Photiadis Joachim, Asfour Boulos, Sinzobahamvya Nicodème, Fink Christoph, Schindler Ehrenfried, Brecher Anne-Marie, Urban Andreas E
Department of Pediatric Thoracic and Cardiovascular Surgery, German Pediatric Heart Institute, Sankt Augustin, Germany.
Ann Thorac Surg. 2006 Mar;81(3):976-81. doi: 10.1016/j.athoracsur.2005.09.037.
Recently introduced cardiopulmonary bypass techniques to avoid circulatory arrest were proposed to improve organ function of the modified Norwood operation for hypoplastic left heart syndrome. This study compares postoperative hemodynamics and survival in patients who underwent Norwood procedure on the beating heart to those operated on with cardioplegic cardiac arrest.
Between October 2002 and January 2005, 26 consecutive patients aged 4 to 275 days (median, 9 days) and weighing 2.9 to 4.4 kg (median, 3.4 kg) underwent Norwood palliation: 13 with continuous coronary and systemic perfusion (group 1), and 13 with only continuous systemic perfusion but arrested heart (group 2). Standard hemodynamic measurements, lactate levels, arterial and superior vena cava oxygen saturations, and inotropic agents required for postoperative hours 0, 6, 12, 18, 24, and 48 were retrospectively analyzed. For univariate comparison of different variables, chi2 test, Fisher's exact test, or Student's t test was used as appropriate.
In group 1 significantly higher mean arterial pressure (53 +/- 0.8 versus 50 +/- 1.2 mm Hg; p = 0.04), higher central oxygen saturation (54% +/- 1.1% versus 50% +/- 1.5%; p = 0.03), higher urinary output (5.3 +/- 0.4 versus 4.4 +/- 0.4 mL.kg(-1).h(-1); p = 0.09), lower lactate levels (2.4 +/- 0.1 versus 4.1 +/- 0.6 mmol/L; p = 0.009) with lower doses of norepinephrine (0.03 +/- 0.004 versus 0.14 +/- 0.03 microg.kg(-1).min(-1); p = 0.002) were recognized. Hospital mortality was 0% in group 1 and 38.5% (5 of 13) in group 2 (p = 0.04). Univariate analysis revealed mortality to be also correlated with preoperative intubation (p = 0.02) and the use of preoperative inotropic agents (p = 0.03).
Avoidance of cardiac arrest by means of continuous coronary perfusion in addition to continuous systemic perfusion significantly improves postoperative hemodynamic performance and thus helps to reduce hospital mortality after the modified Norwood procedure.
最近引入的避免循环骤停的体外循环技术旨在改善左心发育不全综合征改良诺伍德手术的器官功能。本研究比较了在心脏跳动下接受诺伍德手术的患者与在心脏停搏下接受手术的患者的术后血流动力学和生存率。
2002年10月至2005年1月期间，连续26例年龄4至275天（中位数9天）、体重2.9至4.4千克（中位数3.4千克）的患者接受了诺伍德姑息手术：13例采用持续冠状动脉和全身灌注（第1组），13例仅采用持续全身灌注但心脏停搏（第2组）。回顾性分析了术后0、6、12、18、24和48小时的标准血流动力学测量值、乳酸水平、动脉和上腔静脉血氧饱和度以及所需的血管活性药物。对于不同变量的单因素比较，根据情况使用卡方检验、费舍尔精确检验或学生t检验。
第1组的平均动脉压显著更高（53±0.8对50±1.2毫米汞柱；p = 0.04），中心血氧饱和度更高（54%±1.1%对50%±1.5%；p = 0.03），尿量更高（5.3±0.4对4.4±0.4毫升·千克⁻¹·小时⁻¹；p = 0.09），乳酸水平更低（2.4±0.1对4.1±0.6毫摩尔/升；p = 0.009），去甲肾上腺素剂量更低（0.03±0.004对0.14±0.03微克·千克⁻¹·分钟⁻¹；p = 0.002）。第1组的医院死亡率为0%，第2组为38.5%（13例中的5例）（p = 0.04）。单因素分析显示死亡率还与术前插管（p = 0.02）和术前使用血管活性药物（p = 0.03）相关。
除持续全身灌注外，通过持续冠状动脉灌注避免心脏停搏可显著改善术后血流动力学表现，从而有助于降低改良诺伍德手术后的医院死亡率。
