Section of Cardiothoracic Surgery, St. Louis University School of Medicine, St. Louis, Missouri 63104, USA.
Ann Thorac Surg. 2010 Mar;89(3):851-6; discussion 856-7. doi: 10.1016/j.athoracsur.2009.11.060.
We evaluated left heart bypass (LHB) for spinal cord protection during aortic coarctation repair in patients with mild (primary, postsurgical, or intervention) and complex coarctation.
Between 1990 and 2008, 19 patients (mean age, 21 years; weight, 70 +/- 16 kg) using LHB were compared with 27 patients (mean age, 16 years; weight, 65 +/- 8 kg) undergoing coarctation repair without LHB (non-LHB). Follow-up was similar (LHB, 5 +/- 4 vs non-LHB 4 +/- 3 years; p = 0.81).
Cohorts were similar in age and body surface area. No non-LHB patient lost somatosensory evoked potential or had a femoral artery pressure below 45 mm Hg with test clamping. LHB more often allowed graft interposition (18 of 19 [95%] vs non-LHB, 7 of 27 [26%]; p < 0.003) and a longer clamp time (LHB 44 +/- 16 vs non-LHB 31 +/- 12 minutes p < 0.003) without spinal cord ischemia. Two non-LHB patients had temporary spinal cord paresis. No early or late deaths occurred. Reintervention (LHB, 2 of 19 [11%] vs non-LHB, 2 of 27 [7%]; p = 0.82) and antihypertensive requirements were similar (LHB, 9 of 19 [40%] vs non-LHB, 8 of 27 [30%]; p = 0.35). The late peak transcoarctation gradient was 8 +/- 6 mm Hg in the LBH cohort vs 18 +/- 11 mm Hg in non-LBH patients (p= 0.001).
Although the adequacy of spinal cord collateral assessment in coarctation repair is imperfect, no spinal cord ischemia occurred with coarctation repair and LHB. We recommend LHB in patients with mild or complex coarctation.
我们评估了左心旁路（LHB）在主动脉缩窄修复术中对脊髓的保护作用，对象为轻度（原发性、术后或介入后）和复杂主动脉缩窄患者。
1990 年至 2008 年期间，19 名接受 LHB 的患者（平均年龄 21 岁，体重 70±16kg）与 27 名未接受 LHB 的患者（非 LHB 组）进行比较，这些患者接受了主动脉缩窄修复术。随访时间相似（LHB 组为 5±4 年，非 LHB 组为 4±3 年；p=0.81）。
两组患者的年龄和体表面积相似。非 LHB 组患者无一例在测试夹闭时出现体感诱发电位丧失或股动脉压低于 45mmHg。LHB 组更常进行移植物间置（19 例中有 18 例[95%]，而非 LHB 组有 7 例[26%]；p<0.003），夹闭时间更长（LHB 组 44±16 分钟，而非 LHB 组 31±12 分钟；p<0.003），但没有脊髓缺血。两名非 LHB 患者出现短暂性脊髓麻痹。两组均无早期或晚期死亡。再次介入治疗（LHB 组 19 例中有 2 例[11%]，而非 LHB 组有 27 例中有 2 例[7%]；p=0.82）和降压要求相似（LHB 组 19 例中有 9 例[40%]，而非 LHB 组有 27 例中有 8 例[30%]；p=0.35）。LHB 组的晚期跨缩窄压阶差为 8±6mmHg，而非 LHB 组为 18±11mmHg（p=0.001）。
尽管主动脉缩窄修复术中脊髓侧支循环评估的充分性并不完美，但主动脉缩窄修复术和 LHB 均未发生脊髓缺血。我们建议对轻度或复杂主动脉缩窄患者进行 LHB。
