电阻抗成像技术和水通道蛋白4在3岁以下主动脉缩窄手术患儿脑水肿监测中的应用
|
摘要
目的:比较3岁以下主动脉缩窄手术行顺行性脑灌注(antegrade cerebral perfusion,ACP)时在不同温度下患儿脑水肿情况,评估电阻抗成像技术是否可以评估患儿脑水肿情况。方法:回顾性分析重庆医科大学附属儿童医院胸心外科2012年1月至2017年1月收治的60例3岁以下行主动脉缩窄合并心内畸形的手术患儿基本资料(如性别、年龄和体质量),根据停循环时的鼻咽温度分为深低温组(17.0℃～20.0℃)、中低温组(20.1℃～25.0℃)和浅低温组(25.1℃～30.0℃)。检测麻醉诱导后、ACP前、ACP结束时、体外循环(cardiopulmonary bypass,CPB)结束时、术后3 h、术后12 h和术后24 h 7个时间点血清水通道蛋白4(aquaporin 4,AQP4)的表达和脑电阻抗系数。收集同期20例在我院行干下型室间隔缺损修补术的患儿为对照组。结果:采用重复测量方差分析,不同组间同时间点采用简单效应分析的Sidak检验,顺行性脑灌注下深低温组患儿血清AQP4水平在ACP结束、CPB结束、术后3 h、术后12 h、术后24 h相对于中低温组、浅低温组、对照组均明显升高(F组别=160.755,P组别=0.000;F时间=283.208,P时间=0.000,F交互=19.859,P交互=0.000);深低温组患儿脑电阻抗系数在CPB结束、术后3 h、术后12 h、术后24 h相对于中低温组、浅低温组和对照组均明显升高(F组别=55.243,P组别=0.000;F时间=90.805,P时间=0.000,F交互=10.743,P交互=0.000)。结论:3岁以下主动脉缩窄ACP时深低温组脑损伤可能高于中低温组、浅低温组和对照组,基于电阻抗成像技术的脑水肿监测仪可以判断患儿脑水肿情况。
Objective:To compare cerebral edema of antegrade cerebral perfusion(ACP)among different temperatures in patients who underwent surgery for aortic coarctation at age < 3 years,and to evaluate the feasibility of electrical impedance tomographic assessment of cerebral edema. Methods:We retrospectively analyzed the basic data(sex,age,and weight)of 60 patients who underwent aortic coarctation and intracardiac deformity within 3 years of age,between January 2012 and January 2017,in our hospital. According to the nasopharyngeal temperature at the time of stopping circulation,the patients were divided into the deep hypothermia(17.0 ℃-20.0 ℃),medium-low temperature(20.1 ℃-25.0 ℃),and shallow hypothermia groups(25.1 ℃-30.0 ℃). In addition,serum aquaporin4 expression level and brain electrical impedance coefficients(CEICs)were measured at seven time points(including the time after anesthesia induction,before ACP,at the end of ACP,at the end of cardiopulmonary bypass,and 3,12,24 hours after sur-gery). Twenty patients with subarterial ventricular septal defect in our hospital during the same period were included as the control group. Results:Analysis of variance was used to analyze the whole set of data,and the Sidak test of simple effect analysis was used to analyze the difference between groups at the same time point. The serum AQP4 level was significantly higher in the deep hypothermic group than in the moderate hypothermic,mild hypothermic,and control groups at the end of ACP,the end of CPB,3 hours after surgery,12 hours after surgery,and 24 hours after surgery(Famong groups=160.755,Pamong groups=0.000;Ftimes=283.208,Ptimes=0.000;Finteractions=19.859,Pinteractions=0.000). The CEIC level was significantly higher in the deep hypothermic group than in the moderate hypothermic,mild hypothermic,and control groups at the end of CPB,and 3,12,and 24 hours after surgery(Famong groups=55.243,Pamong groups=0.000;Ftimes=90.805,Ptimes=0.000;Finteractions=10.743,Pinteractions=0.000). Conclusion :The cerebral injury in the deep hypothermia group during the antegrade cerebral perfusion of the aortic coarctation at age < 3 years may be higher than that in the moderate hypothermic,mild hypothermic,and control groups. Electrical impedance tomography can be used for assessing cerebral edema.
