Systemic temperature and paralysis after thoracoabdominal and descending aortic operations.

HYPOTHESIS: Systemic temperature influences the development of neurologic deficits after aortic surgery. DESIGN: Retrospective case-comparison study of prospectively collected data. SETTING: Tertiary referral center. PATIENTS AND INTERVENTIONS: We examined spinal cord injury according to mild passive hypothermia (mean temperature, 36.5 degrees C; n = 25), moderate active hypothermia (temperature range, 29 degrees C-32 degrees C; n = 76), or profound hypothermia (temperature, <20 degrees C; n = 31) for complex repairs in 132 patients. Aortic dissection was present in 67 patients (51%), 41 (31%) had leaks or rupture, 39 (30%) were reoperations on the descending thoracic aorta, and 27 (20%) had concurrent arch and/or ascending thoracic aortic repairs. MAIN OUTCOME MEASURE: Occurrence of permanent and transient deficits. RESULTS: Five patients (3.8%) had permanent deficits. One (4.0%) of the 25 patients underwent mild hypothermia, 3 (3.9%) of the 76 patients who underwent moderate hypothermia, and 1 (3.2%) of the 31 patients who underwent profound hypothermia (P =.70). Reversible deficits occurred in 7 patients (total 32%) who underwent mild hypothermia, 2 patients (total 6.6%) underwent moderate hypothermia, and 1 (total 6.5%) underwent profound hypothermia (P =.004). Six were delayed neurologic deficits. Independent predictors were intercostal ischemic time (P =.02), mild hypothermia (P =.004), and no cerebrospinal fluid drainage (P =.05). The total 30-day survival was 92.4% (122 of 132 patients). The only multivariable predictor of death was acuity of surgery (namely, emergent, urgent, or elective) (P =.06). CONCLUSIONS: Moderate or profound hypothermia resulted in fewer transient neurologic deficits. Thus, we recommend active cooling and cerebrospinal fluid drainage for most patients, and profound hypothermia for patients undergoing complex repairs and reoperations.

Multimodal protocol influence on stroke and neurocognitive deficit prevention after ascending/arch aortic operations.

BACKGROUND: Various techniques are used for brain protection during aortic surgery. Rather than evaluate each factor separately, we evaluated the early outcome of a multimodal protocol (mannitol, thiopental, MgSO4, lidocaine, CO2 field flooding, Leukoguard filter, head ice packing, electroencephalographic arrest at 20 degrees C, alpha-stat, increasing right subclavian artery cannulation, and antegrade/retrograde brain perfusion) for brain protection. METHODS: Prospectively collected data were analyzed on 403 ascending or arch aortic operations including 199 (49%) arch replacements conducted between July 25, 1991, and September 25, 2001. The mean age was 61.6 years (range 22 to 91 years); 48 (12%) had Marfan syndrome; 141 (35%) had dissection; 134 (33%) had composite grafts inserted; and 138 (34%) had concurrent coronary bypasses performed. RESULTS: Stroke occurred in 2.0% (8/403) (3 permanent, 5 transient), clinical neurocognitive deficits in 2.5% (10/403) either by testing or patient complaint 2 to 3 weeks after surgery, and 98% (395/403) were 30-day survivors. Univariate predictors of stroke, neurocognitive decline, or death were the following: for stroke, aorta symptom severity grade (1 to 4) (p = 0.001), pump time (p = 0.001), arrest time (p = 0.001), macroscopic atheroma (p = 0.041), concurrent descending/thoracoabdominal aneurysm (p = 0.036), and highest blood rewarming temperature (p = 0.043); for neurocognitive decline, degree of cooling (p = 0.046), pump time (p = 0.001), cooling time (p = 0.001), day extubated (p = 0.042), and antegrade brain perfusion (p = 0.004); for death, pump time (p = 0.001) and clamp time (p = 0.011). The multivariable independent predictors of stroke, neurocognitive decline, or death were the following: for stroke, aorta symptoms grade (p = 0.025), peripheral vascular disease (p = 0.043), and pump time (p = 0.015); neurocognitive decline, preoperative New York Heart Association dyspnea class (p = 0.022), pump time (p = 0.05), arrest time (p = 0.06), day extubated (p = 0.042), and antegrade perfusion (p = 0.023); and for death, pump time (p = 0.018). CONCLUSIONS: Pump time continues to be the most important predictor of adverse events. The benefit of antegrade or retrograde perfusion remains unproven, partly because of the low event rate (< 2.5%) but may be beneficial for prolonged circulatory arrest. Embolic material either from macroscopic atheroma, descending or thoracoabdominal aneurysms, or associated with peripheral vascular disease, increases the risk of stroke. Preoperative symptoms influence outcome.

Results of matching valve and root repair to aortic valve and root pathology.

OBJECTIVE: For patients with aortic root pathology and aortic valve regurgitation, aortic valve replacement is problematic because no durable bioprosthesis exists, and mechanical valves require lifetime anticoagulation. This study sought to assess outcomes of combined aortic valve and root repair, including comparison with matched bioprosthesis aortic valve replacement. METHODS: From November 1990 to January 2005, 366 patients underwent modified David reimplantation (n = 72), root remodeling (n = 72), or valve repair with sinotubular junction tailoring (n = 222). Active follow-up was 99% complete, with a mean of 5.6 ± 4.0 years (maximum 17 years); follow-up for vital status averaged 8.5 ± 3.6 years (maximum 19 years). Propensity-adjusted models were developed for fair comparison of outcomes. RESULTS: Thirty-day and 5-, 10-, and 15-year survivals were 98%, 86%, 74%, and 58%, respectively, similar to that of the US matched population and better than that after bioprosthesis aortic valve replacement. Propensity-score-adjusted survival was similar across procedures (P > .3). Freedom from reoperation at 30 days and 5 and 10 years was 99%, 92%, and 89%, respectively, and was similar across procedures (P > .3) after propensity-score adjustment. Patients with tricuspid aortic valves were more likely to be free of reoperation than those with bicuspid valves at 10 years (93% vs 77%, P = .002), equivalent to bioprosthesis aortic valve replacement and superior after 12 years. Bioprostheses increasingly deteriorated after 7 years, and hazard functions for reoperation crossed at 7 years. CONCLUSIONS: Valve preservation (rather than replacement) and matching root procedures have excellent early and long-term results, with increasing survival benefit at 7 years and fewer reoperations by 12 years. We recommend this procedure for experienced surgical teams.