RESUMEN
BACKGROUND: To determine the optimal method of brain protection during deep hypothermic circulatory arrest (DHCA) for arch repair. METHODS: Of 139 potential aortic arch repairs (denominator), we randomized 30 patients to either DHCA alone (n = 10), DHCA plus retrograde brain perfusion (RBP) (n = 10), or antegrade perfusion (ANTE) (n = 10); a further 5 coronary bypass (CAB) patients were controls. Fifty-one neurocognitive subscores were obtained for each patient at each of four intervals: preoperatively, 3 to 6 days postoperatively, 2 to 3 weeks postoperatively, and 6 months postoperatively. Intraoperative and postoperative S-100 blood levels and electroencephalograms were also obtained. RESULTS: For the denominator, the 30-day and hospital survival rate was 97.8% (136 of 139) and the stroke rate 2.8% (4 of 139). For the randomized patients, the survival rate was 100% and no patient suffered a stroke or seizure. Circulatory arrest (CA) times were not different (DHCA: RBP:ANTE) for 11 total arch repairs (including 6 elephant trunk; mean, 41.4 minutes; standard deviation, 15). Hemiarch repairs (n = 17) were quickest with DHCA (mean 10.0 minutes; standard deviation, 3.6; p = 0.011) and longest with ANTE (mean 23.8 minutes; standard deviation, 10.28; p = 0.004). Of the patients, 96% had clinical neurocognitive impairment at 3 to 6 days, but by 2 to 3 weeks only 9% had a residual new deficit (1 DHCA, 1 RBP, 1 ANTE), and by 6 months these 3 patients had recovered. Comparison of postoperative mean scores showed the DHCA group did better than RBP patients in 5 of 7 significantly different (p < 0.05) scores and versus 9 of 9 ANTE patients. There were no S-100 level differences between CA groups, but levels were significantly higher versus the CAB controls, particularly at the end of bypass (p < 0.0001); however, these may have been influenced by other variables such as greater pump time, cardiotomy use, and postoperative autotransfusion. Circulatory arrest (p = 0.01) and pump time (p = 0.057) correlated with peak S-100 levels. CONCLUSIONS: The results of hypothermic arrest have improved; however, there is no neurocognitive advantage with RBP or ANTE. Nevertheless, retrograde brain perfusion may, in a larger study, potentially reduce the risk of strokes related to embolic material. S-100 levels may be artificial. In patients with severe atheroma or high risk for embolic strokes, we use a combination of retrograde and antegrade perfusion on a selective basis.
Asunto(s)
Aorta Torácica/cirugía , Daño Encefálico Crónico/diagnóstico , Encéfalo/irrigación sanguínea , Paro Cardíaco Inducido , Hipotermia Inducida , Complicaciones Posoperatorias/diagnóstico , Proteínas S100/sangre , Anciano , Puente Cardiopulmonar , Electroencefalografía , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Pruebas Neuropsicológicas , Resultado del TratamientoRESUMEN
OBJECTIVES: Safety and benefits of minimal access ascending aorta and aortic arch surgery, including for re-operations has not been reported. METHODS: Fifty-four patients undergoing minimal access operations were evaluated. Of the 54 patients, valve replacements were performed in 76% (41 patients) (including composite valve grafts), and re-operations in 33% (18 patients). Composite valve grafts were used in 28% (15 patients) patients, and elephant trunk type procedures in 6% (three patients). RESULTS: The survival rate was 96% (52 patients), stroke 3.7% (two patients), and neurocognitive deficit 1.8% (one patient). The circulatory arrest time was 20 min (SD 17), aortic crossclamp time 91 min (SD 45) and cardiopulmonary bypass time 132 min (SD 59). Intraoperative homologous blood transfusion was a mean of 1.3 units (SD 2.3). ICU and postoperative stay were 1.8 days (SD 1.9) and 6.7 days (SD 3.7), respectively. No patient died after re-operation, although one patient had a stroke. CONCLUSIONS: Minimal access aortic surgery does not appear to carry a greater risk and, although more demanding technically, is associated with a reasonable ICU and hospital stay. For re-operations, we particularly recommend the technique.
