加拿大主动脉弓手术不断发展的外科技术与改善的治疗效果
Evolving Surgical Techniques and Improving Outcomes for Aortic Arch Surgery in Canada.
作者信息
Ibrahim Marina, Stevens Louis-Mathieu, Ouzounian Maral, Hage Ali, Dagenais Francois, Peterson Mark, El-Hamamsy Ismail, Boodhwani Munir, Bozinovski John, Moon Michael C, Yamashita Michael H, Atoui Rony, Bittira Bindu, Payne Darrin, Lachapelle Kevin, Chu Michael W A, Chung Jennifer C-Y
机构信息
Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada.
Centre Hospitalier de l'Université de Montreal, University of Montreal, Montreal, Quebec, Canada.
出版信息
CJC Open. 2021 May 12;3(9):1117-1124. doi: 10.1016/j.cjco.2021.05.001. eCollection 2021 Sep.
BACKGROUND
To explore evolving surgical techniques and outcomes for aortic arch surgery.
METHODS
A total of 2435 consecutive patients underwent aortic arch repair with hypothermic circulatory arrest between 2008 and 2018 in 12 institutions across Canada. Trends in patient characteristics, surgical techniques, and in-hospital outcomes, including major morbidity or mortality, were examined.
RESULTS
From 2008 to 2018, the age of patients (62.3 ± 13.2 years) and the proportion of women (30.2%) undergoing arch surgery did not change significantly. Aortic diameters at operation decreased (2008: 58 ± 13 mm; 2018: 53 ± 11 mm; < 0.01). Surgeons performed more valve-sparing root replacements (2008: 0%; 2018: 15%; < 0.001) and fewer Bentall procedures (2008: 27%; 2018: 20%; < 0.01). Total arch replacement rates were similar ( = 0.18); however, elephant trunk (2008: 9.5%; 2018: 19%; < 0.001) and frozen elephant trunk (2008: 3.1%; 2018: 15%; < 0.001) repair rates have increased. Over time, higher nadir temperatures (2008: 18 [17-21]°C; 2018: 25 [23-28]°C; < 0.001), and more frequent antegrade cerebral perfusion (2008: 61%; 2018: 83%; < 0.001) were used. For elective cases, in-hospital mortality rates declined (2008: 6.8%; 2018: 1.2%; = < 0.01), as did major morbidity or mortality (2008: 24%; 2018: 13%; < 0.001) and transfusion rates (2008: 61%; 2018: 41%; < 0.001), but stroke rates remained constant (2008: 6.8%; 2018: 5.3%; = 0.12). Outcomes remained the same over time for urgent or emergent cases.
CONCLUSIONS
Outcomes have improved over the past decade in Canada for elective aortic arch surgery, in the context of operating on smaller aortas, and more frequent use of moderate hypothermia and antegrade cerebral perfusion. Further research is needed to improve stroke rates and outcomes in the emergency setting.
背景
探讨主动脉弓手术不断发展的手术技术及手术效果。
方法
2008年至2018年期间，加拿大12家机构共有2435例连续患者接受了低温循环停搏下的主动脉弓修复术。研究了患者特征、手术技术及住院结局（包括严重并发症或死亡率）的变化趋势。
结果
2008年至2018年，接受主动脉弓手术患者的年龄（62.3±13.2岁）及女性比例（30.2%）无显著变化。手术时的主动脉直径减小（2008年：58±13mm；2018年：53±11mm；<0.01）。外科医生进行保留瓣膜的主动脉根部置换术更多（2008年：0%；2018年：15%；<0.001），而Bentall手术更少（2008年：27%；2018年：20%；<0.01）。全主动脉弓置换率相似（=0.18）；然而，象鼻手术（2008年：9.5%；2018年：19%；<0.001）和冰冻象鼻手术（2008年：3.1%；2018年：15%；<0.001）的修复率有所增加。随着时间推移，最低体温升高（2008年：18[17 - 21]℃；2018年：25[23 - 28]℃；<0.001），顺行性脑灌注使用更频繁（2008年：61%；2018年：83%；<0.001）。对于择期病例，住院死亡率下降（2008年：6.8%；2018年：1.2%；<0.01），严重并发症或死亡率（2008年：24%；2018年：13%；<0.001）及输血率（2008年：61%；2018年：41%；<0.001）也下降，但卒中率保持不变（2008年：6.8%；2018年：5.3%；=0.12）。急诊或紧急病例的结局随时间无变化。
结论
在加拿大，过去十年择期主动脉弓手术的结局有所改善，这与主动脉尺寸变小、更频繁使用中度低温及顺行性脑灌注有关。需要进一步研究以改善急诊情况下的卒中率及手术效果。
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