Department of Cardiovascular Surgery, Guangzhou General Hospital of Guangzhou Military Command, Guangzhou, China.
Department of Cardiology, Guangzhou General Hospital of Guangzhou Military Command, Guangzhou, China.
J Thorac Cardiovasc Surg. 2017 Sep;154(3):767-775. doi: 10.1016/j.jtcvs.2017.02.053. Epub 2017 Mar 12.
Antegrade cerebral perfusion (ACP) is the most widely used cerebral protection strategy for complex aortic repair and includes unilateral (u-ACP) and bilateral (b-ACP) techniques. The superiority of b-ACP over u-ACP has been the subject of much debate. Focusing on type A aortic dissection requiring total arch replacement, we investigated the clinical effects of b-ACP versus u-ACP.
Between September 2006 and August 2014, 203 patients presenting with type A aortic dissection (median age, 51.0 ± 13 years; range, 17-72 years; 128 males) underwent total aortic arch replacement with hypothermic circulatory arrest. ACP was used in all patients, including u-ACP in 82 (40.3%) and b-ACP in 121 (59.7%).
There was no significant difference between the u-ACP and b-ACP groups in terms of cardiopulmonary bypass (CPB) time, cross-clamp time, or circulatory arrest time. Overall 30-day mortality was comparable in the 2 groups (11.6% for b-ACP vs 20.7% for u-ACP; P = .075). The prevalence of postoperative permanent neurologic dysfunction (PND) was comparable as well (8.4% vs 16.9%; P = .091). Mean ventilation time was lower in the b-ACP group (95.5 ± 45.25 hours vs 147.0 ± 82 hours; P < .001). Mean lengths of stay in the intensive care unit and the hospital overall were comparable in the 2 groups (intensive care unit: 16 ± 17.75 days vs 17 ± 11.5 days, P = .454; hospital: 26.5 ± 20.6 days vs 24.8 ± 10.3 days, P = .434). The P values from logistic regression models indicated that in the 2 groups combined, CPB time and circulatory arrest time were independent risk factors for both mortality and PND.
In this, the first published study focusing on the efficacy of u-ACP and b-ACP in total arch replacement for type A aortic dissection, the b-ACP group did not demonstrate significantly lower 30-day mortality or PND rate compared with the u-ACP group. Future large-sample studies are warranted to thoroughly examine this critical issue.
顺行性脑灌注（ACP）是复杂主动脉修复中最广泛使用的脑保护策略，包括单侧（u-ACP）和双侧（b-ACP）技术。b-ACP 优于 u-ACP 的观点一直存在争议。本研究聚焦于需要全主动脉弓置换的急性 A 型主动脉夹层，探讨了 b-ACP 与 u-ACP 的临床效果。
2006 年 9 月至 2014 年 8 月，203 例急性 A 型主动脉夹层患者（中位年龄 51.0±13 岁；范围 17-72 岁；男性 128 例）接受了低温体外循环下全主动脉弓置换术。所有患者均采用 ACP，82 例（40.3%）采用 u-ACP，121 例（59.7%）采用 b-ACP。
u-ACP 组和 b-ACP 组在体外循环时间、主动脉阻断时间和停循环时间方面无显著差异。两组术后 30 天死亡率相当（b-ACP 组 11.6%，u-ACP 组 20.7%；P=0.075）。术后永久性神经功能障碍（PND）的发生率也相似（b-ACP 组 8.4%，u-ACP 组 16.9%；P=0.091）。b-ACP 组的平均通气时间较低（95.5±45.25 小时 vs 147.0±82 小时；P<0.001）。两组患者在重症监护病房和医院的平均住院时间相似（重症监护病房：16±17.75 天 vs 17±11.5 天，P=0.454；医院：26.5±20.6 天 vs 24.8±10.3 天，P=0.434）。来自逻辑回归模型的 P 值表明，在两组联合分析中，体外循环时间和停循环时间是死亡率和 PND 的独立危险因素。
在这项首次发表的研究中，我们关注了单侧和双侧顺行性脑灌注在急性 A 型主动脉夹层全主动脉弓置换术中的疗效，b-ACP 组与 u-ACP 组相比，30 天死亡率和 PND 发生率均无显著降低。未来需要进行大样本研究来彻底研究这一关键问题。
