Department of Cardiac Surgery, Vienna Medical University, Vienna, Austria.
J Thorac Cardiovasc Surg. 2013 Sep;146(3):647-55.e1. doi: 10.1016/j.jtcvs.2012.07.072. Epub 2012 Aug 24.
The aim of the present study was to assess the efficacy and mid- to long-term results of different cerebral protection techniques in the treatment of acute type A aortic dissection.
Between April 1987 and January 2011, 329 patients (220 male patients; median age, 60 years; range, 16-87) with type A aortic dissection underwent replacement of the ascending aorta or aortic arch with an open distal anastomosis. Either hypothermic circulatory arrest alone at 18 °C (n = 116; 35%) or combined with retrograde cerebral perfusion (n = 122; 37%) or antegrade cerebral perfusion at 25 °C (n = 91; 28%) was used.
The median circulatory arrest time was 30 minutes (range, 12-92). The overall 30-day mortality was 19% (62 of 329). The 30-day mortality stratified by group was 26% (30 patients) in the hypothermic circulatory arrest group, 16% in the retrograde cerebral perfusion group (20 patients), and 13% (12 patients) in the antegrade cerebral perfusion group (P = .047). Permanent neurologic dysfunction occurred in 53 patients (16%), with statistically significant differences among the 3 groups (23% for hypothermic circulatory arrest, 12% for retrograde cerebral perfusion, and 12% for antegrade cerebral perfusion; P = .033). Univariate analysis showed a significant effect of the brain protection strategy on 30-day mortality and neurologic outcome. Multivariate analysis revealed preoperative hemodynamic instability, preoperative resuscitation, age, and operative year as independent predictors of 30-day mortality. Regarding permanent neurologic dysfunction, the multivariate analysis could not identify any independent predictors. Kaplan-Meier analyses revealed statistically significant differences among the 3 groups with a 1-, 3-, and 5-year survival rate of 84%, 79%, and 77% with antegrade cerebral perfusion, 75%, 72%, and 66% with retrograde cerebral perfusion, and 66%, 62%, and 60% with hypothermic circulatory arrest alone.
Patients in the antegrade cerebral perfusion group had the best short- and long-term survival rates. However, during the study period, several significant improvements in the treatment of patients with type A aortic dissection were achieved; therefore, independent predictors of mortality and permanent neurologic dysfunction were difficult to identify.
本研究旨在评估不同脑保护技术在急性 A 型主动脉夹层治疗中的疗效和中-长期结果。
1987 年 4 月至 2011 年 1 月，329 例（男 220 例；中位年龄 60 岁；范围 16-87 岁）急性 A 型主动脉夹层患者接受升主动脉或主动脉弓置换，采用单纯低温循环停止 18°C（n = 116；35%）或与逆行性脑灌注（n = 122；37%）或顺行性脑灌注（n = 91；28%）联合治疗。
中位体外循环时间为 30 分钟（范围 12-92）。总体 30 天死亡率为 19%（329 例中 62 例）。按组分层的 30 天死亡率分别为低温循环停止组 26%（30 例）、逆行性脑灌注组 16%（20 例）和顺行性脑灌注组 13%（12 例）（P =.047）。永久性神经功能障碍发生在 53 例患者（16%），3 组间差异有统计学意义（低温循环停止组 23%，逆行性脑灌注组 12%，顺行性脑灌注组 12%；P =.033）。单因素分析显示，脑保护策略对 30 天死亡率和神经功能结果有显著影响。多因素分析显示，术前血流动力学不稳定、术前复苏、年龄和手术年份是 30 天死亡率的独立预测因素。关于永久性神经功能障碍，多因素分析未能确定任何独立的预测因素。Kaplan-Meier 分析显示 3 组间有统计学差异，顺行性脑灌注组 1、3、5 年生存率分别为 84%、79%和 77%，逆行性脑灌注组分别为 75%、72%和 66%，低温循环停止组分别为 66%、62%和 60%。
顺行性脑灌注组患者的短期和长期生存率最佳。然而，在研究期间，急性 A 型主动脉夹层患者的治疗取得了多项显著进展，因此，死亡率和永久性神经功能障碍的独立预测因素难以确定。
