Aortic arch surgery with hypothermic circulatory arrest and unilateral antegrade cerebral perfusion: Perioperative outcomes
Aortic arch surgery with hypothermic circulatory arrest and unilateral antegrade cerebral perfusion: Perioperative outcomes
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DOI：
10.1016/j.jtcvs.2019.01.127
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发表时间：
2020-02-01
影响因子：
6
通讯作者：
Hou, Xiaotong
中科院分区：
文献类型：
--
作者：
Wang, Xiaomeng;Yang, Feng;Hou, Xiaotong
目的：研究目的是根据单中心7年的临床经验，确定手术方式、循环管理策略和脑保护策略对主动脉弓手术短期预后的影响。方法：分析2009 - 2015年在北京安贞医院行主动脉弓手术的1708例明确低温循环停止和单侧顺行脑灌注患者的资料。使用逻辑回归和随机森林回归分析来确定预测因子及其对结果的影响。结果：30天死亡率为6.1%。永久性神经功能障碍发生率为4.8%。需要持续肾替代治疗的患者比例为7.9%。在多变量分析中，年龄、DeBakey I型夹层、纽约心脏协会评分、昏迷、冠状动脉旁路移植术、解剖外旁路移植术和体外循环时间是死亡率的独立危险因素。年龄、DeBakey I型夹层和体外循环时间是永久性神经功能障碍的独立危险因素。在随机森林回归中，当单侧顺行脑灌注时间大于38分钟时，永久性神经功能障碍和死亡的风险增加，当温度低于约24℃时，随着鼻咽温度的升高，永久性神经功能障碍、持续肾替代治疗和截瘫的风险增加。该研究显示，报道的最大的主动脉弓手术患者低温循环停止和单侧脑灌注顺行具有合理的发病率和死亡率。作为一种脑保护策略，单侧顺行脑灌注可能有38分钟的安全阈值。中度低温应保持在24℃以下，以减少永久性神经功能障碍、截瘫和需要持续肾脏替代治疗的急性肾功能障碍的风险。
Objective: The study objective was to determine the effects of surgical procedures, circulatory management strategies, and cerebral protection strategies on the short-term outcomes of aortic arch surgery based on the 7-year clinical experience of a single center.Methods: We analyzed the data of 1708 patients who underwent aortic arch surgery with definite hypothermic circulatory arrest and unilateral antegrade cerebral perfusion at Beijing Anzhen Hospital between 2009 and 2015. Logistic regression and random Forest regression analyses were used to determine predictors and their effects on outcomes.Results: Thirty-day mortality was 6.1%. Permanent neurologic dysfunction incidence was 4.8%. The proportion of patients requiring continuous renal replacement therapy was 7.9%. In multivariable analyses, age, DeBakey type I dissection, New York Heart Association score, coma, coronary artery bypass grafting, extra-anatomic bypass, and cardiopulmonary bypass time were independent risk factors for mortality. Age, DeBakey type I dissection, and cardiopulmonary bypass time were independent risk factors for permanent neurologic dysfunction. In the random Forest regression, the risk for permanent neurologic dysfunction and mortality increased when unilateral antegrade cerebral perfusion time was more than 38 minutes and decreased with an increase in nasopharyngeal temperature when temperature was lower than approximately 24 degrees C. The risk for permanent neurologic dysfunction, continuous renal replacement therapy, and paraplegia increased when temperature was greater than approximately 24 degrees C.Conclusions: The study showed that the largest reported cohort of patients undergoing aortic arch surgery with hypothermic circulatory arrest and unilateral antegrade cerebral perfusion had reasonable morbidity and mortality rates. As a cerebral protection strategy, unilateral antegrade cerebral perfusion may have a 38-minute safety threshold. Moderate hypothermia should be maintained below 24 degrees C to reduce the risk for permanent neurologic dysfunction, paraplegia, and acute renal dysfunction requiring continuous renal replacement therapy.