Neurologic outcome after ascending aorta-aortic arch operations: Effect ofbrain protection technique in high-risk patients

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 operatio ns through a median sternotomy since 1986 were examined for factors influen cing 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 inju ry. Results: Independent risk factors for stroke were as follows: age greater t han 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 r eplace ment or other concomitant procedures (P =.055; odds ratio, = 3.7); a nd total cerebral protection time, defined as the sum of hypothermic circul atory arrest and any retrograde or antegrade cerebral perfusion (P =.001; o dds ratio, 1.02/min). In 453 patients surviving operations without stroke a fter 1993, independent risk factors for temporary neurologic dysfunction in cluded 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 protecti on time (P < .001; odds ratio, 1.02/min). When all patients with total cere bral protection times between 40 and 80 minutes were examined, the method o f cerebral protection did not influence the occurrence of stroke, but anteg rade 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 si gnificantly reduce the occurrence of temporary neurologic dysfunction.