Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany.
Eur J Cardiothorac Surg. 2019 Nov 1;56(5):1001-1008. doi: 10.1093/ejcts/ezz091.
We retrospectively evaluated the outcome after elective aortic arch surgery with circulatory arrest to determine the impact of different brain protection strategies on neurological outcome and early and late survival.
A total of 925 patients were included. The patients were assigned to 2 groups based on the type of cerebral protection strategy used during circulatory arrest [hypothermic circulatory arrest (HCA) n = 224; antegrade selective cerebral perfusion (ASCP) n = 701]. The propensity score matching (1:1; 210 vs 210 patients) approach was used to minimize selection bias and to obtain comparable groups.
The overall in-hospital mortality and permanent focal neurological deficit rates were 5.6% (n = 52) and 5.4% (n = 50) and were significantly lower in patients who received ASCP (4.4% and 3.4%, respectively) as compared to those who underwent HCA (9.4% and 11.6%, respectively) (P = 0.005 and P < 0.001). The propensity-matched analysis showed significantly lower rates of in-hospital mortality [3.8% vs 9.5% (HCA)] and permanent focal neurological deficit in ASCP group [2.9% vs 11.9% (HCA)]. Multivariable logistic regression analysis revealed left ventricular ejection fraction <30%, age >70 years, coronary artery disease, circulatory arrest time >40 min and mitral valve disease as independent predictors of in-hospital mortality. The use of ASCP was protective for early survival. Cox regression analysis revealed that long-term mortality was independently predicted by age, left ventricular ejection fraction <30%, total arch replacement, prior cardiac surgery, PVD, chronic obstructive pulmonary disease and previous stroke, whereas ASCP was protective for late survival.
Elective aortic arch surgery is associated with acceptable early and late outcomes. The ASCP is associated with a significant reduction in-hospital mortality and occurrence of permanent neurological deficits.
我们回顾性评估了选择性主动脉弓手术中使用体外循环循环停止的结果，以确定不同脑保护策略对神经功能结果以及早期和晚期存活率的影响。
共纳入 925 例患者。根据体外循环期间使用的脑保护策略类型将患者分为 2 组[低温体外循环（HCA）n=224；顺行选择性脑灌注（ASCP）n=701]。使用倾向评分匹配（1:1；210 例与 210 例）方法来最小化选择偏差并获得可比的组。
总的院内死亡率和永久性局灶性神经功能缺损率分别为 5.6%（n=52）和 5.4%（n=50），接受 ASCP 的患者明显低于接受 HCA 的患者（分别为 4.4%和 3.4%）（P=0.005 和 P<0.001）。倾向评分匹配分析显示，ASCP 组的院内死亡率[3.8%比 9.5%（HCA）]和永久性局灶性神经功能缺损率[2.9%比 11.9%（HCA）]显著降低。多变量逻辑回归分析显示，左心室射血分数<30%、年龄>70 岁、冠状动脉疾病、体外循环时间>40 分钟和二尖瓣疾病是院内死亡的独立预测因素。ASCP 的使用对早期生存是保护性的。Cox 回归分析显示，年龄、左心室射血分数<30%、全主动脉弓置换、先前心脏手术、周围血管疾病、慢性阻塞性肺疾病和既往卒中是长期死亡率的独立预测因素，而 ASCP 对晚期生存是保护性的。
择期主动脉弓手术具有可接受的早期和晚期结果。ASCP 可显著降低院内死亡率和永久性神经功能缺损的发生。
