Department of Cardiovascular Surgery, The Icahn School of Medicine at Mount Sinai, New York, New York.
Department of Cardiovascular Surgery, The Icahn School of Medicine at Mount Sinai, New York, New York; Division of Cardiothoracic Surgery, The State University of New York, Stony Brook, New York.
Ann Thorac Surg. 2020 Feb;109(2):428-435. doi: 10.1016/j.athoracsur.2019.08.043. Epub 2019 Sep 26.
Limited data inform cerebral protection during circulatory arrest. This study was designed to identify optimal approaches from a national clinical registry.
A total of 7830 adults (mean age, 63.1 years, SD 13.1 years) who underwent hemiarch (n = 6891; 88.0%) or total arch (n = 939; 12.0%) replacement with hypothermic circulatory arrest between 2014 and 2016 were identified from The Society of Thoracic Surgeons Adult Cardiac Surgery Database (version 2.81). Aortic dissections were excluded from the analysis. Multivariable logistic regression was used to adjust for 29 baseline and operative variables, including demographics, comorbidity, surgery, and nadir temperature, comparing outcomes according to protection strategy. The primary end point was a composite of 30-day and in-hospital mortality or major permanent neurologic complications.
The rate of death or permanent neurologic complication was 10.9% (n = 850). Antegrade cerebral perfusion was most commonly used (n = 3369; 43%; median nadir temperature 23°C; median arrest time 30 minutes) compared with retrograde cerebral perfusion (n = 1898; 24%; 20°C; 24 minutes) and no cerebral perfusion (n = 2563; 33%; 20°C, 22 minutes). In multivariable analysis, deep hypothermia with antegrade (odds ratio [OR], 0.65; 95% confidence interval [CI], 0.52 to 0.81) or retrograde (OR, 0.57; 95% CI, 0.45 to 0.71) perfusion and moderate hypothermia with antegrade perfusion (OR, 0.61; 95% CI, 0.46 to 0.79) were associated with significant reductions in death and stroke compared with deep hypothermia without cerebral perfusion. Risk reduction was greatest in circulatory arrest lasting longer than 30 minutes.
For patients without aortic dissection and who require more than 30 minutes of circulatory arrest, optimal cerebral protection strategies are deep hypothermia with either antegrade or retrograde cerebral perfusion and moderate hypothermia with antegrade cerebral perfusion.
低温体外循环停循环期间脑保护的数据有限。本研究旨在从国家临床注册数据库中确定最佳方法。
从胸外科医师学会成人心脏手术数据库（版本 2.81）中确定了 2014 年至 2016 年间接受低温体外循环下半弓（n=6891；88.0%）或全弓（n=939；12.0%）置换的 7830 例成人（平均年龄 63.1 岁，标准差 13.1 岁）。排除主动脉夹层的分析。采用多变量逻辑回归法调整 29 个基线和手术变量，包括人口统计学、合并症、手术和最低温度，根据保护策略比较结果。主要终点是 30 天和住院死亡率或主要永久性神经并发症的复合终点。
死亡率或永久性神经并发症发生率为 10.9%（n=850）。与逆行脑灌注（n=1898；24%；20°C；24 分钟）和无脑灌注（n=2563；33%；20°C，22 分钟）相比，顺行脑灌注（n=3369；43%；最低温度中位数 23°C；中位数停循环时间 30 分钟）更为常用。多变量分析显示，深低温伴顺行（比值比[OR]，0.65；95%置信区间[CI]，0.52 至 0.81）或逆行（OR，0.57；95%CI，0.45 至 0.71）灌注以及中低温伴顺行灌注（OR，0.61；95%CI，0.46 至 0.79）与深低温无脑灌注相比，死亡和卒中风险显著降低。停循环时间超过 30 分钟时，风险降低最大。
对于无主动脉夹层且需要超过 30 分钟体外循环的患者，最佳脑保护策略是深低温伴顺行或逆行脑灌注以及中低温伴顺行脑灌注。
