使用分支型主动脉弓移植物并选择性顺行性脑灌注进行全主动脉弓置换术后的死亡率和发病率。

Mortality and morbidity after total arch replacement using a branched arch graft with selective antegrade cerebral perfusion.

作者信息

Ueda Toshihiko, Shimizu Hideyuki, Hashizume Kenichi, Koizumi Kiyoshi, Mori Mitsuharu, Shin Hankei, Yozu Ryohei

机构信息

Section of Cardiovascular Surgery, School of Medicine, Keio University, Tokyo, Japan.

出版信息

Ann Thorac Surg. 2003 Dec;76(6):1951-6. doi: 10.1016/s0003-4975(03)01136-6.

DOI:10.1016/s0003-4975(03)01136-6

PMID:14667620

Abstract

BACKGROUND

The early outcome after aortic arch surgery has improved. However, some operative survivors have died as a result of postoperative problems soon after discharge. This study determines the factors affecting mortality within 1 year of total arch replacement.

METHODS

Between July 1993 and November 2001, 103 patients (mean age 65 +/- 11 years, 26 women, 35 dissections) underwent total arch replacement through a median sternotomy using a branched arch graft with selective cerebral perfusion. Eighteen operations including 14 acute dissections were performed on an emergency basis. Concomitant procedures were root replacement in 5 patients, mitral valve replacement in 1, coronary artery bypass in 14, and open endovascular stent-graft in 9. The average time (minutes) for bypass, aortic cross-clamp, selective cerebral perfusion, and distal arrest were respectively 273 +/- 79, 163 +/- 54, 145 +/- 36, and 69 +/- 22.

RESULTS

Mechanical heart support was necessary in 3 patients. Stroke occurred in 9 patients, transient neurologic dysfunction in 7, and paraplegia/paraparesis in 4. The only independent determinant for postoperative stroke was a history of stroke (odds ratio 16.3, 95% confidence interval: 2.8 to 93.8). Thirty-one patients required ventilator support for more than 5 days. Hemodialysis was needed in 5 patients. Sternal infection or mediastinitis occurred in 6 patients. The in-hospital mortality was 12% (12 of 103). The actuarial survival rate at 1 year was 83%, and was 67% at 5 years. For the 1-year mortality independent determinants were emergency surgery (odds ratio 5.3, 95% confidence interval: 1.6 to 17.9) and age 75 years or older (odds ratio 4.0, 95% confidence interval: 1.1 to 13.9).

CONCLUSIONS

Total arch replacement using a branched arch graft with selective antegrade cerebral perfusion has a favorable 1-year mortality rate except for patients undergoing emergency surgery and for elderly patients.

摘要

背景

主动脉弓手术的早期预后已有所改善。然而，一些手术幸存者在出院后不久因术后问题死亡。本研究确定了影响全弓置换术后1年内死亡率的因素。

方法

1993年7月至2001年11月期间，103例患者（平均年龄65±11岁，26例女性，35例夹层）通过正中胸骨切开术，使用带分支的弓部移植物并采用选择性脑灌注进行全弓置换。其中18例手术（包括14例急性夹层）为急诊手术。同期手术包括5例根部置换、1例二尖瓣置换、14例冠状动脉搭桥和9例开放式血管内支架植入。体外循环、主动脉阻断、选择性脑灌注和远端阻断的平均时间（分钟）分别为273±79、163±54、145±36和69±22。

结果

3例患者需要机械心脏支持。9例发生卒中，7例出现短暂性神经功能障碍，4例出现截瘫/轻瘫。术后卒中的唯一独立决定因素是卒中病史（比值比16.3，95%置信区间：2.8至93.8）。31例患者需要呼吸机支持超过五天。5例患者需要血液透析。6例患者发生胸骨感染或纵隔炎。住院死亡率为12%（103例中的12例）。1年的精算生存率为83%，5年时为67%。1年死亡率的独立决定因素为急诊手术（比值比5.3，95%置信区间：1.6至17.9）和年龄75岁及以上（比值比4.0，95%置信区间：1.1至13.9）。