Asunto(s)
Aneurisma de la Aorta Torácica/cirugía , Disección Aórtica/cirugía , Procedimientos Quirúrgicos Mínimamente Invasivos , Complicaciones Posoperatorias/cirugía , Adulto , Anciano , Disección Aórtica/mortalidad , Aorta Torácica/cirugía , Aneurisma de la Aorta Torácica/mortalidad , Válvula Aórtica/cirugía , Puente Cardiopulmonar , Femenino , Estudios de Seguimiento , Implantación de Prótesis de Válvulas Cardíacas , Humanos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/mortalidad , Reoperación , Tasa de Supervivencia , Resultado del TratamientoRESUMEN
BACKGROUND: Alternative management strategies for aortic valve disease and aortic operation include valve preservation and aortic repair (VPR), composite valve graft (CVG), or separate valve and aortic repair (SVR). We evaluated these approaches. METHODS: Of 250 ascending/arch operations, 151 patients had aortic valvular disease and dissection (n = 56, 37%) or aneurysms operated between November 1990 and January 1998. Sixty-seven patients underwent CVG insertion, 50 SVR, 13 VPR, and 21 only aortic repair alone (RA). Sixty (40%) patients also had aortic arch repairs and 53 (35%) coronary artery bypasses. RESULTS: The early 30-day survival and stroke rates were 99% (150 of 151) and 0% (0 of 151), respectively: CVG 100% (67 of 67), 0%; VPR 100% (13 of 13), 0%; SVR 98% (49 of 50), 0%; RA 100% (21 of 21), 0% (p = not significant [NS]). On late follow-up of all patients (5 to 92 months; 96% complete 1998), 3 CVG, 2 VPR, 6 SVR, and 0 RA patients died with respective 5-year Kaplan-Meier survival rates of 88.4%, 70%, 69%, and 100% (p = 0.07, log-rank test). The respective linear rates for stroke were 0%, 5.5% (n = 1), 0%, and 0%; for hemorrhage were 0%, 0%, 0%, and 0%; and for endocarditis were 2.2% (n = 3), 0%, 0%, and 0% (p = NS). There were 11 late deaths and no patient required reoperation or ruptured the ascending aorta or the aortic arch. CONCLUSIONS: With careful selection of the appropriate method excellent early and late results can be achieved.
Asunto(s)
Válvula Aórtica/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Procedimientos Quirúrgicos Cardíacos/métodos , Femenino , Estudios de Seguimiento , Enfermedades de las Válvulas Cardíacas/mortalidad , Enfermedades de las Válvulas Cardíacas/cirugía , Humanos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/epidemiología , Tasa de SupervivenciaAsunto(s)
Encéfalo/irrigación sanguínea , Trastornos del Conocimiento/diagnóstico , Trastornos del Conocimiento/etiología , Paro Cardíaco Inducido/efectos adversos , Proteínas S100/sangre , Enfermedades de la Aorta/cirugía , Biomarcadores/sangre , Trastornos del Conocimiento/sangre , Electroencefalografía , Humanos , Hipotermia Inducida , Modelos Lineales , Trastornos del Humor/diagnóstico , Trastornos del Humor/etiología , Pruebas Neuropsicológicas , Perfusión/métodos , Complicaciones Posoperatorias/diagnóstico , Estudios ProspectivosRESUMEN
BACKGROUND: Of all aortic operations, thoracoabdominal aortic repairs have the highest risk of spinal cord neurologic injury, manifest by lower limb paraplegia or paraparesis. Cerebrospinal fluid drainage combined with intrathecal papaverine (CSFDr + IP) may reduce the risk and severity of neurologic injury. The objective of this study was to evaluate the effect of CSFDr + IP to prevent neurologic injury after high-risk thoracoabdominal aneurysm repairs. METHODS: We screened 64 patients before operation with descending thoracic or thoracoabdominal aneurysms for possible inclusion in a prospective, randomized study. Thirty-three patients with high-risk type I and II thoracoabdominal aneurysms met inclusion criteria and 17 were randomly assigned to CSFDr + IP and 16 to the control group. The study was terminated early after interim analysis revealed a significant difference. RESULTS: Of 64 patients screened, 2 patients died after operation (3.1%, 2/64); both were in the randomized study (6%, 2/33), and neither had a neurologic injury. Neurologic injury developed in 2 CSFDr + IP patients and 7 control patients (p = 0.0392). Control patients also had lower postoperative motor strength scores (p = 0.0340). On multivariate analysis, risk factors for neurologic injury included (p < 0.05) longer cross-clamp time, failure to actively cool with bypass, and postoperative hypotension, whereas CSFDr + IP was protective. Logistic regression showed that CSFDr + IP and active cooling significantly reduced the risk of injury and that the two combined modalities were additive. Of 64 patients screened, only 2 (3%) had a permanent neurologic deficit preventing ambulation. CONCLUSIONS: For high-risk thoracoabdominal aneurysms, CSFDr + IP was effective in reducing the incidence and severity of neurologic injury. Active cooling may be further additive to CSFDr + IP protection, although this needs to be confirmed in a larger study.
Asunto(s)
Aneurisma de la Aorta Abdominal/cirugía , Aneurisma de la Aorta Torácica/cirugía , Paraplejía/prevención & control , Paresia/prevención & control , Adulto , Anciano , Puente Cardiopulmonar , Líquido Cefalorraquídeo , Drenaje , Femenino , Humanos , Hipotensión/etiología , Hipotermia Inducida , Inyecciones Espinales , Modelos Logísticos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Contracción Muscular/fisiología , Fármacos Neuroprotectores/administración & dosificación , Fármacos Neuroprotectores/uso terapéutico , Papaverina/administración & dosificación , Papaverina/uso terapéutico , Estudios Prospectivos , Factores de Riesgo , Médula Espinal/fisiopatología , Tasa de Supervivencia , Factores de Tiempo , Vasodilatadores/administración & dosificación , Vasodilatadores/uso terapéuticoRESUMEN
BACKGROUND: The overall incidence of anterior ischemic optic neuropathy after open heart operations at the Lahey Clinic is less than 0.5%. However, during the 2-year period, March 1, 1990, to March 1, 1992, an increased incidence (8 of 602 patients or 1.3%) of this complication was observed. METHODS: A rigorous analysis was conducted of all 602 patients who underwent operation during this period. RESULTS: No preoperative risk factors were identified. The development of anterior ischemic optic neuropathy was associated with prolonged cardiopulmonary bypass time, low hematocrit levels, excessive perioperative body weight gain, and the use of epinephrine and amrinone. Other hypothetical risk factors include systemic hypothermia, anemia, increased intraocular pressure, and microembolization. Treatment options include the use of corticosteroid medications, reduction of intraocular pressure, and optic nerve fenestration, although recent evidence and our experience indicate that the fenestration procedure is of no benefit. CONCLUSIONS: Because all methods of treatment have had limited success, efforts to prevent this complication are of paramount importance.
