RESUMO
AIMS: The aim of this study was to document the postoperative outcomes of patients who underwent hypothermic circulatory arrest (HCA), the evolution of HCA management over time and to identify the risks factor for early mortality and postoperative stroke. METHODS: Four hundred and twenty-four patients who underwent aortic surgery with HCA at our institution between January 1995 and June 2016 were consecutively included. RESULTS: The main indications were degenerative aneurysm (254; 59.9%) and acute type A aortic dissection (146; 34.4%). Interventions were performed under deep (18.4â±â0.9°C; nâ=â350; 82.5%) or moderate (23.9â±â1.9°C; nâ=â74; 17.5%) hypothermia. Antegrade cerebral perfusion (ACP) was employed in 86 (20.3%) cases. The use of moderate hypothermia significantly increased from 2011, to become the preferred strategy in 2016. The in-hospital mortality was 12.5% and the postoperative stroke rate was 7.1%. Kaplan--Meier 5-year survival was 65.7%. Nonelective timing [odds ratio (OR) 4.05; Pâ<â0.001], stroke (OR 3.77' Pâ=â0.032), renal failure (OR 2.49; Pâ=â0.023), redo surgery (2.42; Pâ=â0.049) and CPB time (OR 1.05; Pâ=â0.03) were independent risk factors for in-hospital mortality in multivariate analysis. Femoral cannulation was the only independent risk factor for stroke (OR 3.97; Pâ=â0.002). The level of hypothermia and the use of ACP were not associated with either in-hospital mortality or postoperative stroke. CONCLUSION: HCA might be widely considered to achieve a radical treatment of the aortic disease, provided that hypothermia is maintained below the 24°C safety threshold and ACP is used for HCA exceeding 30âmin, to ensure optimal brain, spinal cord and visceral organs protection.
Assuntos
Aneurisma Aórtico , Dissecção Aórtica , Implante de Prótese Vascular , Parada Circulatória Induzida por Hipotermia Profunda , Complicações Pós-Operatórias , Acidente Vascular Cerebral , Dissecção Aórtica/etiologia , Dissecção Aórtica/mortalidade , Dissecção Aórtica/cirurgia , Aneurisma Aórtico/complicações , Aneurisma Aórtico/mortalidade , Aneurisma Aórtico/cirurgia , Valvopatia Aórtica/epidemiologia , Valvopatia Aórtica/cirurgia , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/métodos , Circulação Cerebrovascular , Parada Circulatória Induzida por Hipotermia Profunda/efeitos adversos , Parada Circulatória Induzida por Hipotermia Profunda/métodos , Feminino , França/epidemiologia , Humanos , Hipotermia Induzida/métodos , Hipotermia Induzida/estatística & dados numéricos , Efeitos Adversos de Longa Duração/diagnóstico , Efeitos Adversos de Longa Duração/mortalidade , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/mortalidade , Complicações Pós-Operatórias/fisiopatologia , Prognóstico , Medição de Risco , Fatores de Risco , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/etiologiaRESUMO
The valve-in-valve (ViV) procedure is an option for patients with symptomatic structural degeneration of a bioprosthesis and excessive reoperative risk. The risk of coronary obstruction appears to be increased if ViV is performed for certain pericardial prostheses in which the leaflets are mounted outside the stent posts. Herein is described a successful ViV for a degenerated Trifecta aortic bioprosthesis, and the technical considerations for performing a ViV procedure within such types of prosthesis are considered. Emphasis is placed on the importance of preoperative investigations (computed tomography scan-based measurements of coronary ostial height and of sinus of Valsalva diameters), and on the precise deployment of the valve (transapical approach with transesophageal echocardiography control) to minimize the risk of major complications. The presence of a failing Trifecta bioprosthesis should not be considered an absolute contraindication to ViV on the basis of the risk of coronary obstruction.
