心臟外科圍手術(shù)期腦損傷防治專(zhuān)家共識(shí)

制訂專(zhuān)家組，由16位國(guó)內(nèi)業(yè)界公認(rèn)的相關(guān)領(lǐng)域?qū)＜医M成包括11位心臟外科醫(yī)師，5位神經(jīng)科醫(yī)師；(2)審核專(zhuān)家組，由84位國(guó)內(nèi)相關(guān)領(lǐng)域具有副高級(jí)及2.資料來(lái)源acsurgery”“ke”“congenitalheartdisease”“valvesurgery”“coronaryartery1990年1月至2023年12月。文獻(xiàn)納入標(biāo)準(zhǔn)：(1)與心臟外科圍手術(shù)期腦損傷相關(guān)的系統(tǒng)評(píng)價(jià)/meta分析；(2)隨機(jī)對(duì)照試驗(yàn)(RCT)、隊(duì)目錄；(2)非英語(yǔ)、非漢語(yǔ)文獻(xiàn)；(3)會(huì)議壁報(bào)、摘要、講座及學(xué)位論文。法(表1)。每條推薦意見(jiàn)均注明證據(jù)等級(jí)及推薦級(jí)別。同質(zhì)性較好的隨機(jī)對(duì)照試驗(yàn)(RCT)系統(tǒng)綜述或同質(zhì)性良好的隊(duì)列研究系統(tǒng)綜述95%CI較窄的單項(xiàng)RCT;單項(xiàng)起點(diǎn)一致的隊(duì)列研究同質(zhì)性較好的隊(duì)列研究的系統(tǒng)綜述；回顧性隊(duì)列或?qū)φ战M為空白對(duì)照(未治療)的RCT的系統(tǒng)綜述單項(xiàng)隊(duì)列研究及質(zhì)量較差的RCT;單項(xiàng)回顧性隊(duì)列或?qū)φ战M為空白對(duì)照(結(jié)局研究(全或無(wú))同質(zhì)性較好的病例對(duì)照研究的系統(tǒng)綜述系列病例分析或質(zhì)量差的病例對(duì)照研究；系列病例報(bào)告或質(zhì)量差的證據(jù)有效(證據(jù)等級(jí)為2級(jí)和3級(jí)),可推薦，可能會(huì)在將來(lái)出現(xiàn)更高質(zhì)量的證據(jù)在一定條件下有效(證據(jù)等級(jí)為4級(jí)),應(yīng)謹(jǐn)證據(jù)的有效性具有局限性(證據(jù)等級(jí)為5級(jí)),僅在較先天性心臟病(congenitalheartdisease,CHD)是最常見(jiàn)的先天性心臟畸形，在新生兒中患病率約1%,隨著醫(yī)療水平提升，90%以上的先天性心臟病患者可以生存至成年，目前CHD的成人患者多于兒童患者[1—5]。隨著壽約0.02%(18~24歲)至0.3%(55~64歲),比普通人群高出約10倍，缺血性卒中后30天病死率為5.1%,還會(huì)增加其他心血管事件的發(fā)生風(fēng)險(xiǎn)[5,8-9]。兒童缺血2.發(fā)病機(jī)制檢查顯示孕中期開(kāi)始胎兒大腦生長(zhǎng)發(fā)育緩慢[2,11]。胎兒的含氧血液通過(guò)多項(xiàng)研究[6,9,11]顯示，手術(shù)時(shí)年齡較大、體外循環(huán)持續(xù)時(shí)間較長(zhǎng)、止血障礙等多因素共同作用的結(jié)果[6,8]。4.術(shù)前影像學(xué)評(píng)估同時(shí)排除是否術(shù)前即存在神經(jīng)系統(tǒng)并發(fā)癥[2]。推薦意見(jiàn)1:患者應(yīng)行經(jīng)胸超聲心動(dòng)圖進(jìn)行初步評(píng)估，并根據(jù)解剖病變嚴(yán)重4.2神經(jīng)系統(tǒng)評(píng)估建議患者術(shù)前完善HUS檢查。HUS能夠評(píng)估大腦的淺表結(jié)構(gòu)(如皮層和靜脈竇)和深層結(jié)構(gòu)。優(yōu)勢(shì)在于價(jià)格低廉，易于在床邊進(jìn)行，輻射少，可快速獲得結(jié)果。局限性包括對(duì)病理變化(尤其是出血)的敏感性和特異性不夠，可能導(dǎo)致成推薦意見(jiàn)2:在以下情況下優(yōu)先行HCT檢查：①患者體征和癥狀均明顯表現(xiàn)檢查難以獲得[12](Level3b,GradeB)。5.術(shù)中處理6.2神經(jīng)監(jiān)測(cè)6.3抗血栓治療7.