Stern A, Tunick P A, Culliford A T, Lachmann J, Baumann F G, Kanchuger M S, Marschall K, Shah A, Grossi E, Kronzon I
Department of Medicine, NYU School of Medicine, New York, 10016, USA.
Am Heart J. 1999 Oct;138(4 Pt 1):746-52. doi: 10.1016/s0002-8703(99)70191-2.
Stroke occurs in 1% to 7% of heart surgery. Aortic arch atherosclerosis is a risk factor for intraoperative stroke, and endarterectomy has been proposed to prevent stroke during heart surgery in patients with arch atheromas.
Intraoperative transesophageal echocardiography was performed in 3404 patients undergoing heart surgery between 1990 and 1996. Use of transesophageal echocardiography was unselected and based on equipment availability. Aortic arch atheromas (>/=5 mm, or mobile) were seen in 268 (8%) patients. They were evaluated for intraoperative stroke (confirmed by a neurologist and cerebral infarction on computed tomography or magnetic resonance imaging). Arch endarterectomy was performed in 43 patients as an adjunct to their cardiac procedure in an attempt to prevent intraoperative stroke. The intraoperative stroke rate in all 268 patients with atheromas was high (15.3%). On univariate analysis, age, previous stroke, and arch endarterectomy were significantly associated with intraoperative stroke. On multivariate analysis, age (odds ratio 3.9, P =.01) and arch endarterectomy (odds ratio 3.6, P =.001) were independently predictive of intraoperative stroke. Mortality rate in all 268 patients was high (14.9%). These patients with atheromas also had a long recovery room, intensive care unit, and total hospital length of stay (48 days).
Patients with protruding aortic arch atheromas are at high risk for intraoperative stroke, significant and multiple morbidity, prolonged hospital stay, and death resulting from heart surgery. Aortic arch endarterectomy is strongly associated with intraoperative stroke; its use should be carefully considered in light of these results.
心脏手术中中风发生率为1%至7%。主动脉弓动脉粥样硬化是术中中风的一个危险因素，对于有主动脉弓粥样斑块的患者，有人提出行内膜切除术以预防心脏手术期间的中风。
1990年至1996年间，对3404例接受心脏手术的患者进行了术中经食管超声心动图检查。经食管超声心动图的使用未作选择，仅根据设备可用性。在268例（8%）患者中发现了主动脉弓粥样斑块（≥5mm或有活动）。对这些患者评估术中中风情况（由神经科医生确诊，计算机断层扫描或磁共振成像显示有脑梗死）。43例患者在心脏手术过程中加行了主动脉弓内膜切除术，试图预防术中中风。所有268例有粥样斑块的患者术中中风发生率较高（15.3%）。单因素分析显示，年龄、既往中风史和主动脉弓内膜切除术与术中中风显著相关。多因素分析显示，年龄（比值比3.9，P = 0.01）和主动脉弓内膜切除术（比值比3.6，P = 0.001）是术中中风的独立预测因素。所有268例患者的死亡率较高（14.9%）。这些有粥样斑块的患者在恢复室、重症监护病房的停留时间以及总住院时间也较长（48天）。
有突出的主动脉弓粥样斑块的患者在心脏手术中发生术中中风、严重和多种并发症、住院时间延长以及死亡的风险很高。主动脉弓内膜切除术与术中中风密切相关；鉴于这些结果，应谨慎考虑使用该手术。
