Division of Cardiac Surgery, University of Verona, Verona, Italy.
Artif Organs. 2011 Nov;35(11):1029-35. doi: 10.1111/j.1525-1594.2011.01355.x. Epub 2011 Oct 14.
Simultaneous cerebro-myocardial perfusion has been described in neonatal and infant arch surgery, suggesting a reduction in cardiac morbidity. Here reported is a novel technique for selective cerebral perfusion combined with controlled and independent myocardial perfusion during surgery for complex or recurrent aortic arch lesions. From April 2008 to April 2011, 10 patients with arch pathology underwent surgery (two hypoplastic left heart syndrome [HLHS], four recurrent arch obstruction, two aortic arch hypoplasia + ventricular septal defect [VSD], one single ventricle + transposition of the great arteries + arch hypoplasia, one interrupted aortic arch type B + VSD). Median age was 63 days (6 days-36 years) and median weight 4.0 kg (1.6-52). Via midline sternotomy, an arterial cannula (6 or 8 Fr for infants) was directly inserted into the innominate artery or through a polytetrafluoroethylene (PTFE) graft (for neonates <2.0 kg). A cardioplegia delivery system was inserted into the aortic root. Under moderate hypothermia, ascending and descending aorta were cross-clamped, and "beating heart and brain" aortic arch repair was performed. Arch repair was composed of patch augmentation in five, end-to-side anastomosis in three, and replacement in two patients. Average cardiopulmonary bypass time was 163 ± 68 min (71-310). In two patients only (one HLHS, one complex single ventricle), a period of cardiac arrest was required to complete intracardiac repair. In such cases, antegrade blood cardioplegia was delivered directly via the same catheter used for selective myocardial perfusion. Average time of splanchnic ischemia during cerebro-myocardial perfusion was 39 ± 18 min (17-69). Weaning from cardiopulmonary bypass was achieved without inotropic support in three and with low dose in seven patients. One patient required veno-arterial extracorporeal membrane oxygenation. Four patients, body weight <3.0 kg, needed delayed sternal closure. No neurologic dysfunction was noted. Renal function proved satisfactory in all, while liver function was adequate in all but one. The present experience suggests that selective and independent cerebro-myocardial perfusion is feasible in patients with complex or recurrent aortic arch disease, starting from premature newborn less than 2.0 kg of body weight to adults. The technique is as safe as previously reported methods of cerebro-myocardial perfusion and possibly more versatile.
在新生儿和婴儿主动脉弓手术中已经描述了同时进行的脑-心肌灌注，这表明心脏发病率降低。这里报告的是一种在复杂或复发性主动脉弓病变手术中进行选择性脑灌注与控制性和独立心肌灌注相结合的新方法。从 2008 年 4 月至 2011 年 4 月，10 例主动脉弓病变患者接受了手术治疗（2 例左心发育不全综合征[HLHS]，4 例复发性弓部梗阻，2 例主动脉弓发育不良+室间隔缺损[VSD]，1 例单心室+大动脉转位+弓部发育不良，1 例 B 型主动脉弓中断+VSD）。中位年龄为 63 天（6 天至 36 岁），体重中位数为 4.0kg（1.6-52）。通过正中胸骨切开术，将动脉插管（婴儿用 6 或 8Fr）直接插入无名动脉或通过聚四氟乙烯（PTFE）移植物（<2.0kg 的新生儿）。将心脏停搏液输送系统插入主动脉根部。在中度低温下，升主动脉和降主动脉被夹闭，并进行“跳动的心脏和大脑”主动脉弓修复。弓部修复由 5 例补片增强、3 例端侧吻合和 2 例置换组成。体外循环时间平均为 163±68 分钟（71-310 分钟）。在仅 2 例患者中（1 例 HLHS，1 例复杂的单心室），需要心脏停搏才能完成心内修复。在这种情况下，直接通过用于选择性心肌灌注的相同导管输送顺行血液心脏停搏液。脑-心肌灌注期间肠系膜缺血的平均时间为 39±18 分钟（17-69 分钟）。3 例患者在没有正性肌力支持的情况下脱机，7 例患者在低剂量下脱机。1 例患者需要静脉-动脉体外膜肺氧合。4 例体重<3.0kg 的患者需要延迟胸骨闭合。无神经功能障碍。所有患者的肾功能均令人满意，除 1 例外所有患者的肝功能均正常。目前的经验表明，选择性和独立的脑-心肌灌注在复杂或复发性主动脉弓疾病患者中是可行的，从体重小于 2.0kg 的早产儿到成人。该技术与先前报道的脑-心肌灌注方法一样安全，并且可能更具多功能性。
