刘楠
中国医学科学院阜外医院 心血管内科
OBJECTIVE:To analyze the risk factors of hepatic dysfunction following Stanford A and stanford B aortic dissection repair with deep hypothermic circulatory arrest (DHCA).METHODS:Between January 2006 and June 2008, 208 patients [156 male and 52 female, mean aged (45 ± 11) years] underwent open repairs of aortic dissection with DHCA. Indications for surgical intervention were type A aortic dissection in 181 patients and type B in 27 patients. Acute aortic dissection occurred on 121 patients, chronic aortic dissection occurred on 87 patients. Complications included hypertension, diabetes, cardiac dysfunction, renal dysfunction, and hepatic dysfunction. Twenty-one patients had previous aortic surgery. Data were gathered for multiple preoperative and intraoperative factors including age, gender, diagnosis, aortic dissection type, preoperative ejection fraction, aortic surgery history, surgical intervention type, cardiopulmonary bypass (CPB) time, aortic cross-clamp time, blood transfusion volume (PRBC). Serum glutamic-pyruvic transaminase (GPT), 1-lactate dehydrogenase (LDH) and total bilirubin (TBIL) were assayed before and after operation, as well as 12 h, 1 d, 3 d, 5 d, 7 d. These valuables were recorded and described statistically. All the factors were evaluated by means of univariate and multivariate Logistic analysis to identify relative risk factors of hepatic dysfunction.RESULTS:The CPB time and aortic cross-clamp time were (189 ± 48) min and (93 ± 41) min, respectively. Hepatic dysfunction occurred in 18 (8.7%) patients. Serum GPT and serum LDH elevated significantly within 24 h after aortic surgery, and then went down gradually. Postoperative serum TBIL were much higher than preoperative level on the first day and there was no significant reduction during the following seven days. Preoperative serum creatinine > 133 µmol/L (P < 0.01), preoperative GPT > 40 U/L (P < 0.01), acute aortic dissection (P < 0.05), CPB time > 180 min (P < 0.05), aortic cross-clamp time > 100 min (P = 0.035), PRBC > 10 unit (P < 0.01) were the risk factors for hepatic dysfunction. Furthermore preoperative GPT > 40 U/L (P < 0.01) and PRBC > 10 unit (P < 0.01) were independent determinants for hepatic dysfunction.CONCLUSIONS:Multiple risk factors impact the onset of postoperative hepatic dysfunction. Rather, a combination of factors, especially preoperative hepatic injury, massive blood transfusion produced the highest odds of deficit.
Zhonghua wai ke za zhi [Chinese journal of surgery] 2010
OBJECTIVE:To analyze the correlation between cerebral oxygenation and cerebral complications after aortic aneurysm operation and to evaluate the protective effects of DHCA and/or ASCP during aortic aneurysm operation.METHODS:Thirty patients with aortic aneurysm, 24 with Stanford type A dissection, 4 with Stanford type B dissection, 1 with degenerative aneurysm in ascending and arch aorta, and 1 with false aneurysm in thoraco-abdominal aorta, 23 males and 7 females, aged 44 +/- 12, underwent aorta operation with circulatory arrest were alternatively allocated to two groups: 22 patients underwent aortic arch replacement under deep hypothermic circulatory arrest (DHCA) plus antegrade selective cerebral perfusion (ASCP), and 8 patients underwent descending thoracic aorta replacement under DHCA only. There was no significant difference in the lowest core temperature, hematocrit at lowest core temperature, and velocity of rewarming between these 2 groups. Near-infrared spectroscopy (NIRS) was used to continuously monitor the cerebral tissue oxygenation index (TOI) percutaneously.RESULTS:The mean circulatory arrest time in the DHCA + ASCP group was 23.25 min, significantly longer than that of the DHCA group (16.67 min, P = 0.022). Cerebral complication occurred in 8 patients after aortic operation (complication group). The baseline TOI of the complication group was 70% +/- 5%, and the maximum decrease in TOI was 58% +/- 8%; and the baseline TOI of the non-complication group was 69% +/- 8%, and the maximum decrease in TOI was 55% +/- 8%; however, there were no significant differences between these 2 groups (both P > 0.05). The TOI decrease was more significant in the DHCA group than in the DHCA + ASCP group. During circulatory arrest, the levels of TOI were higher than the baseline level all along in the ASCP group and were lower than the baseline level 3 to 10 minutes after arrest in the DHCA group. The duration of TOI less than the baseline level in the DHCA group was significantly longer than that in the ASCP group.CONCLUSION:Mild decrease of TOI is not significantly correlated to the occurrence of complication. DHCA + ASCP is more effective in brain protection compared with only DHCA.
Zhonghua yi xue za zhi 2007
OBJECTIVE:To evaluate the clinical efficacy of two brain protective methods for aortic operation according to S100beta protein (S100beta) and interleukin-6 (IL-6) in cerebrospinal fluid (CSF).METHODS:From November 2004 to April 2005, 14 patients who underwent aortic operations with circulatory arrest were alternatively allocated to one of two methods of brain protection: only deep hypothermic circulatory arrest (core temperature, 18 degrees C) for descending thoracic aorta operations (group DHCA, n = 5) or selective antegrade cerebral perfusion (core temperature, 20 degrees C; flow rate, 10 ml kg(-1) min(-1)) for aortic arch operations with DHCA (group ASCP, n = 9). Indications for surgical intervention were Stanford type A dissection in 11 patients, Stanford type B dissection in 2 patients, false aneurysm on thoracoabdominal aorta in 1 patient. S100beta and IL-6 in CSF were assayed in all patients from each group before cardiopulmonary bypass, as well as 0, 6, 12, 24, 48, 72 h after the operation.RESULTS:There were no significant differences in lowest core temperature (P > 0.05), hematocrit in lowest core temperature (P > 0.05) and the velocity of rewarming. Mean circulatory arrest time in ASCP group was significant longer than in DHCA group (P < 0.05). There were much more patients with jugular arteries impaired or accompanied with related cerebrovascular diseases in group ASCP compared to group DHCA. The baseline of S100beta in CSF before cardiopulmonary bypass was no difference. S100beta value in CSF ascended to peak level in 12 h after the operation, showing significantly higher in group DHCA than in group ASCP [DHCA vs. ASCP, (0.90 +/- 0.11) microg/ml vs. (0.61 +/- 0.26) pg/ml]. In most hours after operation there was significant intergroup difference. IL-6 value in CSF ascended to peak level in 12 h postoperative for group DHCA and 0 h postoperative for group ASCP. There was no significance difference observed in IL-6 of CSF between two groups except 6 h and 12 h postoperative.CONCLUSIONS:Brain ischemic injury occurred during aortic operations assisted by brain protective methods is not serious. Unilateral ASCP which can delivery adequate oxygen to brain during circulation arrest has some advantage of alleviating ischemic injury compared with only DHCA.
Zhonghua wai ke za zhi [Chinese journal of surgery] 2007
