be defined. Thus, the current study investigates our clinical results after surgical treatment for AAD in patients with a selective ACP and systemic circulatory arrest time of60 minutes in moderate-to-mild hypothermia ( 28 degrees C).Methods Between January 2000 and April 2016, 63 consecutive patients underwent surgical treatment for AAD employing selective ACP during moderate-to-mild systemic hypothermia ( 28 degrees C) with prolonged ACP and circulatory arrest times. Patients' mean age was 5915 years, and 39 patients (62%) were men. Hemiarch replacement and total arch replacement were performed in 13 (21%) and 50 (79%) patients, respectively. Frozen elephant trunk, arch light, and elephant trunk technique were performed in nine (14%), six (10%), and three patients (5%), respectively. Clinical data were prospectively entered into our institutional database. Mean late follow-up was 64 years and was 98% complete.Results Cardiopulmonary bypass time accounted for 245 +/- 81 minutes and the myocardial ischemic time accounted for 140 +/- 43 minutes. Mean duration of ACP was 74 +/- 12 minutes. The mean lowest core temperature accounted for 28.9 +/- 0.8 degrees C. Unilateral ACP was performed in 44 patients (70%); bilateral ACP was used in the remaining 19 patients (30%). Intensive care unit stay reached 6 +/- 5 days. New onset of acute renal failure requiring hemofiltration was observed in 8% of patients ( n =5). New postoperative permanent neurologic deficits were found in five patients (8%) and transient neurologic deficits in six patients (10%). There was one case of paraplegia. Thirty-day mortality and in-hospital mortality were 8 ( n =5) and 11% ( n =7), respectively. Overall survival at 5 years was 76 +/- 9%.Conclusion Our preliminary data suggest that selective ACP during moderate-to-mild systemic hypothermic circulatory arrest ( 28 degrees C) can safely be applied for more than 1 hour even in the setting of AAD.