Objective:To compare cerebral edema of antegrade cerebral perfusion(ACP)among different temperatures in patients who underwent surgery for aortic coarctation at age < 3 years,and to evaluate the feasibility of electrical impedance tomographic assessment of cerebral edema. Methods:We retrospectively analyzed the basic data(sex,age,and weight)of 60 patients who underwent aortic coarctation and intracardiac deformity within 3 years of age,between January 2012 and January 2017,in our hospital. According to the nasopharyngeal temperature at the time of stopping circulation,the patients were divided into the deep hypothermia(17.0 ℃-20.0 ℃),medium-low temperature(20.1 ℃-25.0 ℃),and shallow hypothermia groups(25.1 ℃-30.0 ℃). In addition,serum aquaporin4 expression level and brain electrical impedance coefficients(CEICs)were measured at seven time points(including the time after anesthesia induction,before ACP,at the end of ACP,at the end of cardiopulmonary bypass,and 3,12,24 hours after sur-gery). Twenty patients with subarterial ventricular septal defect in our hospital during the same period were included as the control group. Results:Analysis of variance was used to analyze the whole set of data,and the Sidak test of simple effect analysis was used to analyze the difference between groups at the same time point. The serum AQP4 level was significantly higher in the deep hypothermic group than in the moderate hypothermic,mild hypothermic,and control groups at the end of ACP,the end of CPB,3 hours after surgery,12 hours after surgery,and 24 hours after surgery(Famong groups=160.755,Pamong groups=0.000;Ftimes=283.208,Ptimes=0.000;Finteractions=19.859,Pinteractions=0.000). The CEIC level was significantly higher in the deep hypothermic group than in the moderate hypothermic,mild hypothermic,and control groups at the end of CPB,and 3,12,and 24 hours after surgery(Famong groups=55.243,Pamong groups=0.000;Ftimes=90.805,Ptimes=0.000;Finteractions=10.743,Pinteractions=0.000). Conclusion :The cerebral injury in the deep hypothermia group during the antegrade cerebral perfusion of the aortic coarctation at age < 3 years may be higher than that in the moderate hypothermic,mild hypothermic,and control groups. Electrical impedance tomography can be used for assessing cerebral edema.
引文
[1]Dijkema EJ,Leiner T,Grotenhuis HB.Diagnosis,imaging and clinical management of aortic coarctation[J].Heart,2017,103(15):1148-1155.
[2]Bachet J,Guilmet D,Goudot B,et al.Antegrade cerebral perfusion with cold blood:a 13-year experience[J].Ann Thorac Surg,1999,67(6):1874-1878.
[3]Dossche KM,Schepepens MA,Morshuis WJ,et al.Antegrade selective cerebral perfusion in operations on the proximal thoracic aorta[J].Ann Thorac Surg,1999,67(6):1904-1910.
[4]Kornilov IA,Sinelnikov YS,Soino IA,et al.Outcomes after aortic arch reconstruction for infants:deep hypothermic circulatory arrest versus moderate hypothermia with selective antegrade cerebral perfusion[J].Eur J Cardiothorac Surg,2015,48(3):e45-50.
[5]Wu Y,Xiao L,Yang T,et al.Aortic arch reconstruction:deep and moderate hypothermic circulatory arrest with selective antegrade cerebral perfusion[J].Perfusion,2017,32(5):389-393.
[6]El-Sayed Ahmad A,Papadopoulos N,Risteski P,et al.The standardized concept of moderate-to-mild(≥28℃)systemic hypothermia during selective antegrade cerebral perfusion for all-comers in aortic arch surgery:single-center experience in 587 consecutive patients over a 15-year period[J].Ann Thorac Surg,2017,104(1):49-55.
[7]Li B,Hu X,Wang Z.The neurologic protection of unilateral versus bilateral antegrade cerebral perfusion in aortic arch surgery with deep hypothermic circulatory arrest:a study of 77 cases[J].Int J Surg,2017,40:8-13.
[8]Di Marco I,Pacini D,Di Bartolomeo R.Cerebral protection in aortic arch surgery[J].G Ital Cardiol(Rome),2010,11(5):357-366.
[9]Hammon JW.Brain protection during cardiac surgery:circa 2012[J].J Extra Corpor Technol,2013,45(2):116-121.