術(shù)后遠(yuǎn)期預(yù)后7.2心理社會(huì)功能冠狀動(dòng)脈旁路移植術(shù)(coronaryarterybypass高于經(jīng)皮冠狀動(dòng)脈介入手術(shù)(PCI,包括藥物洗脫支架)的0.3%,而1年后卒中發(fā)2.2頸動(dòng)脈狹窄2.3心房顫動(dòng)(房顫)2.4體外循環(huán)2.5術(shù)中低灌注3.術(shù)前評(píng)估3.1主動(dòng)脈評(píng)估3.2頸動(dòng)脈評(píng)估推薦意見(jiàn)2:近期(<6個(gè)月)有卒中/TIA病史的患者行頸動(dòng)脈多普勒超聲(L推薦意見(jiàn)3:近期(<6個(gè)月)無(wú)TIA/卒中病史的患者，有以下情況可考慮行3.3腦血管評(píng)估/或基底動(dòng)脈狹窄，或頭部CT顯示陳舊梗死病灶>1.5cm的患者，進(jìn)一步行頭4.術(shù)中處理4.2近端吻合策略4.3術(shù)中血壓管理4.4聯(lián)合頸動(dòng)脈血運(yùn)重建策略推薦意見(jiàn)4:近期(<6個(gè)月)有TIA/卒中病史的患者，頸動(dòng)脈50%~99%狹窄4.5左心耳的處理策略b,GradeB)推薦意見(jiàn)7:CABG術(shù)后6h內(nèi)開(kāi)始服用阿司匹林(100~32至少2天；術(shù)后應(yīng)用低分子肝素(100U/kg)抗凝3天，1次/12h(q12h);術(shù)后盡早恢復(fù)阿司匹林(100mg/天)十氯吡格雷(75mg/天)3個(gè)月以上，之后終身服用阿ABG,術(shù)前>1天停用),術(shù)后應(yīng)用低分子肝素(100U/kg)抗凝3天(q12h),盡早恢復(fù)阿司匹林(100mg/天)十氯吡格雷(75mg/天)3個(gè)月以上，之后終身服用阿司5.3圍手術(shù)期房顫的藥物治療策略5.4抗炎性神經(jīng)保護(hù)藥物糖皮質(zhì)激素類(lèi)(地塞米松)、烏司他丁(胰蛋白酶抑制劑)、氯胺酮(N-甲基-D5.5非抗炎性神經(jīng)保護(hù)藥物6.2腦功能監(jiān)測(cè)FAST癥狀表現(xiàn)包括一側(cè)肢體(伴或不伴面部)無(wú)力或麻木，一側(cè)面部麻木或口反射消失)。水腫可以使用甘露醇125~250ml,q8~6h,聯(lián)合高張鹽水(根據(jù)心劑量>5mg·kg1·h1時(shí)推薦意見(jiàn)10:發(fā)病24h內(nèi)的急性前、后循環(huán)大血管閉塞患者，經(jīng)臨床及影胞輸注、過(guò)度的血液稀釋、心房顫動(dòng)等均可能造成術(shù)后腦損傷。神經(jīng)炎癥(尤其是中樞神經(jīng)系統(tǒng)的炎癥反應(yīng))與術(shù)后認(rèn)知功能障礙顯著相關(guān)[56]。脊髓損傷的發(fā)GradeB)。1℃~28.0℃)、淺低溫(>28.0℃)[63],當(dāng)前中低溫停循環(huán)的安全性和有效性已低溫下腋動(dòng)脈+左頸總動(dòng)脈插管行雙側(cè)順行腦灌注，該兩種方式均在臨床中普遍5.術(shù)后管理善顱腦影像學(xué)檢查，明確診斷，并邀請(qǐng)神經(jīng)內(nèi)科或神經(jīng)外科專(zhuān)家行多學(xué)科診療。應(yīng)盡早行腦脊液穿刺，并將腦脊液壓力控制在10mmHg以下，同時(shí)給予大劑量激推薦意見(jiàn)9:主動(dòng)脈術(shù)后的患者常規(guī)應(yīng)用甘露醇脫水，并應(yīng)用營(yíng)養(yǎng)神經(jīng)的藥物(Level5,GradeD)。推薦意見(jiàn)10:明確發(fā)生術(shù)后截癱的患者，應(yīng)盡早行腦脊液穿刺并將腦脊液循環(huán)灌注壓(Level2b,Gra心臟瓣膜病是因單個(gè)或多個(gè)心臟瓣膜(主動(dòng)脈瓣、二尖瓣、三尖瓣、肺動(dòng)脈瓣)發(fā)生關(guān)閉不全或者狹窄，引起的心臟功能性異常和有心臟瓣膜病患者約2500萬(wàn)例，給社會(huì)帶來(lái)了巨大的疾病和經(jīng)濟(jì)負(fù)擔(dān)[72]。手全引起的解剖和生理變化(包括心房或心室增大、心內(nèi)血栓和心律失常等)導(dǎo)致栓塞，另一方面過(guò)度抗凝也可能導(dǎo)致極其危險(xiǎn)的出血性疾病(如出血性卒中)發(fā)中的危險(xiǎn)因素。