深低温停循环上腔静脉逆行脑灌注在主动脉弓部手术中的应用

摘要

Objective To sum up the experience on retrograde cerebral perfusion applied in aortic arch operation. Methods The patients with aortic aneurysm and DeBakey type I aortic dissection (n=45, male 35, female 10, aged from 23 to 81 and average age=46.7±13.1) were chosen from Jan. 2014 to Aug. 2015, and given the treatment of retrograde cerebral perfusion via superior vena cava (SVC) with deep hypothermic circulatory arrest (DHCA). Results The time of cardiopulmonary bypass (CPB) was 127 min~314 min (168.1±53.7), time of myocardial devascularization was 66 min~201 min (122.4±31.8), DHCA time was 15 min~53 min (24.4±11.5), time of cerebral perfusion via SVC was 13 min~47 min (28.7±13.2), and the lowest nasopharynx temperature was 14.1℃~22.3 ℃ (17.5±3.0) and the lowest anal temperature was 18.5℃~25.8℃(20.9±2.5) during DHCA. After aortic artery was opened, there were 39 cases of auto-rebeat of heart and 6 of rebeat by electric defibrillation. All patients woke up completely within 1 h to 48 h after the operation. There were 2 cases died and the cause was related to multiple organs failure while not to retrograde cerebral perfusion via SVC. The complications after the operation included renal failure in 1 case, re-thoratomy for hemaostsis in 1 case, stroke in 1 case and transitional disorders of nervous system in 4 cases. Other patients were cured and discharged from hospital. Conclusion The method of retrograde cerebral perfusion via SVC is applied during aortic arch operation can protect brain, simplify the procedure, supply sufficient blood perfusion for brain and prolong the safe period significantly.%目的：总结上腔静脉逆行脑灌注在主动脉弓部手术中的应用经验。方法选取2014年1月至2015年8月期间南京医科大学第二附属医院心血管外科收治的主动脉瘤及DeBakeyⅠ型主动脉夹层患者45例，男性35例，女性10例，年龄23~81（46.7±13.1）岁。采用深低温停循环（DHCA）上腔静脉逆行脑灌注的手术方式治疗。结果体外循环时间为127~314（168.1±53.7）min、心肌血运阻断时间为66~201（122.4±31.8）min、深低温停（DHCA）时间为15~53（24.4±11.5）min、经上腔静脉逆行脑灌注时间为13~47（28.7±13.2）min、停循环时最低鼻咽温度14.1~22.3（17.5±3.0）℃、最低肛温18.5~25.8（20.9±2.5）℃。主动脉开放后，心脏自动复跳39例，电击除颤复跳6例；所有患者在术后1~48 h内神志完全清醒。术后死亡2例，死亡原因为多脏器功能衰竭，与上腔静脉逆行脑灌注无关。患者术后并发症包括：肾脏衰竭1例，再次开胸止血1例，术后中期脑卒中1例，一过性神经系统功能障碍4例，余患者经治疗后均顺利痊愈出院。结论在主动脉弓部手术中采用上腔静脉逆行脑灌注脑保护的方式，可以简化手术操作，同时给大脑提供充分的血液灌注，明显延长手术的安全时限。