Department of Pediatric Cardiothoracic Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.
J Thorac Cardiovasc Surg. 2012 Dec;144(6):1323-8, 1328.e1-2. doi: 10.1016/j.jtcvs.2012.03.008. Epub 2012 Apr 13.
Deep hypothermic circulatory arrest (DHCA) and antegrade cerebral perfusion (ACP) are 2 cardiopulmonary bypass strategies mainly used in aortic arch reconstructions. It has been suggested that during ACP, abdominal organs are better protected than during DHCA owing to partial perfusion via collaterals. We tested this hypothesis using intraoperative near-infrared spectroscopy (NIRS), lactate measurements, and biomarkers for early abdominal injury in neonates undergoing complex aortic arch repair.
Neonates scheduled for aortic arch reconstruction via median sternotomy between 2009 and 2011 were randomized to either DHCA or ACP. During surgery, regional oxygen saturations of the abdomen were monitored using NIRS. Immediately aafter DHCA or ACP, lactate concentrations from the inferior vena cava were compared with those from the arterial cannula. Postoperatively, biomarkers for early abdominal organ injury were measured in urine.
Twenty-five neonates were analyzed (DHCA, n = 12; ACP, n = 13). Procedures were performed at 18°C, and ACP flow was set at 35 to 50 mL · kg(-1) · min(-1). Median abdominal NIRS value during DHCA was 31% (IQR, 28%-41%) whereas during ACP it was 56% (IQR, 34%-64%; P < .01 between groups). Immediately after DHCA, median lactate from the inferior vena cava was 4.2 mmol/L (IQR, 3.3-5.3 mmol/L) compared with 3.1 mmol/L (IQR, 2.9-4.4 mmol/L) after ACP (P = .03). Postoperatively, biomarkers for renal and intestinal damage (gluthatione s-transferase and intestinal fatty acid binding protein, respectively) were higher in the DHCA group than for the ACP group (P = .03, P = .04, respectively).
These results substantiate earlier suggestions that ACP provides more abdominal organ protection than DHCA in neonates undergoing aortic arch reconstruction.
深低温停循环（DHCA）和顺行性脑灌注（ACP）是两种主要用于主动脉弓重建的体外循环策略。有研究表明，在 ACP 期间，由于通过侧支循环进行部分灌注，腹部器官的保护效果优于 DHCA。我们使用术中近红外光谱（NIRS）、乳酸测量和用于新生儿复杂主动脉弓修复的早期腹部损伤的生物标志物对此假设进行了测试。
2009 年至 2011 年期间，通过正中胸骨切开术计划进行主动脉弓重建的新生儿被随机分配到 DHCA 或 ACP 组。手术期间，使用 NIRS 监测腹部区域的氧饱和度。DHCA 或 ACP 后，立即比较下腔静脉和动脉插管的乳酸浓度。术后，在尿液中测量早期腹部器官损伤的生物标志物。
25 名新生儿被纳入分析（DHCA 组，n=12；ACP 组，n=13）。手术在 18°C 进行，ACP 流量设定为 35 至 50 mL·kg-1·min-1。DHCA 期间腹部 NIRS 中位数为 31%（IQR，28%-41%），而 ACP 期间为 56%（IQR，34%-64%；组间 P<.01）。DHCA 后立即，下腔静脉的中位数乳酸为 4.2 mmol/L（IQR，3.3-5.3 mmol/L），而 ACP 后为 3.1 mmol/L（IQR，2.9-4.4 mmol/L）（P=.03）。术后，DHCA 组的肾和肠损伤生物标志物（谷胱甘肽转移酶和肠脂肪酸结合蛋白）高于 ACP 组（P=.03，P=.04，分别）。
这些结果证实了先前的研究结果，即在接受主动脉弓重建的新生儿中，ACP 比 DHCA 提供更好的腹部器官保护。
