Vpliv intraoperativnih mikroemboličnih dogodkov na pooperativno poškodbo možganov pri bolnikih po zamenjavi aortne zaklopke z dvema različnima kirurškima pristopoma

Bozhinovska, Marija (author), Šoštarič, Maja (mentor), Podbregar, Matej (comentor)

Izhodišče: Nedavno sprejet pristop za kirurško zamenjavo aortne zaklopke z minitorakotomijo je v primerjavi z običajnejšim pristopom z ministernotomijo pokazal prednosti, kot sta zmanjšana bolečina in hitrejše okrevanje. Kljub temu ostaja odprto vprašanje, ali lahko prostorsko manjša izpostavljenost srca in ascendentne aorte, ki je posledica reza v drugem medrebrnem prostoru, povzroči povečano intraoperativno možgansko embolizacijo in izrazitejši pooperativni nevrološki upad. Cilj naše študije je bil oceniti potencialne nevrološke zaplete po dveh različnih minimalno invazivnih kirurških tehnikah za zamenjavo aortne zaklopke prek zaznavanja intraoperativnih mikroemboličnih signalov v možganskih arterijah in spremljanja pooperativnega kognitivnega upada. Metode: Za zaznavanje mikroemboličnih signalov med zamenjavo aortne zaklopke smo uporabili transkranialno Dopplerjevo sonografijo pri bolnikih, pri katerih je bila operacija izvedena z ministernotomijo in minitorakotomijo. Bolnike smo ocenili z revidiranim kognitivnim preizkusom Addenbrook pred kirurškim posegom in 30 dni po njem. Rezultati: V študijo je bilo zajetih 60 bolnikov. Pri 52 bolnikih smo naredili transkranialno Dopplerjevo sonografijo, pri čemer je bila pri 25 od teh uporabljena ministernotomija, pri 27 pa minitorakotomija. Glede na spol in razvrstitev v klasifikacijo NYHA in EuroSCORE ter površino aortne zaklopke (AVA) med skupinama ni bilo razlik. Bolniki, operirani z ministernotomijo, so bili mlajši (60,8 ± 14,4 v primerjavi z 72 ± 5,84, p = 0,003) in težji (85,2 ± 12,4 v primerjavi z 72,5 ± 12,9, p = 0,002) ter so imeli večjo površino telesa (1,98 ± 0,167 v primerjavi z 1,83 ± 0,178, p = 0,006). Operacija je pri njih potekala dlje kot pri skupini bolnikov, operiranih z minitorakotomijo (158 ± 24 v primerjavi s 134 ± 30 min, p < 0,001). Med skupinama ni bilo razlik v mikroemboličnih dogodkih, trajanju hospitalizacije v intenzivni terapiji in trajanju celotne bolnišnične hospitalizacije. Študija je pokazala, da zaznani mikroembolični dogodki (5,64, 95 % CI 0,677–10,60, p = 0,027) korelirajo s trajanjem zunajtelesnega krvnega obtoka med operacijo. Revidirani kognitivni preizkus Addenbrook je bil v obeh skupinah primerljiv (p = 0,630) (MS: 85,2 ± 9,6 v primerjavi z 82,9 ± 11,4, p = 0,012; MT: 85,2 ± 9,6 v primerjavi z 81,3 ± 8,8, p = 0,001). Zaključek: Med skupinama ni bilo ugotovljenih razlik v mikroemboličnih dogodkih. Število zaznanih mikroemboličnih dogodkov je koreliralo s trajanjem zunajtelesnega krvnega obtoka med operacijo, z njimi pa ni bil povezan pooperativni nevrološki upad. Slednji je bil povezan s starostjo bolnika.

• Language: Slovenian
• Keywords: Zamenjava aortne zaklopke, minimalno invazivne operacije, ministernotomija, minitorakotomija, transkranialna Dopplerjeva sonografija, mikroembolični signali, kognitivni test
• Work type: Doctoral dissertation
• Organization: MF - Faculty of Medicine
• Year: 2022
• PID: 20.500.12556/RUL-137632
• COBISS.SI-ID: 127676419
• Publication date in RUL: 24.06.2022

Secondary language

• Language: English
• Title: The impact of intraoperative microembolic load on postoperative brain injury in patients undergoing aortic valve replacement performed with two different surgical approaches

Abstract

Background: Recently adopted mini-thoracotomy approach for surgical aortic valve replacement has shown benefits such as reduced pain and shorter recovery, compared to more conventional mini-sternotomy access. However, whether limited exposure of the heart and ascending aorta resulting from an incision in the second intercostal space may lead to increased intraoperative cerebral embolization and more prominent postoperative neurologic decline,remains inconclusive. The aim of our study was to assess potential neurological complications after two different minimal invasive surgical techniques for aortic valve replacement by measuring cerebral microembolic signal during surgery and by follow-up cognitive evaluation. Methods: Trans-cranial Doppler was used for microembolic signal detection during aortic valve replacement performed via mini-sternotomy and mini-thoracotomy. Patients were evaluated using Addenbrooke’s Cognitive Examination Revised Test before and 30 days after surgical procedure. Results: A total of 60 patients were recruited in the study. In 52 patients, transcranial Doppler was feasible. Of those, 25 underwent mini-sternotomy and 27 had mini-thoracotomy. There were no differences between groups with respect to sex, NYHA class distribution, Euroscore II or aortic valve area. Patients in mini-sternotomy group were younger (60.8±14.4 vs.72±5.84, p=0.003), heavier (85.2±12.4 vs.72.5±12.9, p=0.002) and had higher body surface area (1.98±0.167 vs. 1.83±0.178, p=0.006).Surgery duration was longer in mini-sternotomy group compared to mini-thoracotomy (158±24 vs. 134±30 min, p<0.001, respectively). There were no differences between groups in microembolic load, length of ICU or total hospital stay. Total microembolic signals count was correlated with cardiopulmonary bypass duration (5.64, 95%CI 0.677–10.60, p=0.027). Addenbrooke’s Cognitive Examination Revised Test score decreased equivalently in both groups (p=0.630) (MS: 85.2±9.6 vs. 82.9±11.4, p=0.012; MT: 85.2±9.6 vs. 81.3±8.8, p=0.001). Conclusion: There is no difference in microembolic load between the groups. Total intraoperative microembolic signals count was associated with cardiopulmonary bypass duration. Age, but not micorembolic signals load, was associated with postoperative neurologic decline.

• Keywords: aortic valve replacement, minimal invasive surgery, mini-sternotomy, mini-thoracotomy, transcranial Doppler, microembolic signals, cognitive test