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The Journal of Thoracic and Cardiovascular Surgery, Vol 106, 19-28, Copyright © 1993 by The American Association for Thoracic Surgery and The Western Thoracic Surgical Association
LG Svensson, ES Crawford, KR Hess, JS Coselli, S Raskin, SA Shenaq and HJ Safi
We have retrospectively evaluated our results after aortic surgery in
adults using deep hypothermia with circulatory arrest to determine the
patient predictors of early death and postoperative stroke by logistic
regression analysis. Of the 656 patients operated on between July 7, 1979,
and January 30, 1991, 43% (n = 283) were female, the median age of the
patients was 64 years (range 10 to 88 years), 12% (n = 77) had acute
dissection, 26% (n = 173) had previously undergone either cardiac or
ascending aortic operations, and 13% (n = 85) had a history of
cerebrovascular disease. Eighty-four patients underwent elephant trunk
procedures. The median circulatory arrest time was 31 minutes (range 7 to
120 minutes). The univariable predictors of transient or permanent stroke,
defined as clinical evidence of neurologic injury, either global or
hemiparetic, which occurred in 44 patients (7%), were as follows (p <
0.05): increased age; a history of cerebrovascular disease; circulatory
arrest time (7 to 29 minutes = 12/298 [4%], 30 to 44 minutes = 15/201
[7.5%], 45 to 59 minutes 9/84 [10.7%], 60 to 120 minutes 7/48 [14.6%];
cardiopulmonary bypass time; and concurrent descending thoracic aorta
repair. The multivariably determined predictors were as follows (p <
0.05): a history of cerebrovascular disease; previous aortic surgery distal
to the left subclavian artery; and cardiopulmonary bypass time. A history
of aortic valve incompetence, however, was associated with a lower risk of
stroke (adjusted odds ratio 0.42, p = 0.015). The multivariably determined
predictors for increased risk of early death (p < 0.05), which occurred
in 66 (10%) patients, were as follows: increased age; Marfan syndrome;
concurrent distal aortic aneurysm; previous ascending aortic operation;
cardiopulmonary bypass time; cardiac complications; renal complications;
and stroke. In this study, the occurrence of stroke was observed to
increase after 40 minutes of circulatory arrest; furthermore, the mortality
rate increased markedly after 65 minutes of circulatory arrest. Thus the
"safe" period for strokes not developing appeared to be limited to
approximately 40 minutes. We conclude that deep hypothermia with
circulatory arrest is a safe technique for the repair of complex aortic
problems provided both the circulatory arrest and the cardiopulmonary
bypass times are not excessive. In addition, the clinical characteristics
of the patients are important determinants of stroke and death.
ARTICLES
Deep hypothermia with circulatory arrest. Determinants of stroke and early mortality in 656 patients
Department of Surgery, Baylor College of Medicine, Houston, Tex.
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