Asunto(s)
Procedimientos Quirúrgicos Cardíacos/efectos adversos , Neuropatía Óptica Isquémica/etiología , Anciano , Amrinona/efectos adversos , Puente Cardiopulmonar/efectos adversos , Epinefrina/efectos adversos , Femenino , Hematócrito , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Neuropatía Óptica Isquémica/diagnóstico , Neuropatía Óptica Isquémica/epidemiología , Neuropatía Óptica Isquémica/terapia , Estudios Retrospectivos , Factores de Riesgo , Aumento de PesoRESUMEN
The feasibility, safety, and impact on postoperative hospital stay of performing ascending aorta and aortic arch operations without homologous blood transfusions have not been evaluated. Sixty consecutive patients, 38 (63%) of whom also had aortic valve replacements and 17 (28%) of whom also had coronary artery bypass grafting, were evaluated for participation in blood conservation measures. Of the 45 who were able to use blood conservation techniques, 87% (39/45) required no intraoperative and 69% (31/45) required no in-hospital homologous blood transfusions. The 30-day survival rate was 98.3% (59/60), and no patient sustained a new stroke, neurologic cognitive deficit, or infection. Multivariate analysis of the 60 patients showed that the predictors of in-hospital homologous transfusion were (p < 0.05) age, cardiopulmonary bypass time, and postoperative chest tube drainage. Preoperative autologous blood donation was associated with a significantly lower risk of homologous transfusion (p = 0.0006). Indeed, patients participating in blood conservation techniques had a significantly (p < 0.05) lower incidence of homologous transfusions, required less intraoperative shed blood washing, were extubated earlier, gained less weight, had shorter hospital stays, and were discharged in a better dyspnea functional class. Most major elective cardiovascular operations on the ascending aorta and aortic arch can be safely performed without homologous transfusions.
Asunto(s)
Enfermedades de la Aorta/cirugía , Transfusión Sanguínea/estadística & datos numéricos , Anciano , Aorta/cirugía , Aorta Torácica/cirugía , Estudios de Factibilidad , Humanos , Modelos Lineales , Persona de Mediana Edad , Análisis Multivariante , Valor Predictivo de las Pruebas , Estudios Prospectivos , Análisis de SupervivenciaRESUMEN
A 68-year-old patient presented with an extensive aortic aneurysm extending from the aortic valve to the aortic bifurcation associated with severe continuous pain, dysphagia, and hoarseness. Because of the risk of impending rupture and an "elephant trunk" procedure not being an option, the entire aorta from the aortic valve to the aortic bifurcation was replaced during one operation using deep hypothermia with circulatory arrest and retrograde perfusion of the brain through the jugular veins. Seven months after the operation the patient walks more than 3 km a day and lives a normal life. The operative repair is presented.
Asunto(s)
Aorta/cirugía , Aneurisma de la Aorta/cirugía , Prótesis Vascular/métodos , Anciano , Aneurisma de la Aorta Abdominal/cirugía , Aneurisma de la Aorta Torácica/cirugía , Humanos , MasculinoAsunto(s)
Puente Cardiopulmonar/efectos adversos , Enfermedad Coronaria/cirugía , Paro Cardíaco/terapia , Corazón Auxiliar , Adulto , Enfermedad Coronaria/fisiopatología , Femenino , Paro Cardíaco/etiología , Paro Cardíaco/fisiopatología , Humanos , Factores de Tiempo , Función Ventricular IzquierdaRESUMEN
The cell kinetics of the sebaceous gland of the hamster ear were analysed in untreated animals, in animals treated with cyproterone acetate, and in animals treated with estradiol. Both active substances lead to a reduction in the size of the sebaceous gland (measurement with the integration plate), to a reduction of mitoses (colcemide method), to a reduction in the 3H-thymidine labelling index, to a prolongation of the S-phase (double labelling technique with 3H- and 14C-thymidine), and to a decrease in the number of cells labelled with 3H-thymidine which remain in contact with the basal lamina of the sebaceous gland 6 days after application of the isotope. The results indicate that, like cyproterone acetate, estradiol reduces the effect of androgens on cell kinetics in the sebaceous gland under the test conditions chosen, even if in an entirely different way.