Division of Thoracic and Cardiovascular Surgery, Johann Wolfgang Goethe University, Frankfurt/Main, Germany.
Ann Thorac Surg. 2011 Jun;91(6):1868-73. doi: 10.1016/j.athoracsur.2011.02.077.
Aortic arch replacement remains a surgical challenge because of prolonged operative times, bleeding complications, and a considerable risk of neurologic morbidity and mortality. This study investigates our clinical results after modification of perfusion technique for cardiopulmonary bypass as well as temperature management for these high- risk patients.
Between January 2000 and January 2009, 245 consecutive patients underwent aortic arch repair during selective antegrade cerebral perfusion (ACP) with mild systemic hypothermia (30.5°C±1.4°C). Mean age was 63±12 years, 175 patients (71%) were men and 141 patients (58%) had acute type A dissection. Hemiarch replacement was performed in 152 patients (62%) while the remaining 93 patients (38%) underwent total arch replacement.
Cardiopulmonary bypass time accounted for 168±62 minutes, and myocardial ischemic time was 103±45 minutes. Isolated ACP was performed for 38±27 (range 12 to 135) minutes. Chest tube drainage during the first 24 hours was 563±248 mL. Mean ventilation time was 44±22 hours. Serum lactate levels at 1, 12, and 24 hours postoperatively rose to 19±11, 33±14, and 20±8 mg/dL, respectively. We observed new postoperative permanent neurologic deficits in 14 patients (6%) and transient neurologic deficits in 12 patients (5%). The operative mortality rate was 8% (n=20). Among patients with ACP times 60 minutes or greater (n=28; 92±29 minutes), permanent neurologic deficits occurred in 2 individuals (n=2 of 28; 7%) and operative mortality was 7% (n=2 of 28). At late follow-up (3.8±3.2 years, 98% complete), 196 patients (80%) were still alive.
Selective ACP in combination with mild hypothermia offered sufficient cerebral as well as distal organ protection in our patient cohort. Thus, current data suggest that this standardized perfusion and temperature management protocol can safely be applied to complex aortic arch surgery requiring up to 90 minutes of isolated ACP times.
由于手术时间延长、出血并发症以及相当大的神经发病率和死亡率风险，主动脉弓置换仍然是一项具有挑战性的手术。本研究调查了我们在体外循环灌注技术修改以及高危患者体温管理后的临床结果。
在选择性顺行脑灌注（ACP）和轻度全身低温（30.5°C±1.4°C）下，2000 年 1 月至 2009 年 1 月期间，245 例连续患者接受了主动脉弓修复。平均年龄为 63±12 岁，175 例（71%）为男性，141 例（58%）为急性 A 型夹层。152 例（62%）患者行半弓置换，93 例（38%）患者行全弓置换。
体外循环时间为 168±62 分钟，心肌缺血时间为 103±45 分钟。孤立的 ACP 进行了 38±27 分钟（范围 12 至 135）。术后 24 小时内胸腔引流 563±248mL。平均通气时间为 44±22 小时。术后 1、12 和 24 小时血清乳酸水平分别升高至 19±11、33±14 和 20±8mg/dL。我们观察到 14 例患者（6%）出现新的术后永久性神经功能缺损，12 例患者（5%）出现一过性神经功能缺损。手术死亡率为 8%（n=20）。在 ACP 时间 60 分钟或更长时间的患者中（n=28；92±29 分钟），2 例患者（n=28；7%）出现永久性神经功能缺损，7%（n=28）的患者发生手术死亡。在晚期随访（3.8±3.2 年，98%完全）中，196 例患者（80%）仍然存活。
在本患者队列中，选择性 ACP 联合轻度低温为大脑和远端器官提供了足够的保护。因此，目前的数据表明，这种标准化的灌注和温度管理方案可以安全地应用于需要长达 90 分钟的孤立 ACP 时间的复杂主动脉弓手术。
