Zhang Bowen, Liu Yanxiang, Guo Hongwei, Li Yunfeng, Shi Yi, Liang Shenghua, Liu Hong, Sun Xiaogang
Department of Cardiovascular Surgery, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China.
Ann Cardiothorac Surg. 2020 May;9(3):209-219. doi: 10.21037/acs-2019-0177.
Organ dysfunction caused by hypothermic circulatory arrest continues to concern surgeons. The aortic balloon occlusion (ABO) technique can significantly shorten the circulatory arrest time in total arch replacement with frozen elephant trunk (TAR with FET). This study aims to analyze the renal protective effect of the ABO technique and to analyze the predictors of acute kidney injury (AKI) and continuous renal replacement therapy (CRRT) after TAR with FET.
Between August 2017 and September 2018, 247 patients who underwent TAR with FET were divided into ABO and moderate hypothermic circulatory arrest (MHCA) groups. The primary endpoint was postoperative AKI defined by the Kidney Disease Improving Global Outcomes (KDIGO) criteria. Multivariable logistic analysis was used to identify the predictors of AKI and CRRT after TAR with FET.
With the application of the ABO technique, the circulatory arrest time was significantly shortened (ABO 4, IQR: 3-6 MHCA 18, IQR: 16-20, P<0.001). Meanwhile, surgeons safely set the lowest nasopharyngeal temperature at a higher grade (ABO 28.1, IQR: 27.4-28.5 MHCA 24.7, IQR: 24.1-25.1, P<0.001). The peak serum creatinine (SCr) values within 48 hours after the surgery was lower in the ABO group than in the MHCA group (ABO 124, IQR: 97-173 MHCA 146, IQR: 108-221, P=0.008). The distribution of AKI grade according to the KDIGO criteria differed between the two groups (P=0.04): more patients in the ABO group were free from AKI (Grade 0) than patients in the MHCA group (33% 23.1%), and the proportion of patients with high-grade AKI (Grades 2 and 3) in the ABO group was lower than that in the MHCA group (21% 32%). The ABO technique was associated with reduced potential for AKI, but was not protective for CRRT.
The ABO technique significantly shortened the circulatory arrest time and safely elevated temperature, and provided better renal protection in patients undergoing TAR with FET. The ABO technique did not reverse the need for CRRT, nor did it reduce mortality or major adverse events.
低温循环停搏引起的器官功能障碍一直困扰着外科医生。主动脉球囊阻断（ABO）技术可显著缩短带冷冻象鼻支架的全弓置换术（TAR with FET）中的循环停搏时间。本研究旨在分析ABO技术的肾脏保护作用，并分析TAR with FET术后急性肾损伤（AKI）和持续肾脏替代治疗（CRRT）的预测因素。
2017年8月至2018年9月期间，247例行TAR with FET的患者被分为ABO组和中度低温循环停搏（MHCA）组。主要终点是根据改善全球肾脏病预后组织（KDIGO）标准定义的术后AKI。采用多变量逻辑分析确定TAR with FET术后AKI和CRRT的预测因素。
应用ABO技术后，循环停搏时间显著缩短（ABO组4分钟，四分位间距：3 - 6分钟；MHCA组18分钟，四分位间距：16 - 20分钟，P<0.001）。同时，外科医生能够安全地将最低鼻咽温度设定在更高水平（ABO组28.1℃，四分位间距：27.4 - 28.5℃；MHCA组24.7℃，四分位间距：24.1 - 25.1℃，P<0.001）。术后48小时内ABO组的血清肌酐（SCr）峰值低于MHCA组（ABO组124，四分位间距：97 - 173；MHCA组146，四分位间距：108 - 221，P = 0.008）。根据KDIGO标准，两组间AKI分级分布不同（P = 0.04）：ABO组无AKI（0级）的患者多于MHCA组（33%对23.1%），且ABO组中重度AKI（2级和3级）患者的比例低于MHCA组（21%对32%）。ABO技术与降低AKI发生可能性相关，但对CRRT无保护作用。
ABO技术显著缩短了循环停搏时间并安全地提高了体温，为行TAR with FET的患者提供了更好的肾脏保护。ABO技术并未改变对CRRT的需求，也未降低死亡率或主要不良事件的发生率。