缺血性卒中病史可能提示患者有腦血管病變或頸動(dòng)脈狹窄，22.推薦意見(jiàn)1:瓣膜手術(shù)前應(yīng)對(duì)嚴(yán)重頸動(dòng)脈疾病患者進(jìn)行多學(xué)科評(píng)估，對(duì)高風(fēng)4.術(shù)中保護(hù)5.術(shù)后管理5~2.5)治療，或給予阿司匹林(100mg/天)治療3~6個(gè)月(Level2,Gradg,1次/天)抗血小板治療(Level1,GradeA)。對(duì)于高栓塞風(fēng)險(xiǎn)的患者，可以考慮阿司匹林(100mg,1次/天)聯(lián)合氯吡格雷(75mg,1次/天)治療3~6個(gè)月，之后改為阿司匹林(100mg,1次/天)單藥治療，終身服用(Level2a狀動(dòng)脈綜合征(CCS)的患者]或12個(gè)月[急性冠狀動(dòng)脈綜合征(ACS)的患者],S患者)或3~6個(gè)月(ACS患者)(Level2a,GradeC)。薦氯吡格雷75mg,1次/天)6個(gè)月(CCS患者)或12個(gè)月(ACS患者)。出血風(fēng)CS患者)(Level2a,GradeC)。效),迅速逆轉(zhuǎn)VKA;也可使用血漿制品 (口服在24h內(nèi)，靜脈用通常在4~6h內(nèi)),但一旦給藥，其對(duì)VKA的逆轉(zhuǎn)作用持續(xù)時(shí)間更長(zhǎng)(維生素K為數(shù)日，而PCC或血漿為6~8h)。推薦意見(jiàn)2:對(duì)應(yīng)用Sentinel系統(tǒng)小板/抗凝治療(Level3a,GradeC)。推薦意見(jiàn)3:建議在應(yīng)用Sentinel系統(tǒng)之前，評(píng)估推薦意見(jiàn)5:不建議使用Sentinel系統(tǒng)為患者輸送任何類(lèi)型的液體，推薦意見(jiàn)6:不建議將Sentinel系統(tǒng)過(guò)濾器置于既往進(jìn)行過(guò)手術(shù)或用于透推薦意見(jiàn)7:Sentinel系統(tǒng)的停留時(shí)間2.正在研發(fā)的腦保護(hù)裝置者中，采用1:1隨機(jī)對(duì)照試驗(yàn)方法，比較Emboliner與Sentinel圍手術(shù)期32.4FLOWer系統(tǒng)水平被捕獲(腦保護(hù)),84%的顆粒在主動(dòng)脈弓遠(yuǎn)端被捕獲到下游循環(huán)(全身保護(hù))[97]。2016年進(jìn)行的一項(xiàng)薈萃分析顯示，腦保護(hù)裝置的效果與瓣膜類(lèi)型無(wú)關(guān)，術(shù)中腦推薦意見(jiàn)8:應(yīng)用腦保護(hù)裝置的患者，在出院前及出院后30天應(yīng)積極進(jìn)行MCABG圍手術(shù)期常發(fā)生神經(jīng)系統(tǒng)并發(fā)癥。停搏CABG等心臟手術(shù)需在體外循環(huán)推薦意見(jiàn)9:在冠狀動(dòng)脈旁路移植術(shù)中應(yīng)用動(dòng)態(tài)氣泡捕集器時(shí)，最好聯(lián)用氣[1]BaumgartnerH,DeBackerJ,BdelinesforthemanagementofadultHeartJ,2021,42(6):563-645.doi:10.1093/euatalconsiderationsforperioperativeneNeurol,2020,108:23-30.doi:10.1016/j.pediatrneurol.2020.01.002.-4):300-307.doi:10.101[4]GiangKW,FedchenkoM,DellborgM,etal.Burdenontrolstudy[J].JAmHea/jaha.120.020939.