Hage Ali, Stevens Louis-Mathieu, Ouzounian Maral, Chung Jennifer, El-Hamamsy Ismail, Chauvette Vincent, Dagenais Francois, Cartier Andreanne, Peterson Mark D, Boodhwani Munir, Guo Ming, Bozinovski John, Moon Michael C, White Abigail, Kumar Kanwal, Lodewyks Carly, Bittira Bindu, Payne Darrin, Chu Michael W A
Division of Cardiac Surgery, Department of Surgery, Western University, London, ON, Canada.
Division of Cardiac Surgery, Department of Surgery, University of Montreal, Montreal, QC, Canada.
Eur J Cardiothorac Surg. 2020 Jul 1;58(1):95-103. doi: 10.1093/ejcts/ezaa023.
The aim of this study was to investigate the impact of various brain perfusion techniques and nadir temperature cooling strategies on outcomes after aortic arch repair in a contemporary, multicentre cohort.
A total of 2520 patients underwent aortic arch repair with hypothermic circulatory arrest (HCA) between 2002 and 2018 in 11 centres of the Canadian Thoracic Aortic Collaborative. Primary outcomes included mortality; stroke; a composite of mortality or stroke; and a Society of Thoracic Surgeons-defined composite (STS-COMP) end point for mortality or major morbidity including stroke, reoperation, renal failure, prolonged ventilation and deep sternal wound infection. Multivariable logistic regression and propensity score matching were performed for cerebral perfusion and nadir temperature practices.
Antegrade cerebral perfusion was found on multivariable analysis to be protective against mortality [odds ratio (OR) 0.64, 95% confidence interval (CI) 0.48-0.86; P = 0.005], stroke (OR 0.55, 95% CI 0.37-0.81; P = 0.006), composite of mortality or stroke (OR 0.57, 95% CI 0.45-0.72; P = 0.0001) and STS-COMP (OR 0.53, 95% CI 0.41-0.67; P < 0.0001), as compared to HCA alone. Retrograde cerebral perfusion yielded similar outcomes as compared to antegrade cerebral perfusion. When compared to HCA with nadir temperature <24°C, a propensity score analysis of 647 matched pairs identified nadir temperature ≥24°C as predictor of lower mortality (OR 0.62, 95% CI 0.40-0.98; P = 0.04), stroke (OR 0.51, 95% CI 0.31-0.84; P = 0.008), composite of mortality or stroke (OR 0.62, 95% CI 0.43-0.89; P = 0.01) and STS-COMP (OR 0.64, 95% CI 0.49-0.85; P = 0.002).
Antegrade cerebral perfusion and nadir temperature ≥24°C during HCA for aortic arch repair are predictors of improved survival and neurological outcomes.
本研究旨在调查在当代多中心队列中，各种脑灌注技术和最低体温冷却策略对主动脉弓修复术后结局的影响。
2002年至2018年期间，加拿大胸主动脉协作组的11个中心共有2520例患者接受了低温循环停止（HCA）下的主动脉弓修复术。主要结局包括死亡率、中风、死亡率或中风的复合结局，以及胸外科医师协会定义的死亡率或主要并发症的复合结局（STS-COMP），包括中风、再次手术、肾衰竭、通气时间延长和深部胸骨伤口感染。对脑灌注和最低体温实践进行了多变量逻辑回归和倾向得分匹配。
多变量分析发现，与单纯HCA相比，顺行性脑灌注可降低死亡率[比值比（OR）0.64，95%置信区间（CI）0.48 - 0.86；P = 0.005]、中风（OR 0.55，95% CI 0.37 - 0.81；P = 0.006）、死亡率或中风的复合结局（OR 0.57，95% CI 0.45 - 0.72；P = 0.0001）以及STS-COMP（OR 0.53，95% CI 0.41 - 0.67；P < 0.0001）。逆行性脑灌注与顺行性脑灌注产生相似的结局。与最低体温<24°C的HCA相比，对647对匹配病例进行的倾向得分分析确定最低体温≥24°C是较低死亡率（OR 0.62，95% CI 0.40 - 0.98；P = 0.04）、中风（OR 0.51，95% CI 0.31 - 0.84；P = 0.008）、死亡率或中风的复合结局（OR 0.62，95% CI 0.43 - 0.89；P = 0.01）以及STS-COMP（OR 0.64，95% CI 0.49 - 0.85；P = 0.002）的预测因素。
主动脉弓修复术在HCA期间进行顺行性脑灌注和最低体温≥24°C是生存率提高和神经学结局改善的预测因素。
