title: Neurologic outcome after ascending aorta-aortic arch operations: effect of brain protection technique in high-risk patients.
abstract: OBJECTIVE
  We sought to assess the optimal strategy for avoiding neurologic injury after aortic operations requiring hypothermic circulatory arrest.
  
  
  METHODS
  All 717 patients who survived ascending aorta-aortic arch operations through a median sternotomy since 1986 were examined for factors influencing stroke. Temporary neurologic dysfunction was assessed in all patients who survived the operation without stroke since 1993. Multivariate analyses were carried out to determine independent risk factors for neurologic injury.
  
  
  RESULTS
  Independent risk factors for stroke were as follows: age greater than 60 years (P <.001; odds ratio, 4.5); emergency operation (P =.02; odds ratio, 2.2); new preoperative neurologic symptoms (P =.05; odds ratio, 2.9); presence of clot or atheroma (P <.001; odds ratio, 4.4); mitral valve replacement or other concomitant procedures (P =.055; odds ratio, = 3.7); and total cerebral protection time, defined as the sum of hypothermic circulatory arrest and any retrograde or antegrade cerebral perfusion (P =.001; odds ratio, 1.02/min). In 453 patients surviving operations without stroke after 1993, independent risk factors for temporary neurologic dysfunction included age (P <.001; odds ratio, 1.06/y), dissection (P =.001; odds ratio, 2.2), need for coronary artery bypass grafting (P =.006; odds ratio, 2.1) or other procedures (P =.023; odds ratio, 3.4), and total cerebral protection time (P <.001; odds ratio, 1.02/min). When all patients with total cerebral protection times between 40 and 80 minutes were examined, the method of cerebral protection did not influence the occurrence of stroke, but antegrade cerebral perfusion resulted in a significant reduction in incidence on temporary neurologic dysfunction (P =.05; odds ratio, 0.3).
  
  
  CONCLUSIONS
  The occurrence of stroke is principally determined by patient- and disease-related factors, but use of antegrade cerebral perfusion can significantly reduce the occurrence of temporary neurologic dysfunction.
authors.affiliation: Department of Cardiothoracic Surgery, Mount Sinai School of Medicine/New York University, One Gustave L. Levy Place, New York, NY 10029, USA. chagl@hotmail.com
authors.forename: C
authors.initials: C
authors.lastname: Hagl
authors.forename: M A
authors.initials: MA
authors.lastname: Ergin
authors.forename: J D
authors.initials: JD
authors.lastname: Galla
authors.forename: S L
authors.initials: SL
authors.lastname: Lansman
authors.forename: J N
authors.initials: JN
authors.lastname: McCullough
authors.forename: D
authors.initials: D
authors.lastname: Spielvogel
authors.forename: P
authors.initials: P
authors.lastname: Sfeir
authors.forename: C A
authors.initials: CA
authors.lastname: Bodian
authors.forename: R B
authors.initials: RB
authors.lastname: Griepp
mesh_terms: D000293:Adolescent; D000328:Adult; D017677:Age Distribution; D000368:Aged; D000369:Aged, 80 and over; D000704:Analysis of Variance; D017545:Aortic Aneurysm, Thoracic / Q000175:diagnosis / Q000601:surgery*; D002648:Child; D005260:Female; D006801:Humans; D007036:Hypothermia, Induced / Q000379:methods*; D015994:Incidence; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D016017:Odds Ratio; D011183:Postoperative Complications / Q000517:prevention & control*; D011336:Probability; D018570:Risk Assessment; D012307:Risk Factors; D017678:Sex Distribution; D020521:Stroke / Q000453:epidemiology* / Q000517:prevention & control*; D016019:Survival Analysis; D014656:Vascular Surgical Procedures / Q000009:adverse effects* / Q000379:methods*