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J Thorac Cardiovasc Surg 2001;121:1107-1121
© 2001 The American Association for Thoracic Surgery
Surgery for Acquired Cardiovascular Disease |
From the Departments of Cardiothoracic Surgerya and Biomathematics,b Mount Sinai School of Medicine/New York University, New York, NY.
Received for publication July 5, 2000 Revisions requested Oct 23, 2000; revisions received Nov 15, 2000. Accepted for publication Nov 27, 2000. Address for reprints: Christian Hagl, MD, Department of Cardiothoracic Surgery, Mount Sinai School of Medicine, One Gustave L. Levy Place, PO Box 1028, New York, NY 10029 (E-mail: chagl{at}hotmail.com).
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.
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