心脏搭桥术后认知障碍

“泵头”是真的吗?这是什么意思?

绕道手术
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For many years,in the surgeon's locker room (which actually has much in common with other kinds of locker rooms),cardiac surgeons would mention to each other a phenomenon they often referred to as "pump head." Pump head was a term used to describe an impairment in mental capacity they sometimes noticed in their patients following冠状动脉搭桥手术.It got this name because the presumption was that cognitive impairment after bypass surgery was related to the use of the体外循环泵during the procedure.

很长一段时间,谈论这一现象,永远不会超出更衣室。

In 2001,杜克大学的一项研究似乎证实了许多医生长期以来的怀疑,但一直不愿公开讨论。Namely,冠状动脉搭桥手术后,有相当一部分人随后会经历可测量的(但通常是暂时的)精神能力损伤。这项研究在发表于新英格兰医学杂志,and caused a lot of concern among both doctors and their prospective patients.But the worry quickly faded away,从那以后,公众对它的了解就很少了。

然而,在随后的几年里,人们对旁路手术后的精神变化有了更多的了解。一方面,这种现象是真实的。另一方面,可能与旁路泵的使用无关,更确切地说,is more likely related to the manipulation of the large blood vessels that is necessary during this type of surgery.

尽管外科医生们仍然不愿意公开谈论这件事,搭桥术后认知障碍很常见,因此接受此项手术的人及其亲人应事先意识到这一点,因此,他们准备应对这种情况。

What Is Meant by Cognitive Impairment?

Simply speaking,"认知障碍" is the terminology doctors use for a range of general neurological deficits that can be seen after bypass surgery.

这些可能包括以下任何或全部内容:注意力广度差,记忆力差,决策失误,inability to concentrate,移动速度降低,以及思维能力的普遍缺陷。更严重的症状,如明显的谵妄can also be seen rarely.这些症状会在手术后立即出现,在严重程度上,从丧失能力到几乎看不见(在这种情况下,复杂神经认知研究are required to detect them).

Cognitive deficits most commonly resolve gradually,几个星期或几个月后,但在某些情况下,它们可以持续数年。

问题有多普遍?

除了第一次真正研究这种现象外,the 2001 Duke study also made it clear that cognitive impairment can be surprisingly frequent,而且相当持久。在这项研究中,261名接受搭桥手术的人(平均61岁)被正式测试以测量他们的认知能力(即mental ability) at four different times: before surgery,六周后,六个月后,在旁路手术后五年。Participants were deemed to have significant impairment if they had a 20% decrease in test scores.The investigators found that 42% of patients had at least a 20% drop in test scores after surgery,and that in many cases the decrease in cognitive capacity persisted for 5 years.

对于任何照顾这些人的人来说,旁路手术后发生认知障碍的发现并不令人惊讶。令人惊讶的是,杜克大学的研究中这个问题的高发率,以及它的持久性。本研究因此,在医生和公众中引起了很大的恐慌。

The Duke study has been appropriately criticized because it did not have a randomized control group.Instead,investigators compared their results with results from a similar study among patients with冠状动脉疾病同龄人没有做过搭桥手术。They found that those who received bypass surgery had a higher incidence of cognitive impairment than people with CAD who did not have surgery.然而,because people who get bypass surgery often have more severe CAD,这些人口没有直接的可比性。

Still,一项真正的随机研究non-surgery decision made randomly) would be infeasible (if not unethical).为了更明确地描述问题的频率,在这几年中,对这一现象进行了其他几项研究,using various neurocognitve testing procedures,different types of bypass surgery procedures,以及不同的随访时间间隔。

虽然这些研究的结果非常多变(认知障碍的发生率在3%到79%之间)。there is really no question any more about whether the phenomenon is real or not.It is.Furthermore,认知障碍是心脏外科手术的特殊风险,因为其他类型的血管手术没有同样的发病率,比如手术周围血管疾病.

旁路手术后什么引起认知障碍?

The exact cause of cognitive impairment following bypass surgery is unknown.可能有几个因素可以实现这一目标。

最初,它被认为是由于使用心肺转流泵引起的大脑小血块引起的。然而,最近的研究表明,采用更现代的方法,"off pump" bypass surgeryhas not reduced the incidence of cognitive impairment.

今天最有吸引力的理论是,操纵心脏和主动脉可以产生微小的血块,叫微栓子,that can travel to the brain and cause damage there.术中研究使用经颅多普勒技术已经证实,在搭桥手术中,脑部微栓子的阵雨是常见的。以及使用术前和术后的其他研究核磁共振扫描have shown tiny ischemic lesions (small strokes) in the brains of people who experience cognitive decline.然而,even these studies have yielded mixed results,and the causative role of microemboli is not yet proven.

其他潜在原因,比如血压下降,热疗(体温过高)and a prolonged reduction of oxygen levels in the blood,所有这些都可能发生在心脏手术期间或术后立即,may also play a role.

我们所知道的是,那些具有广泛性血管疾病的重要危险因素的人更有可能经历认知障碍。These risk factors includedisease of the carotid arteries,高龄,hypertension,以及过去的历史.

有认知障碍的人怎么办?

大多数旁路手术后有一定程度认知障碍的人完全康复,3-12个月内恢复术前精神功能状态。只有轻微损伤的人,and who have higher levels of education and daily activity seem to recover more completely than other people.

不幸的是,有相当一部分人从未完全恢复到手术前的状态。

预防认知障碍

对这个问题的更广泛的认识促使外科医生和麻醉师设计技术来帮助预防旁路手术后的认知障碍。These techniques include the use of membrane oxygenators,动脉线过滤器,minimizing the manipulation of the aorta,减少使用心脏或动脉吸入,仔细控制病人的体温。这些技术中的大多数被认为对大脑提供了相当程度的保护。

A Word From 必威下载Verywell

When making major decisions about your medical care,你要确保你的医生考虑到了所有潜在的风险和利益,即使是那些令人不愉快的事情,such as the risk of cognitive impairment.

如果你的医生建议冠状动脉搭桥手术,您应该确保对以下问题有答案:

  • 手术会延长你的生存时间吗?或者只是为了减轻症状而做的选择?
  • 还有其他可行的替代方案吗?如药物治疗,或A支架?
  • 这些替代方案的相对风险和好处是什么?
  • 如果你做了手术并且有认知症状,你的医生有什么资源来对付他们,to help you recover,and to help you and your loved ones to cope until your symptoms improve?

如果建议进行手术而不认为是紧急情况,this is one decision for which you might strongly considergetting a second opinion.

If you do decide to have bypass surgery,请记住,大多数研究中的大多数人在日常生活中都注意到了这一点,他们的精神能力没有退化,在大多数人中,他们的认知障碍最终解决了。

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