[10]Hu Z,Wang Z,Ren Z,et al.Similar cerebral protective effectiveness of antegrade and retrograde cerebral perfusion combined with deep hypothermia circulatory arrest in aortic arch surgery:a meta-analysis and systematic review of 5060 patients[J].J Thorac Cardiovasc Surg,2014,148(2):544-560.
[11]Rohlwink UK,Figaji AA.Biomarkers of brain injury in cerebral infections[J].Clin Chem,2014,60(6):823-834.
[12]Stammet P.Blood biomarkers of hypoxic-ischemic brain injury after cardiac arrest[J].Semin Neurol,2017,37(1):75-80.
[13]Yokobori S,Hosein K,Burks S,et al.Biomarkers for the clinical differential diagnosis in traumatic brain injury--a systematic review[J].CNS Neurosci Ther,2013,19(8):556-565.
[14]Zelenina M,Zelenen S,Aperia A.Water channels(aquaporins)and their role for postnatal adaptation[J].Pediatr Res,2005,57(5 Pt2):47R-53R.
[15]Yool AJ.Aquaporins:multiple roles in the central nervous system[J].Neuroscientist,2007,13(5):470-485.
[16]Kiening KL,Van Landeghem FK,Schreiber S,et al.Decreased hemispheric aquaporin-4 is linked to evolving brain edema following controlled cortical impact injury in rats[J].Neurosci Lett,2002,324(2):105-108.
[17]Amiry-Moghaddam M,Ottersen OP.The molecular basis of water transport in the brain[J].Nat Rev Neurosci,2003,4(12):991-1001.
[18]Chen JQ,Zhang CC,Jing SN,et al.Effects of aquaporin 4 knockdown on brain edema of the uninjured side after traumatic brain injury in rats[J].Med Sci Monit,2016,22:4809-4819.
[19]Du Y,Xu JT,Jin HN,et al.Increased cerebral expressions of MMPs,CLDN5,OCLN,ZO1 and AQPs are associated with brain edema following fatal heat stroke[J].Sci Rep,2017,7(1):1691.
[20]FilippidisS AS,Carozza RB,Rekate HL.Aquaporins in brain edema and neuropathological conditions[J].Int J Mol Sci,2016,18(1):E55.
[21]Leitao RA,Sereno J,Castelhano JM,et al.Aquaporin-4 as a new target against methamphetamine-induced brain alterations:focus on the neurogliovascular unit and motivational behavior[J].Mol Neurobiol,2017[Epub ahead of print].
[22]常明秀,陈丽霞,陈立杰,等.脑水肿时紧密连接蛋白occludin及AQP4的表达变化[J].现代生物医学进展,2014,14(7):1258-1262.
[23]李敏,陈少军,陈学群,等.脑水肿的AQP4调节机制研究进展[J].浙江大学学报(医学版),2013,42(1):114-122.
[24]鲁红霞,姜荣建.七叶皂甙钠对高血压并发脑出血患者血清水通道蛋白水平的影响[J].重庆医学,2010,39(2):230-232.
[25]吴春,魏光辉,代江涛,等.体外循环术致婴幼儿脑损害的研究[J].重庆医科大学学报,2010,35(7):1092-1095.
[26]Miedema M,McCall KE,Perkins EJ,et al.First real-time visualization of a spontaneous pneumothorax developing in a preterm lamb using electrical impedance tomography[J].Am J Respir Crit Care Med,2016,194(1):116-118.
[27]Morais CC,De Santis Santlago RR,Filho JR,et al.Monitoring of pneumothorax appearance with electrical impedance tomography during recruitment maneuvers[J].Am J Respir Crit Care Med,2017,195(8):1070-1073.
[28]Miedema M,Waldmann A,Mccall KE,et al.Individualized multiplanar electrical impedance tomography in infants to optimize lung monitoring[J].Am J Respir Crit Care Med,2017,195(4):536-538.
[29]Franchineau G,Brechot N,Lereton G,et al.Bedside contribution of electrical impedance tomography to setting positive end-expiratory pressure for extracorporeal membrane oxygenation-treated patients with severe acute respiratory distress syndrome[J].Am J Respir Crit Care Med,2017,196(4):447-457.
[30]Xu S,Dai M,Xu C,et al.Performance evaluation of five types of Ag/AgCl bio-electrodes for cerebral electrical impedance tomography[J].Ann Biomed Eng,2011,39(7):2059-2067.
