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摘要: 深低温停循环技术(DHCA)被广泛应用于复杂心脏外科手术，有脑保护作用。由于顺行性脑灌注(ACP)能在停循环期间给大脑供血，所以大部分中心目前多采取DHCA+ACP的技术。然而，随着DHCA技术的广泛应用，深低温导致的术后凝血功能异常、出血风险增加、红细胞压积增加、肾脏损伤成为临床关注的重点。为了减少相关并发症，人们开始探索中低温甚至浅低温的安全性和有效性。本文旨在介绍中/浅低温停循环相关基础和临床研究，为临床诊疗提供思路。Abstract: Aortic disease is an important part of cardiac surgery which is usually resolved by surgery. In order to get a bloodless operating field and reduce postoperative mortality, Deep Hypothermic Circulatory Arrest(DHCA) has been widely applicated in aortic disease surgery. Because of the benefits of blood and oxygen provided by antegrade cerebral perfusion(ACP), most centers incline to use DHCA+ACP during circulatory arrest. However, percent of postoperative coagulopathy induced by hypothermia, bleeding, increased HCT, kidney dysfunction were increased with the application of DHCA. So surgeons explore the security and effectiveness of Moderate or Mild Hypothermic Circulatory Arrest. This paper aims to review the newest basic and clinical research, and provides evidences for clinic process.
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表 1 中低温下神经系统并发症和肾损伤
Table 1. Nervous system complications and renal injury under moderate hypothermia
作者 样本量/例 MT/℃ 神经系统并发症/% 透析/% 研究类型 Leshnower等[6] 145 25.8 TND 5.1，PND 3.6 4.6 回顾性 Keeling等[16] 342 26.2 TND 5.6，PND 2.8 2.8 回顾性 Leshnower等[5] 412 25.7 TND 5.9 9.7 回顾性 Ma等[17] 99 17.9 vs 23.6 TND 8.6 vs 7.9(ns)；
PND 1.7 vs 3.1(ns)7.8 vs 4.8(ns) 回顾性 Tsai等[18] 221 16.8 vs 22.9 卒中8 vs 3(ns) 3 vs 2(ns) 回顾性 Vallabhajosyula等[19] 376 ＜20 vs 27 卒中1.7 vs 1.7(ns) 0.6 vs 4.5(ns) 回顾性 Arnaoutakis等[14] 586 17.5 vs 26.4 卒中1.9 vs 0.6(ns)；
TIA 1.9 vs 0(ns)0.6 vs 4.5(ns) 回顾性 Perreas等[7] 80 18 vs 23.3 50.0 vs 17.5(P=0.001) - 匹配分析 Keenan等[4] 310 17 vs 24 TND 1.3 vs 40.4(P=0.04)；
PND 3.8 vs 2.1(ns)3.8vs6.4(ns) 匹配分析 Pupovac等[15] 732 18 vs 25 10.5 vs 7.5(ns) - 匹配分析 Keeling等[8] 1388 18 vs 24.6 TND 4.0 vs 6.2(ns)；
PND 8.8 vs 5.7(ns)- 匹配分析 Kamenskaya等[12] 58 18 vs 24 37.9 vs 17.8(P=0.03) - 随机对照试验 MT：平均温度；ns：无统计学差异；-表示文章未提及。 
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表 2 中低温下出血二次手术和死亡率
Table 2. Secondary operations and mortality rates for hemorrhage under moderate hypothermia
作者 样本量/例 MT/℃ 出血导致二次手术/% 死亡率/% 研究类型 Leshnower等[6] 145 25.8 6.6 (住院+术后30 d)9.7 回顾性 Keeling等[16] 342 26.2 - 住院11.7 回顾性 Leshnower等[5] 412 25.7 7.6 (住院+术后30 d)7 回顾性 Ma等[17] 99 17.9 vs 23.6 9.5 vs 8.5(ns) 术后30 d 14.9 vs 19.2(ns) 回顾性 Tsai等[18] 221 16.8 vs 22.9 3 vs7 住院8 vs 1(P=0.005)；
