Type-A Aortic Dissection and Cerebral Perfusion: The Society of Thoracic Surgeons Database Analysis
Type-A Aortic Dissection and Cerebral Perfusion: The Society of Thoracic Surgeons Database Analysis
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DOI：
10.1016/j.athoracsur.2020.04.144
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发表时间：
2020-11-01
影响因子：
4.6
通讯作者：
Chikwe, Joanna
中科院分区：
文献类型：
--
作者：
O'Hara, Danielle;McLarty, Allison;Chikwe, Joanna
背景。急性A型主动脉夹层低温停循环修复时的最佳脑灌注策略存在争议。本研究采用国家临床登记来评估脑保护策略。利用胸外科学会成人心脏外科数据库，研究人员在美国确定了6387例主动脉夹层患者（平均年龄60.4岁，SD 13.5岁），这些患者在2014年至2016年期间接受了全弓置换（n = 872; 13.7%）或上升或出血置换（n = 5515; 86.3%）合并循环骤停。多变量分析调整了潜在的混杂因素，包括人口统计学和合并症。根据以下结果进行比较：使用逆行、顺行或无脑灌注；谷底温度;循环停止的持续时间。主要终点是30天和住院死亡率或中风的综合。死亡或中风发生率为25.5% （n = 1627）。46.2% （n = 2950）患者行顺行脑灌注，22.6% （n = 1445）患者行逆行脑灌注，31.2% （n = 1992）患者不行脑灌注。在多变量分析中，死亡或卒中风险随着循环骤停时间的延长而增加（加比= or），每10分钟增加1.11；95%可信区间[CI]， 1.08至1.14)。按温度分层的多变量分析显示，脑灌注（顺行或逆行）和深度（or, 0.86; 95% CI， 0.74至0.98）或中度（or, 0.78; 95% CI， 0.65至0.95）低温循环骤停与无脑灌注的循环骤停相比，结果有所改善。最低温度与主要结果之间有轻微的相关性。由于与不进行脑灌注的低温循环骤停相比，逆行和顺行脑灌注策略可降低死亡和卒中风险，因此在主动脉夹层的弓修复中应采用脑灌注。(C) 2020年由胸外科学会出版
Background. The optimal cerebral perfusion strategy during hypothermic circulatory arrest for acute type A aortic dissection repair is controversial. This study used a national clinical registry to evaluate cerebral protection strategies.Methods. Using the Society of Thoracic Surgeons Adult Cardiac Surgical Database, study investigators identified 6387 patients with aortic dissection (mean age, 60.4 years, SD 13.5 years) who underwent total arch (n = 872; 13.7%) or ascending or hemiarch (n = 5515; 86.3%) replacement with circulatory arrest between 2014 and 2016 in the United States. Multivariable analysis adjusted for potential confounders, including demographics and comorbidity. Outcomes were compared according to the following: use of retrograde, antegrade, or no cerebral perfusion; nadir temperature; and duration of circulatory arrest. The primary end point was a composite of 30-day and in-hospital mortality or stroke.Results. The rate of death or stroke was 25.5% (n = 1627). Antegrade cerebral perfusion was used in 46.2% (n = 2950) patients, retrograde cerebral perfusion was used in 22.6% (n = 1445), and no cerebral perfusion was used in 31.2% (n = 1992). In multivariable analysis, death or stroke risk increased with longer circulatory arrest duration (adds ratio =OR], 1.11 per 10-minute increment; 95% confidence interval [CI], 1.08 to 1.14). Multivariate analysis stratified by temperature showed improved outcomes with cerebral perfusion (antegrade or retrograde) and deep (OR, 0.86; 95% CI, 0.74 to 0.98), or moderate (OR, 0.78; 95% CI, 0.65 to 0.95) hypothermic circulatory arrest vs circulatory arrest without cerebral perfusion. There was a slight correlation between nadir temperature and the primary outcome.Conclusions. Cerebral perfusion should be used during arch repair for aortic dissection because antegrade and retrograde cerebral perfusion strategies are associated with reduced death and stroke risk compared with hypothermic circulatory arrest without cerebral perfusion. (C) 2020 by The Society of Thoracic Surgeons