- 作者：Dominik Wiedemann ; Alfred Kocher ; Marion Dorfmeister ; Amit Vadehra ; Stephane Mahr ; G¨¹nther Laufer ; Marek Ehrlich
- 关键词：ACP ; antegrade cerebral perfusion ; bACP ; bilateral ACP ; CPB ; cardiopulmonary bypass ; HCA ; hypothermic circulatory arrest ; PND ; permanent neurologic deficit ; RCP ; retrograde cerebral perfusion ; uACP ; unilateral ACP
- 刊名：The Journal of Thoracic and Cardiovascular Surgery
- 出版年：2013
- 出版时间：September, 2013
- 年：2013
- 卷：146
- 期：3
- 页码：647-655.e1
- 全文大小：607 K
Objective
The aim of the present study was to assess the efficacy and mid- to long-term results of different cerebral protection techniques in the treatment of acute type A aortic dissection.Methods
Between April 1987 and January 2011, 329 patients (220 male patients; median age, 60 years; range, 16-87) with type A aortic dissection underwent replacement of the ascending aorta or aortic arch with an open distal anastomosis. Either hypothermic circulatory arrest alone at 18¡ãC (n?=?116; 35 % ) or combined with retrograde cerebral perfusion (n?=?122; 37 % ) or antegrade cerebral perfusion at 25¡ãC (n?=?91; 28 % ) was used.
Results
The median circulatory arrest time was 30 minutes (range, 12-92). The overall 30-day mortality was 19 % (62 of 329). The 30-day mortality stratified by group was 26 % (30 patients) in the hypothermic circulatory arrest group, 16 % in the retrograde cerebral perfusion group (20 patients), and 13 % (12 patients) in the antegrade cerebral perfusion group (P?=?.047). Permanent neurologic dysfunction occurred in 53 patients (16 % ), with statistically significant differences among the 3 groups (23 % for hypothermic circulatory arrest, 12 % for retrograde cerebral perfusion, and 12 % for antegrade cerebral perfusion; P?=?.033). Univariate analysis showed a significant effect of the brain protection strategy on 30-day mortality and neurologic outcome. Multivariate analysis revealed preoperative hemodynamic instability, preoperative resuscitation, age, and operative year as independent predictors of 30-day mortality. Regarding permanent neurologic dysfunction, the multivariate analysis could not identify any independent predictors. Kaplan-Meier analyses revealed statistically significant differences among the 3 groups with a 1-, 3-, and 5-year survival rate of 84 % , 79 % , and 77 % with antegrade cerebral perfusion, 75 % , 72 % , and 66 % with retrograde cerebral perfusion, and 66 % , 62 % , and 60 % with hypothermic circulatory arrest alone.
Conclusions
Patients in the antegrade cerebral perfusion group had the best short- and long-term survival rates. However, during the study period, several significant improvements in the treatment of patients with type A aortic dissection were achieved; therefore, independent predictors of mortality and permanent neurologic dysfunction were difficult to identify.