Department of Cardiovascular Surgery, University Hospital Bern, Bern, Switzerland.
Collaborative Research (CORE) Group, Macquarie University, Sydney, NSW, Australia.
Eur J Cardiothorac Surg. 2018 Dec 1;54(6):1045-1051. doi: 10.1093/ejcts/ezy194.
Our objective was to evaluate the impact of reimplantation techniques of the supra-aortic branches in total arch replacement on the rates of permanent neurological deficit (PND) and survival.
We identified patients enrolled in the ARCH registry who underwent total arch replacement between 2000 and 2015 with either en bloc or separate reimplantation of the supra-aortic branches.
A total of 3345 patients were included in the present analysis. From this cohort, 686 patients underwent en bloc and 2659 patients had separate reimplantation of the supra-aortic branches. Propensity score analysis identified 461 matched patient pairs. In the matched cohort, there were no differences regarding the mortality rate (15.6% vs 15.7%, P = 0.710) or PND (9.2% vs 12.1%, P = 0.231). Although separate reimplantation of the supra-aortic branches was not associated with an increased mortality rate on multivariable logistic regression, it increased the risk of PND [odds ratio (OR) 1.56, 95% confidence interval (CI) 1.06-2.29; P = 0.023]. Propensity-adjusted regression confirmed these findings and found a similar risk for PND with separate reimplantation of the supra-aortic branches (OR 1.50, 95% CI 1.01-2.23; P = 0.047), although this significance was not found with conditional logistic regression (P = 0.20). No significant differences between survival were seen between the 2 matched cohorts (stratified log rank P = 0.35).
Separate reimplantation of the supra-aortic branches in total arch replacement is a significant predictor of stroke in the overall group, although comparable stroke rates were observed in the matched cohort. The current trend towards separate reimplantation of supra-aortic branches may expose certain subgroups of patients to an increased risk of stroke, e.g. those with a high atherosclerotic burden.
我们旨在评估全主动脉弓置换术中对升主动脉分支再植入技术对永久性神经功能缺损（PND）和生存率的影响。
我们在 ARCH 注册中心中确定了 2000 年至 2015 年间接受全主动脉弓置换术且升主动脉分支采用整块或单独再植入的患者。
共有 3345 例患者纳入本分析。在此队列中，686 例患者接受整块再植入，2659 例患者接受升主动脉分支单独再植入。倾向评分分析确定了 461 对匹配患者。在匹配队列中，死亡率（15.6%比 15.7%，P=0.710）或 PND（9.2%比 12.1%，P=0.231）无差异。虽然多变量逻辑回归分析显示升主动脉分支单独再植入与死亡率增加无关，但它增加了 PND 的风险[比值比（OR）1.56，95%置信区间（CI）1.06-2.29；P=0.023]。倾向评分调整的回归证实了这些发现，并发现升主动脉分支单独再植入的 PND 风险相似（OR 1.50，95%CI 1.01-2.23；P=0.047），尽管条件逻辑回归未发现这种显著性（P=0.20）。两个匹配队列之间的生存率无显著差异（分层对数秩 P=0.35）。
全主动脉弓置换术中升主动脉分支单独再植入是总体卒中的一个显著预测因子，尽管在匹配队列中观察到相似的卒中率。目前，升主动脉分支单独再植入的趋势可能会使某些亚组患者面临更高的卒中风险，例如那些有高动脉粥样硬化负担的患者。