[31]Bagshaw AP,Liston AD,Bayford RH,et al.Electrical impedance tomography of human brain function using reconstruction algorithms based on the finite element method[J].NeuroImage,2003,20(2):752-764.
[32]Gilad O,Holder DS.Impedance changes recorded with scalp electrodes during visual evoked responses:implications for electrical impedance tomography of fast neural activity[J].Neuroimage,2009,47(2):514-522.
[33]Bodo M,Pearce FJ,Montgomery LD,et al.Measurement of brain electrical impedance:animal studies in rheoencephalography[J].Aviat Space Environ Med,2003,74(5):506-511.
[34]Fu F,LiB,Dai M,et al.Use of electrical impedance tomography to monitor regional cerebral edema during clinical dehydration treatment[J].PLoS One,2014,9(12):e113202.
[35]He LY,Wang J,Luo Y,et al.Application of non-invasive cerebral electrical impedance measurement on brain edema in patients with cerebral infarction[J].Neurol Res,2010,32(7):770-774.
[36]Liu L,Dong W,Ji X,et al.A new method of noninvasive brainedema monitoring in stroke:cerebral electrical impedance measurement[J].Neurol Res,2006,28(1):31-37.
[2]Bachet J,Guilmet D,Goudot B,et al.Antegrade cerebral perfusion with cold blood:a 13-year experience[J].Ann Thorac Surg,1999,67(6):1874-1878.
[3]Dossche KM,Schepepens MA,Morshuis WJ,et al.Antegrade selective cerebral perfusion in operations on the proximal thoracic aorta[J].Ann Thorac Surg,1999,67(6):1904-1910.
[4]Kornilov IA,Sinelnikov YS,Soino IA,et al.Outcomes after aortic arch reconstruction for infants:deep hypothermic circulatory arrest versus moderate hypothermia with selective antegrade cerebral perfusion[J].Eur J Cardiothorac Surg,2015,48(3):e45-50.
[5]Wu Y,Xiao L,Yang T,et al.Aortic arch reconstruction:deep and moderate hypothermic circulatory arrest with selective antegrade cerebral perfusion[J].Perfusion,2017,32(5):389-393.
[6]El-Sayed Ahmad A,Papadopoulos N,Risteski P,et al.The standardized concept of moderate-to-mild(≥28℃)systemic hypothermia during selective antegrade cerebral perfusion for all-comers in aortic arch surgery:single-center experience in 587 consecutive patients over a 15-year period[J].Ann Thorac Surg,2017,104(1):49-55.
[7]Li B,Hu X,Wang Z.The neurologic protection of unilateral versus bilateral antegrade cerebral perfusion in aortic arch surgery with deep hypothermic circulatory arrest:a study of 77 cases[J].Int J Surg,2017,40:8-13.
[8]Di Marco I,Pacini D,Di Bartolomeo R.Cerebral protection in aortic arch surgery[J].G Ital Cardiol(Rome),2010,11(5):357-366.
[9]Hammon JW.Brain protection during cardiac surgery:circa 2012[J].J Extra Corpor Technol,2013,45(2):116-121.
[10]Hu Z,Wang Z,Ren Z,et al.Similar cerebral protective effectiveness of antegrade and retrograde cerebral perfusion combined with deep hypothermia circulatory arrest in aortic arch surgery:a meta-analysis and systematic review of 5060 patients[J].J Thorac Cardiovasc Surg,2014,148(2):544-560.
[11]Rohlwink UK,Figaji AA.Biomarkers of brain injury in cerebral infections[J].Clin Chem,2014,60(6):823-834.
[12]Stammet P.Blood biomarkers of hypoxic-ischemic brain injury after cardiac arrest[J].Semin Neurol,2017,37(1):75-80.
[13]Yokobori S,Hosein K,Burks S,et al.Biomarkers for the clinical differential diagnosis in traumatic brain injury--a systematic review[J].CNS Neurosci Ther,2013,19(8):556-565.
[14]Zelenina M,Zelenen S,Aperia A.Water channels(aquaporins)and their role for postnatal adaptation[J].Pediatr Res,2005,57(5 Pt2):47R-53R.
[15]Yool AJ.Aquaporins:multiple roles in the central nervous system[J].Neuroscientist,2007,13(5):470-485.
