Single crossclamp improves 6-month cognitive outcome in high-risk coronary bypass patients: The effect of reduced aortic manipulation
Single crossclamp improves 6-month cognitive outcome in high-risk coronary bypass patients: The effect of reduced aortic manipulation
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DOI：
10.1016/j.jtcvs.2005.08.057
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发表时间：
2006-01-01
影响因子：
6
通讯作者：
Kon, ND
中科院分区：
文献类型：
--
作者：
Hammon, JW;Stump, DA;Kon, ND
目的：我们假设，与“传统”方法相比，减少主动脉操作可以降低冠状动脉搭桥术患者认知障碍的发生率，减少主动脉操作策略的神经行为结果将接近非体外循环冠状动脉旁路手术的结果。方法：同意接受冠状动脉搭桥术和体外循环的高危患者(年龄较大、糖尿病或高血压患者)被随机分配到两种主动脉管理方案中的一种：(1)传统的主动脉管理方案。远端吻合术是指在阻断主动脉的同时缝合近端吻合口的方法(多个主动脉阻断组)，或(2)一种简化的主动脉操作方法，即用降压钳夹住主动脉一次(单一阻断组)，不使用部分阻断钳。一组同时接受非体外循环冠状动脉旁路手术的患者也被纳入其中。3组受试者在手术前后均进行了神经学和神经心理学测试。在随机化后，如果主治医生确定患者的安全需要这种改变，则分配到任何一种方法的患者可以改变为另一种策略。研究设计预计手术技术将在患者登记的过程中发展，并预计一些患者的术中超声心动图结果将要求放弃传统的方法(例如，严重的动脉粥样硬化)或简化的操作方案(例如，严重的缺血或左心功能不佳)。因此，患者分布不均是意料之中的。根据外科医生的决定，84例多重主动脉阻断患者中有20例改行单一主动脉阻断，85例单一主动脉阻断患者中有3例转为多重主动脉阻断。符合条件的患者在手术前和手术后6个月进行了一系列神经心理测试。在两次或两次以上测试中减少20%被定义为神经心理缺陷。结果：[图表]结论：与传统技术相比，旨在最大限度减少主动脉操作的手术策略可以显著降低冠状动脉旁路移植术患者认知障碍的发生率。在本系列中，降主动脉操作策略的结果与非体外循环冠状动脉旁路手术患者的结果没有显著差异，因此强调手术技术是冠状动脉旁路移植患者脑损伤的主要原因。
Objective: We hypothesized that a strategy that reduced aortic manipulation would reduce the incidence of cognitive deficits in patients undergoing coronary artery bypass grafting compared with the "traditional" approach and that neurobehavioral outcomes with the reduced aortic manipulation strategy would approach those obtained with off-pump coronary artery bypass surgery.Methods: Consenting high-risk patients (those with older age, diabetes, or hypertension) scheduled for coronary artery bypass grafting and cardiopulmonary bypass were randomly assigned to 1 of 2 aortic management protocols: (1) a traditional. approach in which distal anastomoses were accomplished while the aorta was crossclamped but in which proximal anastomoses were sewn while a partial occlusion clamp was applied to the aorta (multiple aortic clamping group) or (2) a reduced aortic manipulation approach in which the aorta was clamped a single time with a reduced-pressure clamp (single aortic clamping group) and the partial occlusion clamp was not used. A contemporaneous group of patients undergoing off-pump coronary artery bypass surgery without cardiopulmonary bypass was also enrolled. Subjects in all 3 groups underwent neurologic and neuropsychological testing before and after surgery. After randomization, patients assigned to either approach could be changed to another strategy if the attending surgeon determined that patient safety demanded this change. The study design anticipated that surgical techniques would evolve over the course of patient enrollment and anticipated that some patients would have intraoperative echocardiographic findings that would demand that the traditional approach (eg, severe aortic atherosclerosis) or the reduced manipulation protocol (eg, severe ischemia or poor left ventricular function) be abandoned. Thus, an unequal distribution of patients was expected. By surgeon decision, 20 of 84 multiple aortic clamping patients crossed over to single aortic clamping, and 3 of 85 single aortic clamping patients switched to multiple aortic clamping. Eligible patients had a battery of neuropsychological tests before surgery and at 6 months after surgery. A 20% decrement in 2 or more tests was defined as a neuropsychological deficit.Results:[GRAPHICS]Conclusions: A surgical strategy designed to minimize aortic manipulation can significantly reduce the incidence of cognitive deficits in coronary artery bypass grafting patients compared with traditional techniques. In this series, the results of the reduced aortic manipulation strategy were not significantly different from those in patients having off-pump coronary artery bypass surgery, thus emphasizing surgical technique as the primary cause of brain damage in coronary artery bypass grafting patients.