术后30 d 9 vs 2(P=0.02)回顾性 Vallabhajosyula等[19] 376 ＜20 vs 27 14.7 vs 17.0(ns) 术后30 d 1 vs 1(ns) 回顾性 Arnaoutakis等[14] 586 17.5 vs 26.4 13.5 vs 14.2(ns) 术后30 d 0.9 vs 0(ns) 回顾性 Perreas等[7] 80 18 vs 23.3 2.5 vs 5.0(ns) 住院27.5 vs 10.0(P=0.045)；
术后30 d 22.5 vs 7.5(ns)匹配分析 Keenan等[4] 310 17 vs 24 17.3 vs 8.5(ns) 术后30 d 1.3 vs 3.2(ns) 匹配分析 Pupovac等[15] 732 18 vs 25 5.5 vs 5.0(ns) 住院13.0 vs 16.6(ns) 匹配分析 Keeling等[8] 1，388 18 vs 24.6 - 住院13.7 vs 16.9(ns) 匹配分析 Kamenskaya等[12] 58 18 vs 24 13.7 vs 10.3(ns) 住院13.7 vs 10.3(ns) 随机对照试验
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表 3 浅低温下神经系统并发症和肾损伤
Table 3. Nervous system complications and renal injury under mild hypothermia
作者 样本量/例 MT/℃ 神经系统并发症/% 透析/% 研究类型 Zierer等[25] 245 30.5 TND 5，PND 6 9 回顾性 Urbanski等[26] 347 31.5 TND 2.3，PND 0.9 1.5 回顾性 Ahmd等[21] 587 28.7 TND 5，PND 6 8 回顾性 Zierer等[20] 1002 30 TND 5，PND 4 4 回顾性 Jiang等[27] 70 28 vs 32 TND 12.9 vs 16.1(ns)；
PND 3.2 vs 0(ns)- 回顾性 Goto等[28] 72 30.1 vs 26.5 PND 0 vs 3(ns) - 回顾性 Dong等[23] 88 25.9 vs 30.0 PND 8.5 vs 0(P=0.120)；
TND 6.4 vs 7.3(ns)0 vs 2.4(ns) 回顾性 Hata等[24] 187 29.5 vs 27.4 TND 1.8 vs 3.1(ns)；
PND 0 vs 4.6(ns)1.8 vs 1.5(ns) 回顾性 Leshnower等[22] 500 24.3 vs 28.6 TND 6.3 vs 4.3(ns)；
PND 7.2 vs 2.5(P=0.01)4.1 vs 4.0(ns) 回顾性
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表 4 浅低温下出血二次手术和死亡率
Table 4. Secondary operation and mortality of bleeding under mild hypothermia
作者 样本量/例 MT/℃ 出血导致二次手术/% 死亡率/% 研究类型 Zierer等[25] 245 30.5 13 住院8 回顾性 Urbanski等[26] 347 31.5 - 术后30 d 0.9，住院1.2 回顾性 Ahmd等[21] 587 28.7 13 术后30 d 6 回顾性 Zierer等[20] 1002 30 6 术后30 d 5 回顾性 Jiang等[27] 70 28 vs 32 - 住院5.15 vs 6.50(ns) 回顾性 Goto等[28] 72 30.1 vs 26.5 - 术后30 d 0 回顾性 Dong等[23] 88 25.9 vs 30.0 4.3 vs 2.4(ns) 住院8.5 vs 2.4(ns) 回顾性 Hata等[24] 187 29.5 vs 27.4 2 vs 7(ns) 住院2.3 vs 0(ns) 回顾性 Leshnower等[22] 500 24.3 vs 28.6 7.2 vs7.2(ns) 择期住院4.2 vs 4.8(ns)
急诊住院11.7 vs7.7(ns)回顾性
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| 引用本文: |
余明寰, 刘志刚, 刘晓程. 中/浅低温停循环在主动脉手术中的应用进展[J]. 临床心血管病杂志, 2022, 38(9): 699-705. doi: 10.13201/j.issn.1001-1439.2022.09.004
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| Citation: |
YU Minghuan, LIU Zhigang, LIU Xiaocheng. The state of moderate/mild hypothermic circulatory arrest in aortic surgery[J]. J Clin Cardiol, 2022, 38(9): 699-705. doi: 10.13201/j.issn.1001-1439.2022.09.004
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