[16]Kiening KL,Van Landeghem FK,Schreiber S,et al.Decreased hemispheric aquaporin-4 is linked to evolving brain edema following controlled cortical impact injury in rats[J].Neurosci Lett,2002,324(2):105-108.
[17]Amiry-Moghaddam M,Ottersen OP.The molecular basis of water transport in the brain[J].Nat Rev Neurosci,2003,4(12):991-1001.
[18]Chen JQ,Zhang CC,Jing SN,et al.Effects of aquaporin 4 knockdown on brain edema of the uninjured side after traumatic brain injury in rats[J].Med Sci Monit,2016,22:4809-4819.
[19]Du Y,Xu JT,Jin HN,et al.Increased cerebral expressions of MMPs,CLDN5,OCLN,ZO1 and AQPs are associated with brain edema following fatal heat stroke[J].Sci Rep,2017,7(1):1691.
[20]FilippidisS AS,Carozza RB,Rekate HL.Aquaporins in brain edema and neuropathological conditions[J].Int J Mol Sci,2016,18(1):E55.
[21]Leitao RA,Sereno J,Castelhano JM,et al.Aquaporin-4 as a new target against methamphetamine-induced brain alterations:focus on the neurogliovascular unit and motivational behavior[J].Mol Neurobiol,2017[Epub ahead of print].
[22]常明秀,陈丽霞,陈立杰,等.脑水肿时紧密连接蛋白occludin及AQP4的表达变化[J].现代生物医学进展,2014,14(7):1258-1262.
[23]李敏,陈少军,陈学群,等.脑水肿的AQP4调节机制研究进展[J].浙江大学学报(医学版),2013,42(1):114-122.
[24]鲁红霞,姜荣建.七叶皂甙钠对高血压并发脑出血患者血清水通道蛋白水平的影响[J].重庆医学,2010,39(2):230-232.
[25]吴春,魏光辉,代江涛,等.体外循环术致婴幼儿脑损害的研究[J].重庆医科大学学报,2010,35(7):1092-1095.
[26]Miedema M,McCall KE,Perkins EJ,et al.First real-time visualization of a spontaneous pneumothorax developing in a preterm lamb using electrical impedance tomography[J].Am J Respir Crit Care Med,2016,194(1):116-118.
[27]Morais CC,De Santis Santlago RR,Filho JR,et al.Monitoring of pneumothorax appearance with electrical impedance tomography during recruitment maneuvers[J].Am J Respir Crit Care Med,2017,195(8):1070-1073.
[28]Miedema M,Waldmann A,Mccall KE,et al.Individualized multiplanar electrical impedance tomography in infants to optimize lung monitoring[J].Am J Respir Crit Care Med,2017,195(4):536-538.
[29]Franchineau G,Brechot N,Lereton G,et al.Bedside contribution of electrical impedance tomography to setting positive end-expiratory pressure for extracorporeal membrane oxygenation-treated patients with severe acute respiratory distress syndrome[J].Am J Respir Crit Care Med,2017,196(4):447-457.
[30]Xu S,Dai M,Xu C,et al.Performance evaluation of five types of Ag/AgCl bio-electrodes for cerebral electrical impedance tomography[J].Ann Biomed Eng,2011,39(7):2059-2067.
[31]Bagshaw AP,Liston AD,Bayford RH,et al.Electrical impedance tomography of human brain function using reconstruction algorithms based on the finite element method[J].NeuroImage,2003,20(2):752-764.
[32]Gilad O,Holder DS.Impedance changes recorded with scalp electrodes during visual evoked responses:implications for electrical impedance tomography of fast neural activity[J].Neuroimage,2009,47(2):514-522.
[33]Bodo M,Pearce FJ,Montgomery LD,et al.Measurement of brain electrical impedance:animal studies in rheoencephalography[J].Aviat Space Environ Med,2003,74(5):506-511.
[34]Fu F,LiB,Dai M,et al.Use of electrical impedance tomography to monitor regional cerebral edema during clinical dehydration treatment[J].PLoS One,2014,9(12):e113202.
[35]He LY,Wang J,Luo Y,et al.Application of non-invasive cerebral electrical impedance measurement on brain edema in patients with cerebral infarction[J].Neurol Res,2010,32(7):770-774.
[36]Liu L,Dong W,Ji X,et al.A new method of noninvasive brainedema monitoring in stroke:cerebral electrical impedance measurement[J].Neurol Res,2006,28(1):31-37.