Division of Cardiac Surgery, Department of Surgery, University of Southern California, Keck School of Medicine, Los Angeles, Calif.
Division of Cardiac Surgery, Department of Surgery, University of Southern California, Keck School of Medicine, Los Angeles, Calif.
J Thorac Cardiovasc Surg. 2024 Jun;167(6):2005-2012.e1. doi: 10.1016/j.jtcvs.2023.08.012. Epub 2023 Aug 12.
Sparce evidence suggests superiority of total arch replacement with the branch-first technique and antegrade cerebral perfusion over conventional techniques with respect to morbidity and mortality. Thus, we aimed to compare perioperative outcomes of patients undergoing traditional total arch replacement versus branch-first total arch replacement.
We retrospectively reviewed 144 patients undergoing total arch replacement from January 2017 to December 2021. Patients were dichotomized based on technique, either traditional total arch replacement or branch-first total arch replacement. Primary end points were 30-day mortality and adverse events. Branch-first total arch replacement and traditional total arch replacement cohorts were compared using Student t tests and chi-square tests. Univariable and multivariable logistic regressions were performed to identify risk factors associated with 30-day mortality.
A total of 68 patients (47.2%) underwent traditional total arch replacement, and 76 patients (52.8%) underwent branch-first total arch replacement. The branch-first total arch replacement cohort had higher rates of chronic kidney disease, hypertension, atrial fibrillation, and previous myocardial infarction (P = .04, .002, .035, and .031 respectively). The majority of total arch replacements (78, 55%) were performed for aneurysmal disease. Median antegrade cerebral perfusion times were significantly shorter in the branch-first total arch replacement cohort (P = .001). There were no significant differences in rates of stroke, reintubation, postoperative lumbar drainage, renal failure, reoperation for bleeding, or prolonged ventilation between total arch replacement cohorts. The branch-first total arch replacement group had significantly lower 30-day mortality compared with the traditional total arch replacement group (4% vs 19%, P = .004). After adjustment for chronic kidney disease, nonelective status, antegrade cerebral perfusion time, rates of dissections arriving in extremis or with malperfusion, and primary surgeon, undergoing a branch-first total arch replacement was associated with a 93% reduced odds of 30-day mortality (odds ratio, 0.07, 95% CI, 0.009-0.48, P = .007).
We provide evidence that branch-first total arch replacement significantly reduces 30-day mortality compared with traditional total arch replacement.
有少量证据表明，与传统技术相比，在分阶段弓部置换和顺行脑灌注方面，全弓置换加分支技术在发病率和死亡率方面具有优势。因此，我们旨在比较接受传统全弓置换与分阶段全弓置换的患者的围手术期结局。
我们回顾性分析了 2017 年 1 月至 2021 年 12 月期间接受全弓置换的 144 例患者。根据技术（传统全弓置换或分阶段全弓置换）将患者分为两组。主要终点为 30 天死亡率和不良事件。使用学生 t 检验和卡方检验比较分阶段全弓置换和传统全弓置换组。采用单变量和多变量逻辑回归分析确定与 30 天死亡率相关的危险因素。
共有 68 例（47.2%）患者接受了传统全弓置换，76 例（52.8%）患者接受了分阶段全弓置换。分阶段全弓置换组慢性肾脏病、高血压、心房颤动和既往心肌梗死的发生率较高（P=.04、.002、.035 和.031）。大多数全弓置换术（78 例，55%）是为动脉瘤性疾病而进行的。分阶段全弓置换组顺行脑灌注时间明显缩短（P=.001）。两组之间的中风、再插管、术后腰大池引流、肾衰竭、再次出血手术或延长通气时间无显著差异。与传统全弓置换组相比，分阶段全弓置换组 30 天死亡率显著降低（4%比 19%，P=.004）。在调整了慢性肾脏病、非选择性状态、顺行脑灌注时间、到达终末状态或灌注不良的夹层发生率以及主刀医生后，分阶段全弓置换与 30 天死亡率降低 93%相关（比值比，0.07；95%置信区间，0.009-0.48；P=.007）。
我们提供的证据表明，与传统全弓置换相比，分阶段全弓置换可显著降低 30 天死亡率。
