AORTIC-ARCH SURGERY - RETROSPECTIVE ANALYSIS OF OUTCOME AND NEUROPROTECTIVE STRATEGIES

Background. Objective: To review intra- and postoperative data regardi ng surgical reconstruction of the aortic arch performed at our cardios urgical centre during the past four years, and thus to deepen understa nding of neurologic morbidity and of what constitutes the most effecti ve neuroprotection. Experimental design. Retrospective study. Setting. Regional University Hospital. Patients. 29 patients who underwent rec onstruction 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 o f selective cerebral perfusion. Evaluation of the importance to neurol ogical outcome of age, modality of operation (emergency or routine), b iochemical parameters (glycemia, hematocrit) and perfusion technique. Recording of postoperative time of arousal, and possible correlation w ith length of selective cerebral perfusion. Results. We observed a mor tality rate of 39% (11 deaths) and a neurologic morbidity rate of 34%. Hypothermic circulatory arrest alone did not assure valid neuroprotec tion (5 cases, all with severe neurologic impairment), while better re sults were obtained with selective cerebral perfusion, especially ante grade (14 cases, with only 7% of neurologic morbidity rate). Hyperglyc emia (>250 mg%) proved to be significantly associated (p=0.002) with i ncreased incidence of adverse neurologic outcome, and the same associa tion was observed between emergency status and adverse neurologic outc ome (p=0.002). Moreover, we found an unexpected Linear correlation bet ween time of selective cerebral perfusion and postoperative time of ar ousal (r=0.728, p=0.000). Conclusions. Deep hypothermic circulatory ar rest with selective cerebral perfusion currently represent a valid the rapeutic option for brain preservation during reconstruction of the ao rtic arch in adults. It is mandatory to carry out a tight control of p erfusion parameters (flow, pressures and temperature gradients) and bi ochemical variables (avoidance of hyperglycemia and modified ultrafilt ration for fluid balance).