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| 优化选择性动脉灌注策略在Stanford A型主动脉夹层全弓置换术中的应用 |
| 于浩,童光,颜涛,王晓莉,王晓武,马涛,董文鹏,吴路加,张卫达* |
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(海军军医大学(第二军医大学)附属广州临床医学院, 解放军广州总医院心血管外科, 广州 510010
*通信作者) |
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| 摘要: |
| 目的 探讨优化选择性动脉灌注策略在Stanford A型主动脉夹层全主动脉弓置换术中的疗效。方法 2016年9月至2017年10月，我院31例接受全主动脉弓置换孙氏手术的Stanford A型主动脉夹层患者应用优化选择性动脉灌注策略（O-CPB组），其中男25例、女6例，平均年龄（50.87±9.08）岁；以2015年1月至2017年10月我院60例应用传统体外循环灌注方式完成全主动脉弓置换孙氏手术的Stanford A型主动脉夹层患者为对照组（T-CPB组），其中男52例、女8例，平均年龄（48.38±12.46）岁。比较两组围手术期血生化指标和临床数据，并用多因素logistic回归方法分析术后30 d患者死亡的危险因素。结果 与T-CPB组比较，O-CPB组患者的手术体外循环时间短、停循环时间短、手术耗时少[（206.90±39.92） min vs（276.37±29.92） min、（5.03±1.54） min vs（21.73±6.67） min、（396.68±58.57） min vs（469.28±69.77） min，P均<0.01]。O-CPB组患者血制品消耗量少于T-CPB组、重症监护病房（ICU）滞留时间短于T-CPB组[（1 401±738） mL vs（1 705±580） mL、（5.94±2.45） d vs（7.42±3.53） d，P均<0.05]。O-CPB组患者的术后血乳酸浓度和C-反应蛋白浓度均低于T-CPB组[（6.10±3.80） mmol/L vs（8.11±4.51） mmol/L、（72.13±22.86） mg/L vs（84.78±17.07） mg/L；P<0.05，P<0.01]。O-CPB组患者术后清醒时间早于T-CPB组[（3.32±1.11） h vs（4.14±1.59） h，P<0.05）]。O-CPB组和T-CPB组患者的术后24 h内Richmond镇静程度评分绝对值分别为1.23±1.06和2.15±1.30，差异有统计学意义（P<0.01）。O-CPB组患者的术后氧合指数高于T-CPB组[（234.42±79.51） mmHg vs（183.10±77.26） mmHg，P<0.01；1 mmHg=0.133 kPa]，有创通气时间短于T-CPB组[（50.19±37.63） h vs（70.12±40.84） h，P<0.05）。O-CPB组和T-CPB组患者的术后30 d内病死率分别为6.45%（2/31）和11.67%（7/60），两组间差异无统计学意义（P>0.05）。多因素logistic回归分析结果显示，停循环时间≥ 31 min和血制品消耗量≥ 1 390 mL是Stanford A型主动脉夹层患者全主动脉弓置换术后30 d内死亡的独立危险因素，OR（95% CI）分别为1.517（1.153~1.995）和1.006（1.002~1.010）。结论 优化选择性动脉灌注策略采用双侧顺行选择性脑灌注和中低温下半身优化灌注方法，与传统体外循环灌注方式相比可缩短停循环时间、减少临床用血，且对Stanford A型主动脉夹层全主动脉弓置换患者围手术期脑、肺保护效果较好。 |
| 关键词: 主动脉夹层 主动脉弓置换术 体外循环 中低体温 双侧顺行脑灌注 |
| DOI：10.16781/j.0258-879x.2018.04.0404 |
| 投稿时间：2017-12-04修订日期：2018-03-28 |
| 基金项目:国家自然科学基金青年科学基金（81500183），军队临床高新技术重大项目（2014gxjs031），广东省医学科学技术研究基金（A2014486）. |
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| Optimized selective arterial perfusion approach in total aortic arch replacement of Stanford type A aortic dissection |
| YU Hao,TONG Guang,YAN Tao,WANG Xiao-li,WANG Xiao-wu,MA Tao,DONG Wen-peng,WU Lu-jia,ZHANG Wei-da* |
(Department of Cardiovascular Surgery, PLA Guangzhou General Hospital, Guangzhou Clinical Medicine College of Navy Medical University(Second Military Medical University), Guangzhou 510010, Guangdong, China
*Corresponding author) |
| Abstract: |
| Objective To explore the curative effect of optimized selective arterial perfusion approach in the total aortic arch replacement of the Stanford type A aortic dissection. Methods From Sep. 2016 to Oct. 2017, 31 Stanford A aortic dissection patients received total aortic arch replacement with cardiopulmonary bypass of optimized selective arterial perfusion approach (O-CPB group, 25 males and 6 females, aged[50.87±9.08] years old) in our hospital. And 60 Stanford A aortic dissection