Fernandes P, Cleland A, Adams C, Chu M W A
Clinical Perfusion Services, Cardiac Care, University of Western Ontario, Lawson Health Research Institute, London Health Sciences Centre, London, Ontario, Canada.
Perfusion. 2012 Nov;27(6):493-501. doi: 10.1177/0267659112453753. Epub 2012 Jul 16.
Surgical repair of transverse aortic arch aneurysms frequently employ hypothermia and antegrade cerebral perfusion as protective strategies during circulatory arrest. However, prolonged mesenteric and lower limb ischemia can lead to significant lactic acidosis and end organ dysfunction, which remains a significant cause of post-operative morbidity and mortality. We report our experience with additive warm mesenteric and lower body perfusion (1-3 L/min, 30°C) in addition to continuous cerebral and myocardial perfusion in 5 patients who underwent total aortic arch replacement with trifurcated head vessel re-implantation and distal elephant trunk reconstruction. Concomitant surgical procedures included re-operations (2), aortic root operations (2), coronary artery bypass (2) and descending thoracic aortic replacement (1). Serum lactate levels demonstrated a rapid decline from a peak 9.9 ± 2.6 post circulatory arrest to 3.4 ± 2.0 in the intensive care unit (ICU). The lowest serum bicarbonate levels were 19.3 ± 3.5 mmol/L, intra-operatively, which normalized to 28.4 ± 2.4 mmol/L on return to the ICU. The lowest pH levels were 7.25 ± 0.10, corrected to 7.43 ± 0.04 on return to the ICU. Mean cardiopulmonary bypass and aortic cross-clamp times were 361 ± 104 and 253 ± 85 minutes, respectively. Mean cerebral and lower body circulatory arrest times were 0 (0) and 50 ± 35 minutes, respectively. The mean time required for systemic rewarming was 95 ± 66 minutes. There were no in-hospital mortalities and no patient experienced any neurological, mesenteric, renal or lower limb ischemic complications. Two patients required mechanical ventilation >24 hours, and one patient returned for reoperation for bleeding. Median intensive care unit and total hospital lengths of stay were 5 and 16 days, respectively. Our results suggest early serum lactate clearance, normalization of acidosis, and metabolic recovery when utilizing a simultaneous cerebral perfusion and warm body protection strategy for complex aortic arch surgery. This additive perfusion strategy may attenuate visceral and lower body ischemia that normally develops during periods of deep hypothermic circulatory arrest.
在循环停止期间，横断主动脉弓动脉瘤的外科修复经常采用低温和顺行性脑灌注作为保护策略。然而，肠系膜和下肢的长时间缺血可导致显著的乳酸酸中毒和终末器官功能障碍，这仍然是术后发病和死亡的重要原因。我们报告了5例接受全主动脉弓置换、三叉头血管再植入和远端象鼻重建术的患者，除了持续的脑灌注和心肌灌注外，加用肠系膜和下半身温暖灌注（1-3升/分钟，30°C）的经验。同期手术包括再次手术（2例）、主动脉根部手术（2例）、冠状动脉搭桥术（2例）和胸降主动脉置换术（1例）。血清乳酸水平显示从循环停止后的峰值9.9±2.6迅速下降至重症监护病房（ICU）的3.4±2.0。术中最低血清碳酸氢盐水平为19.3±3.5毫摩尔/升，返回ICU时恢复正常至28.4±2.4毫摩尔/升。最低pH值为7.25±0.10，返回ICU时校正至7.43±0.04。平均体外循环和主动脉阻断时间分别为361±104分钟和253±85分钟。平均脑循环和下半身循环停止时间分别为0（0）分钟和50±35分钟。全身复温所需平均时间为95±66分钟。无院内死亡病例，无患者出现任何神经、肠系膜、肾脏或下肢缺血并发症。2例患者需要机械通气超过24小时，1例患者因出血返回进行再次手术。ICU中位住院时间和总住院时间分别为5天和16天。我们的结果表明，在复杂主动脉弓手术中采用同步脑灌注和身体温暖保护策略时，血清乳酸早期清除、酸中毒正常化和代谢恢复。这种附加灌注策略可能减轻在深度低温循环停止期间通常发生的内脏和下半身缺血。