[5]SahaP,PotinyP,RigdonJ,etal.Substantialcardiovascrbidityinadults[7]KumarK.Neurologic[J].JAmHeartAssoc,2019,ccatheterizationinctrokeinchildrenwithcardiac[12]MedleyTL,MiteffCsensusguideline:thediagnosisandacute907patients[J].IntJCardiol,2021,322:114-120.doi:ease[J].SeminPediatrNeurol,2017,24(1):3-13.d[15]FallonP,AparícioJM,ElliottMJ,etal.IncidenceofneurologisChild,1995,72(5):418-422.doi:[16]StoutKK,DanielsCJ,Aneforthemanagementofadultswithcongenitalheartdisease:areportoftheamericancollegeofcardiology/americanheartasso4):e698-e800.doi:10.1161/ci[17]MasseySL,WeinermanB,Naim40(1):116-129.doi:10.1[18]BonthroneAF,StegemanR,FeldmannM,etaerioperativebrainlesionsininfantswithcongenitalaeuropeancollaboration[J].Stroke,2022,53(12):3652-3661.doi:10.[19]PulcineE,deVeberG.Neurolgenitalheartdisease[J].HandbClinNeurol,2021,177:1-13.doi:10.most,2021,19(10):2428-2439.doi:10.11[21]McDonaghDL,Bergeionsofcardiacsurgery[J].LancetNeurol,2014,13(5):490-502.d[22]PalmeriniT,Biondi-ZoccaiG,Deoi:10.1016/S0140-6736(12)60324-9.a-analysisofrandomizntingandcarotidendarterectomyinthetreatment[J].AnnVascSurg,2012,26(4):576-590.doi:10.1016/j.avsg.2011.09.[24]HillisLD,SmithPrtoftheamericancollegeofcardiologyfoundation/americ[25]LikoskyDS,LeavittBJ,Marrivepredictorsofstrokeaftercoronaryarterybypassgrafting[J]nThoracSurg,2003,76(2):428-434;10.1016/s0003-4975(03)00490-9.d[26]SaxenaA,DinhDT,SmithJA,etal.Usefulnessof9(2):219-225.doi:10[27]HogueCWJr,PalinANE.0000220035.82989.79.[28]HusebratenIM,Fianeeousmicroemboliintheprimebeforetheinitiationofcardiopulmonarybypass[J].Perfusion,2018,33(1):30-35.doi:10.1177/02676591172015,115(3):427-433.doi:10.1093/bja/aev256.[30]VedelAG,HolmgaardF,Raslow-targetbloodpressuremanagementduringcardiopulmonarybypasstopreventcerebralinjuryincardiacsurgerypatients:arandomizedcolandcost-effectiveassessmentofcarotidstenosisinta10300.[32]NeumannFJ,Sousa-UvaM,Ahlssonlinesonmyocardialrevaationwithasymptomaticcarotiddisease:anentswithcoronaryarterydisease[J].PresseMed,2009,3doi:10.1016/j.lpm.2009.02.015.y:areportoftheamericancollegeofcardiology/americanheciationjointcommitteeonclinicoutcomesfollowingstagedandsynchronouscarotidendarterectomyand 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