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A Journal on Cardiac, Vascular and Thoracic Surgery

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The Journal of Cardiovascular Surgery 1998 June;39(3):337-42

language: English

Aortic ­arch sur­gery: ret­ro­spe­citve anal­ysis of out­come and neu­ro­pro­tec­tive strat­e­gies

Ceriana P., Barzaghi N., Locatelli A., Veronesi R., De Amici D.*

From the Division of Anesthesia and Resuscitation
*Division of Clinical Epideiology and Biometry Scientific Management IRCCS San ­Matteo Hospital, ­Pavia, ­Italy


Back­ground. Objec­tive: To ­review ­intra- and post­op­e-r­a­tive ­data ­regarding sur­gical recon­struc­tion of the ­aortic ­arch per­formed at our car­di­o­sur­gical ­centre ­during the ­past ­four ­years, and ­thus to deepen under­standing of neu­ro­logic mor­bidity and of ­what con­sti­tutes the ­most effec­tive neu­ro­pro­tec­tion.
­Experi­mental ­design. Ret­ro­spec­tive ­study.
Set­ting. ­Regional Uni­ver­sity Hos­pital.
­Patients. 29 ­patients who under­went recon­struc­tion of aneu­rysm or dis­sec­tion of the ­aortic ­arch.
Inter­ven­tion. Sur­gical replace­ment of the dis­esased ­aorta ­during ­deep hypo­thermia, ­alone or ­with selec­tive cere­bral per­fu­sion (ante­grade or ret­ro­grade).
Meas­ures. ­Overall mor­tality ­rate, neu­ro­logic mor­bidity ­rate, dura­tion of extra­cor­po­real cir­cu­la­tion, of hypo­thermic cir­cu­la­tory ­arrest or of selec­tive cere­bral per­fu­sion. Eval­u­a­tion of the impor­tance to neu­ro­log­ical out­come of age, ­modality of oper­a­tion (emer­gency or rou­tine), bio­chem­ical param­e­ters (gly­cemia, hem­a­tocrit) and per­fu­sion tech­nique. ­Recording of ­postoper­a­tive ­time of ­arousal, and pos­sible cor­re­la­tion ­with ­length of selec­tive cere­bral per­fu­sion.
­Results. We ­observed a mor­tality ­rate of 39% (11 ­deaths) and a neu­ro­logic mor­bidity ­rate of 34%. Hypo­thermic cir­cu­la­tory ­arrest ­alone did not ­assure ­valid neu­ro­pro­tec­tion (5 ­cases, all ­with ­severe neu­ro­logic impair­ment), ­while ­better ­results ­were ­obtained ­with selec­tive cere­bral per­fu­sion, espe­cially ante­grade (14 ­cases, ­with ­only 7% of neu­ro­logic mor­bidity ­rate). Hyper­gly­cemia (>250 mg%) ­proved to be sig­nif­i­cantly asso­ciated (p=0.002) ­with ­increased inci­dence of ­adverse neu­ro­logic out­come, and the ­same asso­ci­a­tion was ­observed ­between emer­gency ­status and ­adverse neu­ro­logic out­come (p=0.002). More­over, we ­found an unex­pected ­linear cor­re­la­tion ­between ­time of selec­tive cere­bral per­fu­sion and ­postoper­a­tive ­time of ­arousal (r=0.728, p=0.000).
Con­clu­sions. ­Deep hypo­thermic cir­cu­la­tory ­arrest ­with selec­tive cere­bral per­fu­sion cur­rently rep­re­sent a ­valid ther­a­peutic ­option for ­brain pres­er­va­tion ­during recon­struc­tion of the ­aortic ­arch in ­adults. It is man­da­tory to ­carry out a ­tight con­trol of per­fu­sion param­e­ters (­flow, pres­sures and tem­per­a­ture gra­dients) and bio­chem­ical var­i­ables (avoid­ance of hyper­gly­cemia and mod­i­fied ultra­fil­tra­tion for ­fluid bal­ance).

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