Department of Cardiac Surgery, Leipzig Heart Center - University of Leipzig, Leipzig, Germany.
Eur J Cardiothorac Surg. 2014 Jan;45(1):27-39. doi: 10.1093/ejcts/ezt154. Epub 2013 Apr 28.
Arch surgery is undoubtedly among the most technically and strategically challenging endeavours in aortic surgery, requiring thorough understanding not only of cardiovascular physiology, but also in particular, of neurophysiology (cerebral and spinal cord), and is still associated with significant mortality and morbidity. In the late 1980s, when deep hypothermic circulatory arrest (HCA) had gained widespread acceptance as the standard approach for arch surgery, antegrade selective cerebral perfusion (SCP), as an adjunct to deep HCA, began its triumphal march, offering excellent neuroprotection and improved overall outcome. This encouraged the use of antegrade SCP in combination with steadily increasing body core temperatures--a trend culminating in the progressive advocation of moderate-to-mild temperatures up to 35 °C, and even normothermia. The impetus for progressive temperature elevation was the limitation of adverse effects of profound hypothermia and the most welcome side effect of significantly shorter cooling and rewarming periods on cardiopulmonary bypass (CPB), and thereby, potentially, the alleviation of the systemic inflammatory response and, in particular, the risk of severe postoperative bleeding (and other organ dysfunctions). The safe limits of prolonged distal circulatory arrest, particularly with regard to the ischaemic tolerance of the viscera and the spinal cord, have not yet been clearly defined. Adverse outcomes due to inappropriate temperature management (core temperatures too high for the required duration of distal arrest) are probably highly underreported. Complications historically associated with hypothermia, namely excessive bleeding, are possibly overestimated. Trading effective neuroprotection and excellent outcomes for the risk of prolonged 'warm' distal ischaemia might constitute a significant step back, jeopardizing visceral and, in particular, spinal cord integrity, with unpredictable consequences for long-term outcome and quality of life, particularly affecting those in need of more complex surgery or with previous neurological deficits.
主动脉弓手术无疑是心血管外科中最具技术和策略挑战性的手术之一，不仅需要深入了解心血管生理学，还需要特别了解神经生理学（脑和脊髓），而且仍然与较高的死亡率和发病率相关。20 世纪 80 年代末，深低温停循环（HCA）广泛应用于主动脉弓手术时，顺行选择性脑灌注（SCP）作为深 HCA 的辅助手段，开始取得显著成效，为患者提供了卓越的神经保护和更好的整体预后。这鼓励了顺行 SCP 与不断升高的核心体温联合使用的趋势，这一趋势最终导致了从中等到轻度温度（高达 35°C，甚至正常体温）的逐渐倡导。逐渐升高温度的动力是限制深低温的不良反应，以及在体外循环（CPB）期间冷却和复温时间显著缩短的最受欢迎的副作用，从而可能减轻全身炎症反应，特别是严重术后出血（和其他器官功能障碍）的风险。长时间远端循环阻断的安全极限，特别是关于内脏和脊髓的缺血耐受，尚未明确界定。由于不适当的温度管理导致的不良结果（核心温度对于所需的远端阻断时间过高）可能被严重低估。与低温相关的历史并发症，即过度出血，可能被高估。为了延长“温暖”的远端缺血而牺牲有效的神经保护和出色的结果，可能是一个重大的倒退，危及内脏，特别是脊髓的完整性，对长期结果和生活质量产生不可预测的后果，特别是影响那些需要更复杂手术或有先前神经功能障碍的患者。
