Gaseous and solid cerebral microembolization during proximal aortic anastomoses in off-pump coronary surgery: The effect of an aortic side-biting clamp and two clampless devices
Gaseous and solid cerebral microembolization during proximal aortic anastomoses in off-pump coronary surgery: The effect of an aortic side-biting clamp and two clampless devices
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DOI：
10.1016/j.jtcvs.2006.10.002
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发表时间：
2007-02-01
影响因子：
6
通讯作者：
Taggart, David P.
中科院分区：
文献类型：
--
作者：
Wolf, Lorenzo Guerrieri;Abu-Omar, Yasir;Taggart, David P.
目的：术中脑微栓塞是心脏手术后脑功能障碍的一个原因，而微粒微栓塞是最具破坏性的。使用新一代经颅多普勒超声，我们比较了接受非体外循环冠状动脉旁路移植术的患者在使用三种技术进行近端闭塞期间微栓子的数量和性质：一个主动脉侧咬夹和两个无夹装置（Enclose II装置[Novare Surgical Systems，Inc，库比蒂诺，加利福尼亚]和Heartstring II装置[Guidant Corporation，Santa Clara，Calif]）开发的，以避免需要一个主动脉侧咬钳，从而减少脑microembolis.Methods的数量：双侧连续监测大脑中动脉进行了多范围，多频率经颅多普勒设备，既自动拒绝伪影在线和固体和气体之间的微栓子的歧视。在42例患者的66个近端主动脉瓣狭窄的手术过程中连续进行记录。35例患者使用主动脉侧咬钳，20例使用Enclose器械，11例使用Hearstring device.Results：大多数微栓子发生在应用/插入和从升主动脉取出每个器械期间。侧夹期间总微栓子的中位数（四分位距）为11（6-32），Enclose器械为11（6-15），Heartstring器械为40（31-48）（P < .01）。侧夹组的固体微栓子比例（23%）显著高于Enclose和Heartstring组的6%和1%（P <0.01）。结论：避免主动脉侧夹导致经颅多普勒检测到的固体微栓子比例显著降低。由于固体微栓子可能是最具破坏性的，使用Enclose和Heartstring器械可能是近端主动脉瓣狭窄期间最大限度减少脑损伤的重要策略。
Objectives: Intraoperative cerebral microembolism is a cause of cerebral dysfunction after cardiac surgery, and particulate microemboli are the most damaging. Using a new-generation transcranial Doppler ultrasound, we compared the number and nature of microemboli in patients undergoing off-pump coronary artery bypass grafting during performance of proximal anastomoses with three techniques: an aortic side-biting clamp and two clampless devices (the Enclose II device [Novare Surgical Systems, Inc, Cupertino, Calif] and the Heartstring II device [Guidant Corporation, Santa Clara, Calif]) developed to obviate the need for an aortic side-biting clamp, thereby reducing the number of cerebral microemboli.Methods: Bilateral continuous monitoring of the middle cerebral arteries was performed with a multirange, multifrequency transcranial Doppler device that both automatically rejects artifacts online and discriminates between solid and gaseous microemboli. Recordings were continuously undertaken during performance of 66 proximal aortic anastomoses in 42 patients. Thirty-five anastomoses were performed with an aortic side-biting clamp, 20 with the Enclose device, and 11 the Hearstring device.Results: Most microemboli occurred during application/insertion and removal of each device from the ascending aorta. The median number (interquartile range) of total microemboli was 11 (6-32) during side clamping, 11 (6-15) with the Enclose device, 40 (31-48) with the Heartstring device (P < .01). The proportion of solid microemboli was significantly higher in the side-clamp group (23%) compared with 6% and 1% in the Enclose and Heartstring groups, respectively (P < .01).Conclusions: Avoidance of aortic side clamping results in a significant reduction in the proportion of solid microemboli detected with transcranial Doppler. As solid microemboli are probably the most damaging, use of the Enclose and Heartstring devices may represent an important strategy for minimizing cerebral injury during proximal aortic anastomoses.