中度低温停循环结合选择性脑灌注在婴儿主动脉弓部手术中的应用

目的 总结中度低温停循环(moderate hypothermia circulatory arrest,MHCA)结合选择性顺行脑灌注(sective antegrade cerebral perfusion,SACP)技术在婴儿主动脉弓重建手术中的应用经验.方法 回顾性分析上海市儿童医院心胸外科于2012年1月至2018年12月间完成的主动脉弓病变合并心内畸形矫正的患儿50例.依据中心温度将患儿分为深低温停循环(deep hypothermia circulatory arrest,DHCA)组及MHCA组,每组25例.所有患儿均在体外循环(cardiopulmonary bypass,CPB)下行一期手术治疗.主动脉弓重建过程中采用低温停循环技术,通过无名动脉SACP(25~40 ml·kg^-1·min^-1)的CPB管理方法.心肌保护采用康斯特器官保护液(HTK液).记录两组患者的一般资料及术中、术后指标.结果 两组均无与CPB相关的神经系统并发症.两组患儿年龄、体重、病种、术前肝肾功能及术前左心室射血分数值比较差异均无统计学意义(P>0.05).CPB时间MHCA组较DHCA组明显缩短[(120.00±22.60)min比(137.40±22.88)min,P=0.019];术后24 h胸腔引流量及正性肌力药物评分MHCA组较DHCA组明显减少,分别为[(49.84±20.66)ml比(78.20±52.31)ml,P=0.03;(9.72±2.47)分比(12.24±3.07)分,P=0.004].结论 在婴儿主动脉弓重建手术中,采用DHCA或MHCA结合SACP的技术均能均减少术后神经系统并发症发生,不增加术后其他并发症.MHCA可减少CPB时间、术后胸腔引流量及术后血管活性药物的使用量.

Application of Moderate Hypothermia Circulatory Arrest Combined with Selective Cerebral Perfusion in Infant Aortic Arch Surgery

Objective To summarize the experience of the application of moderate hypothermia circulatory arrest(MHCA)combined with selective antegrade cerebral perfusion(SACP)in infant aortic arch reconstruction.Methods A retrospective analysis was conducted on 50 cases of infants with aortic arch reconstruction from January 2012 to December 2018 in the department of cardiothoracic surgery of Shanghai children's hospital.The children were divided into deep hypothermia circulatory arrest(DHCA)group and moderate hypothermia circulatory arrest(MHCA)group according to the intraoperative central temperature.with 25 cases in each group.All the children underwent one-stage operation under cardiopulmonary bypass(CPB).Hypothermia circulatory arrest combined with SACP(25-40 ml kg^-1 min^-1)through innominate artery was applied for the reconstruction of the aortic arch.HTK solution was used for myocardial protection.The clinical characteristics,intraoperative parameters and postoperative indexes in both groups were recorded.Results There were no neurological complications related to CPB observed in both groups.There was no statistical difference in age,weight.disease type,preoperative liver and kidney function and preoperative left ventricular ejection fraction between the two groups(P>0.05).The CPB time in MHCA group was significantly shorter than that in DHCA group[(120.00±22.60)min vs.(137.40±22.88)min,P=0.019].MHCA group showed a greater decline in 24-hour thoracic drainage volume[(49.84±20.66)ml vs.(78.20±52.31)ml,P=0.03]and positive inotropic drug score after operation[(9.72±2.47)score vs.(12.24±3.07)score,P=0.004]compared with DHCA group.There was no statistical difference in postoperative mortality,incidence of acute renal failure,incidence of low cardiac output and incidence of other complications(atelectasis,pleural effusion,pneumothorax,secondary thoracotomy)(P>0.05).Conclusion During aortic arch reconstruction surgery in infants,the use of DHCA or MHCA combined with SACP both can reduce the occurrence of postoperative neurological complications without increasing other postoperative complications.Moreover,compared with DHCA,MHCA can reduce CPB time,postoperative thoracic drainage volume and the use of postoperative vasoactive drugs.