Papalexopoulou N, Attia R Q, Bapat V N
Guy's and St Thomas' NHS Foundation Trust, UK.
Ann R Coll Surg Engl. 2013 Oct;95(7):127-9. doi: 10.1308/003588413X13629960047957.
We report successful surgical treatment of type A aortic dissection in a Jehovah's Witness without the use of any blood products. An interposition graft replacement of the ascending aorta was carried out. This was under right axillo-atrial cardiopulmonary bypass with antegrade cerebral perfusion via right a subclavian and left carotid cannula for 24 minutes at 28°C. Body temperature was kept at 32°C throughout. Autologous transfusion was deployed using cell salvage and a preoperative haemodilution technique. The patient was given tranexamic acid, desmopressin, recombinant factor VIIa, folic acid and epoetin alfa. Patients who object to transfusion represent a significant challenge, especially those who are at a high risk of coagulopathy associated with inherent aortic dissection leading to perturbed haemodynamics, cardiopulmonary bypass and hypothermic circulatory arrest. Type A aortic dissection repair is possible in patients refusing the use of blood products with blood salvage techniques and synthetic products that can limit the risk of bleeding. Minimal hypothermia is vital to preserve platelet function and avoid coagulopathy. Thus, a combination of normothermic/minimal hypothermia and antegrade cerebral protection with a blood conservation strategy can be deployed for a successful surgical outcome in aortic dissection without transfusion.
我们报告了一例在不使用任何血液制品的情况下成功对一名耶和华见证会信徒进行A型主动脉夹层手术治疗的案例。实施了升主动脉置换术。手术在右腋-房体外循环下进行，通过右锁骨下动脉和左颈动脉插管在28°C下进行顺行脑灌注24分钟。术中体温全程维持在32°C。采用自体血液回收和术前血液稀释技术进行自体输血。给患者使用了氨甲环酸、去氨加压素、重组凝血因子VIIa、叶酸和促红细胞生成素。反对输血的患者是一个重大挑战，尤其是那些因主动脉夹层本身导致血流动力学紊乱、体外循环和低温循环停搏而有高凝血病风险的患者。对于拒绝使用血液制品的患者，通过血液回收技术和能降低出血风险的合成制品，A型主动脉夹层修复是可行的。轻度低温对于维持血小板功能和避免凝血病至关重要。因此，结合常温/轻度低温和顺行脑保护以及血液保护策略，可在不输血的情况下成功进行主动脉夹层手术。
