Svensson L G, Nadolny E M, Penney D L, Jacobson J, Kimmel W A, Entrup M H, D'Agostino R S
Center for Aortic Surgery, Lahey Clinic, Burlington, Massachusetts 01805, USA.
Ann Thorac Surg. 2001 Jun;71(6):1905-12. doi: 10.1016/s0003-4975(01)02570-x.
To determine the optimal method of brain protection during deep hypothermic circulatory arrest (DHCA) for arch repair.
Of 139 potential aortic arch repairs (denominator), we randomized 30 patients to either DHCA alone (n = 10), DHCA plus retrograde brain perfusion (RBP) (n = 10), or antegrade perfusion (ANTE) (n = 10); a further 5 coronary bypass (CAB) patients were controls. Fifty-one neurocognitive subscores were obtained for each patient at each of four intervals: preoperatively, 3 to 6 days postoperatively, 2 to 3 weeks postoperatively, and 6 months postoperatively. Intraoperative and postoperative S-100 blood levels and electroencephalograms were also obtained.
For the denominator, the 30-day and hospital survival rate was 97.8% (136 of 139) and the stroke rate 2.8% (4 of 139). For the randomized patients, the survival rate was 100% and no patient suffered a stroke or seizure. Circulatory arrest (CA) times were not different (DHCA: RBP:ANTE) for 11 total arch repairs (including 6 elephant trunk; mean, 41.4 minutes; standard deviation, 15). Hemiarch repairs (n = 17) were quickest with DHCA (mean 10.0 minutes; standard deviation, 3.6; p = 0.011) and longest with ANTE (mean 23.8 minutes; standard deviation, 10.28; p = 0.004). Of the patients, 96% had clinical neurocognitive impairment at 3 to 6 days, but by 2 to 3 weeks only 9% had a residual new deficit (1 DHCA, 1 RBP, 1 ANTE), and by 6 months these 3 patients had recovered. Comparison of postoperative mean scores showed the DHCA group did better than RBP patients in 5 of 7 significantly different (p < 0.05) scores and versus 9 of 9 ANTE patients. There were no S-100 level differences between CA groups, but levels were significantly higher versus the CAB controls, particularly at the end of bypass (p < 0.0001); however, these may have been influenced by other variables such as greater pump time, cardiotomy use, and postoperative autotransfusion. Circulatory arrest (p = 0.01) and pump time (p = 0.057) correlated with peak S-100 levels.
The results of hypothermic arrest have improved; however, there is no neurocognitive advantage with RBP or ANTE. Nevertheless, retrograde brain perfusion may, in a larger study, potentially reduce the risk of strokes related to embolic material. S-100 levels may be artificial. In patients with severe atheroma or high risk for embolic strokes, we use a combination of retrograde and antegrade perfusion on a selective basis.
确定在进行主动脉弓修复的深低温停循环（DHCA）期间脑保护的最佳方法。
在139例可能进行主动脉弓修复的患者（分母）中，我们将30例患者随机分为单纯DHCA组（n = 10）、DHCA加逆行脑灌注（RBP）组（n = 10）或顺行灌注（ANTE）组（n = 10）；另外5例冠状动脉搭桥（CAB）患者作为对照。在四个时间点对每位患者获取51项神经认知子评分：术前、术后3至6天、术后2至3周以及术后6个月。还获取了术中和术后的S - 100血药浓度水平及脑电图。
对于分母中的患者，30天和住院生存率为97.8%（139例中的136例），卒中率为2.8%（139例中的4例）。对于随机分组的患者，生存率为100%，且无患者发生卒中或癫痫。在11例全主动脉弓修复（包括6例象鼻手术；平均41.4分钟；标准差15）中，停循环（CA）时间在DHCA、RBP和ANTE组之间无差异。半主动脉弓修复（n = 17）中，DHCA用时最短（平均10.0分钟；标准差3.6；p = 0.011），ANTE用时最长（平均23.8分钟；标准差10.28；p = 0.004）。96%的患者在术后3至6天有临床神经认知障碍，但到术后2至3周时，仅有9%有残留的新缺陷（1例DHCA、1例RBP、1例ANTE），到6个月时这3例患者已恢复。术后平均评分比较显示，在7项有显著差异（p < 0.05）的评分中，DHCA组在5项上优于RBP组患者，在9项评分中优于9例ANTE组患者。CA组之间S - 100水平无差异，但与CAB对照组相比显著更高，尤其是在体外循环结束时（p < 0.0001）；然而，这些可能受到其他变量的影响，如更长的泵血时间、使用心内吸引以及术后自体输血。停循环（p = 0.01）和泵血时间（p = 0.057）与S - 100峰值水平相关。
低温停循环的结果有所改善；然而，RBP或ANTE并无神经认知优势。尽管如此，在更大规模的研究中，逆行脑灌注可能会潜在降低与栓塞物质相关的卒中风险。S - 100水平可能是人为因素导致的。对于有严重动脉粥样硬化或栓塞性卒中高风险的患者，我们选择性地联合使用逆行和顺行灌注。
