Aortic arch surgery: retrospective analysis of outcome and neuroprotective strategies.
BACKGROUND



OBJECTIVE
To review intra- and postoperative 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.


METHODS
Retrospective study.


METHODS
Regional University Hospital.


METHODS
29 patients who underwent reconstruction of aneurysm or dissection of the aortic arch. Intervention. Surgical replacement of the diseased aorta during deep hypothermia, alone or with selective cerebral perfusion (antegrade or retrograde).


METHODS
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).
Division of Anesthesia and Resuscitation, Scientific Management, IRCCS San Matteo Hospital, Pavia, Italy.
P
P
Ceriana
N
N
Barzaghi
A
A
Locatelli
R
R
Veronesi
D
D
De Amici
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000784:Aortic Dissection / Q000601:surgery*; D001013:Aorta, Thoracic; D017545:Aortic Aneurysm, Thoracic / Q000601:surgery*; D002545:Brain Ischemia / Q000517:prevention & control*; D005112:Extracorporeal Circulation; D005260:Female; D006324:Heart Arrest, Induced; D006801:Humans; D008297:Male; D008875:Middle Aged; D010477:Perfusion; D011183:Postoperative Complications / Q000517:prevention & control*; D012189:Retrospective Studies; D016896:Treatment Outcome