Cefarelli Mariano, Murana Giacomo, Surace Giuseppina G, Castrovinci Sebastiano, Jafrancesco Giuliano, Kelder Johannes Christiaan, Klein Patrick, Sonker Uday, Morshuis Wim J, Heijmen Robin H
Department of Cardiothoracic Surgery, St. Antonius Hospital, Nieuwegein, the Netherlands.
Department of Cardiothoracic Surgery, St. Antonius Hospital, Nieuwegein, the Netherlands.
Ann Thorac Surg. 2017 Dec;104(6):2016-2023. doi: 10.1016/j.athoracsur.2017.05.009. Epub 2017 Jul 29.
The aim of this study was to determine perioperative factors influencing neurologic outcome in a single-center cohort of patients undergoing elective aortic arch operations.
From January 2005 to June 2015, 791 consecutive patients received open aortic arch operations with either antegrade selective cerebral perfusion (ASCP) (636 patients [80.4%]) or deep hypothermic circulatory arrest (DHCA) (155 patients [19.6%]). Main indications were degenerative aneurysm (85%) and chronic postdissection aneurysm (9.1%).
Hospital mortality (30 days) was 5.3%. Permanent neurologic dysfunction (PND) was observed in 42 patients (5.3%). Significant risk factors for PND appeared to be femoral artery cannulation (p = 0.003), progressive cardiopulmonary bypass (p = 0.001), circulatory arrest (p = 0.001), and ASCP time (p = 0.011). ASCP, in contrast to DHCA, was protective against PND (odds ratio [OR], 0.37; p = 0.003). Temporary neurologic dysfunction (TND) was observed in 49 patients (6.2%). Preoperative transient ischemic attack (TIA) (p = 0.001), progressive EuroSCORE (p = 0.001), left ventricular ejection fraction (LVEF) less than 50% (p = 0.003), and the use of femoral artery cannulation (p = 0.049) showed correlation in the univariate analysis. Stepwise logistic regression indicated TIA (p = 0.002; OR, 3.24) and the EuroSCORE (p = 0.003; OR, 1.23) as independent predictors of TND.
Contemporary elective aortic arch repair can be achieved with low mortality and a low incidence of neurologic dysfunction. ASCP was confirmed to be the safest method of cerebral protection. The extent of aortic arch replacement (apart from the frozen elephant trunk [FET] procedure) was not related to increased rates of TND or PND.
本研究旨在确定影响择期主动脉弓手术单中心队列患者围手术期神经学转归的因素。
2005年1月至2015年6月，791例连续患者接受了开放性主动脉弓手术，采用顺行选择性脑灌注（ASCP）（636例患者[80.4%]）或深低温停循环（DHCA）（155例患者[19.6%]）。主要适应证为退行性动脉瘤（85%）和慢性夹层后动脉瘤（9.1%）。
医院死亡率（30天）为5.3%。42例患者（5.3%）出现永久性神经功能障碍（PND）。PND的显著危险因素似乎是股动脉插管（p = 0.003）、体外循环进展（p = 0.001）、停循环（p = 0.001）和ASCP时间（p = 0.011）。与DHCA相比，ASCP对PND有保护作用（比值比[OR]，0.37；p = 0.003）。49例患者（6.2%）出现短暂性神经功能障碍（TND）。术前短暂性脑缺血发作（TIA）（p = 0.001）、欧洲心脏手术风险评估系统（EuroSCORE）进展（p = 0.001）、左心室射血分数（LVEF）低于50%（p = 0.003）以及股动脉插管的使用（p = 0.049）在单因素分析中显示出相关性。逐步逻辑回归表明TIA（p = 0.002；OR，3.24）和EuroSCORE（p = 0.003；OR，1.23）是TND的独立预测因素。
当代择期主动脉弓修复术可实现低死亡率和低神经功能障碍发生率。ASCP被证实是最安全的脑保护方法。主动脉弓置换范围（除了“象鼻”技术[FET]）与TND或PND发生率增加无关。