patients, who underwent total aortic arch replacement with cardiopulmonary bypass of traditional approach in our hospital from Jan. 2015 to Oct. 2017, were included as control (T-CPB group, 52 males and 8 females, aged[48.38±12.46] years old). The perioperative blood biochemistry parameters and clinical data were compared between the two groups. Multivariate logistic regression was used to analyze the risk factors for postoperative 30-day mortality. Results Compared with the T-CPB group, the O-CPB group had significantly shorter extracorporeal circulation time, circulatory arrest time and operation time ([206.90±39.92] min vs[276.37±29.92] min,[5.03±1.54] min vs[21.73±6.67] min and[396.68±58.57] min vs[469.28±69.77] min, all P<0.01). The blood consumption volume and ICU detention time were significantly less in the O-CPB group versus the T-CPB group ([1 401±738] mL vs[1 705±580] mL and[5.94±2.45] d vs[7.42±3.53] d, both P<0.05). The postoperative blood lactate and C-reactive protein concentrations in the O-CPB group were significantly lower than those in the T-CPB group ([6.10±3.80] mmol/L vs[8.11±4.51] mmol/L and[72.13±22.86] mg/L vs[84.78±17.07] mg/L; P<0.05, P<0.01). The patients in the O-CPB group were awake earlier than those in the T-CPB group ([3.32±1.11] h vs[4.14±1.59] h, P<0.05). The absolute value of postoperative Richmond agitation-sedation scale (RASS) score of the O-CPB and T-CPB groups were 1.23±1.06 and 2.15±1.30, respectively, and the difference was statistically significant (P<0.01). In O-CPB group, the oxygenation index was significantly higher and mechanical ventilation time was significantly shorter versus the T-CPB group ([234.42±79.51] mmHg vs[183.10±77.26] mmHg and[50.19±37.63] h vs[70.12±40.84] h; P<0.01, P<0.05; 1 mmHg=0.133 kPa). There was no significant difference in the postoperative 30-day mortality rate between the O-CPB and T-CPB groups (6.45%[2/31] vs 11.67%[7/60], P>0.05). Multivariate logistic regression showed that circulatory arrest time ≥ 31 min and blood consumption volume ≥ 1 390 mL were independent risk factors of postoperative 30-day mortality of Stanford A aortic dissection patients undergoing total aortic arch replacement, with OR(95% CI) being 1.517 (1.153-1.995) and 1.006 (1.002-1.010), respectively. Conclusion With bilateral antegrade selective cerebral perfusion and moderate hypothermia perfusion in lower body, the optimized selective arterial perfusion approach needs shorter circulatory arrest time, and less blood consumption compared with cardiopulmonary bypass of traditional approach. Moreover, it has a good protective effect on the brain and lung during total aortic arch replacement of Stanford type A aortic dissection. |
| Key words: dissection of aorta aortic arch replacement extracorporeal circulation moderate hypothermia bilateral antegrade cerebral perfusion |
