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Impact of the Haga Braincare Strategy on the burden ofhaemodynamic and emb...

发布日期【2017-06-19】 已浏览【】次

研究目标:本前瞻性研究选取了于2012年至2015年期间在海牙医院接受冠状动脉旁路移植术与瓣膜置换术组合手术的患者,评估了他们采用的海牙脑监护方案(HBS)对脑血流动力学和卒中发生率的影响。
研究方法:HBS是一种双重监护方案,包括经颅多普勒(德力凯-经颅多普勒血流分析仪)对脑循环的术前血管检查与脑循环血氧饱和度的围术期检测。高危患者术前还需接受颈动脉血管的计算机双向和(或)断层造影,做进一步检查;有严重颈动脉狭窄的患者术前需接受颈动脉血管成形术,否则放弃手术。
研究结果:共纳入1065例患者,其中22例(2.1%)经德力凯-经颅多普勒血流分析仪发现脑血流动力学状态差。基于HBS方案,3例患者放弃手术,4例接受颈动脉血管成形术后再行心脏手术,其余患者则在双侧脑血氧饱和度监护下进行手术。在整个研究队列中,总计23例(2.2%)患者已有卒中史,且他们术后没有被诊断为脑出血;其他大多患者则被预估为有轻至中度卒中(的风险)。
结论:在这个单中心前瞻性的随访研究中,基于HBS的脑灌注监测显著降低了卒中的发生率,且大部分残留中风者具有良好的预后。

Friso Duynsteea, RuudW.M. Keunena,*, Agnes van Sonderena, Ali M. Keyhan-Falsafib, Gerard J.F. Hoohenkerkb, Gayleen Stephensb, Erik Teeuwsb, Jan W.K. van Alphenc, De´nes L.J. Tavya, ArneMoscha, Sebastiaan F.T.M. de Bruijna, Hans van Overhagend, Frank E.E. Treurnietd, Lucas C. vanDijkd and PaulienM. van Kampene
Abstract
OBJECTIVES
: This study prospectively evaluates the impact of the Haga Braincare Strategy (HBS) on the occurrence of haemodynamic and embolic stroke in a cohort of patients who underwent coronay artery bypass grafting (CABG), valve replacement of a combination of both types of surgery between 2012 and 2015 at the Haga Teaching Hospitals.
METHODS: The HBS is a dual strategy based on a preoperative vascular work-up of the cerebral circulation by transcranial Doppler and a perioperative monitoring of the cerebral circulation by cerebral oximetry. Duplex of the carotid arteries and/or computed tomography angiography prior to surgery was performed in high-risk patients. Patients with severe carotid artery stenosis were scheduled for carotid angioplasty prior to surgery or waived from surgery.
RESULTS: A total of 1065 patients were included. Poor cerebral haemodynamics were identified by transcranial Doppler in 2.1% of patients (n = 22). Based on the HBS, 3 patients were waived from surgery, 4 received preoperative carotid angioplasty followed by cardiac surgery and the remaining patients were operated while being monitored with bilateral cerebral oximetry sensors. In all, 2.2% of the study group experienced a stroke (n = 23), of which none were classified as haemodynamic. Most of the remaining presumed embolic strokes showed a minor to moderate stroke severity.
CONCLUSIONS: In this single-centre prospective follow-up study, surveillance of cerebral perfusion by the HBS eliminated the occurrence of haemodynamic stroke while most of the residual strokes had a good to favourable prognosis.
Keywords: TCD • cerebral oximetry • CABG • Stroke
INTRODUCTION
Perioperative stroke (POS) can be a devastating complication following cardiac surgery. The incidence of POS in the literature varies between 1 and 5% [1, 2]. POS is an important cause of morbidity and mortality after cardiac surgery. Most of POS are embolic in nature and presumed to be the result of intraoperative surgical manipulation of the aortic arch or postoperative atrial fibrillation (AF). However, a substantial number of the POS are haemodynamic in nature. Haemodynamic strokes are due to the combination of (i) high-grade stenosis or occlusions of conductance vessels (for instance the brachiocephalic artery, carotid and/or middle cerebral arteries [MCAs]), (ii) poor collaterals and/or (iii) a drop in systemic blood pressure and/or blood oxygenation. On computed tomography (CT) and magnetic resonance imaging a haemodynamic stroke appears as a so-called watershed infarct (see Fig. 1). With the ischaemia sensitive diffusion weighted magnetic resonance imaging watershed infarcts can be seen in up to 48% of the patients following a cardiosurgical procedure [3]. A recent systemic review and observational studies estimated that 10–50% of POS in cardiac surgery are haemodynamic in nature [4–6]. Recent CABG trials in patients with occlusive cerebrovascular disease showed stroke/death ratios ranging from 3.8% to 20.6%, indicating that poor-cerebral perfusion is associated with poor outcome. carotid arteries. Moreover, we combined preoperative TCD with non-invasive cerebral oximetry monitoring during and after the first hours of surgery in order to detect perioperative cerebral low-flow states. We called this dual strategy the ‘Haga Braincare Strategy’ (HBS). It turned out that implementation of the HBS reduced the incidence of ischaemic postoperative delirium at the Haga by more than 50% [10]. Since the last years, we have systematically implemented and documented the results of the HBS in a prospective follow-up study. In this article, we describe the results with special focus on the impact of the HBS on stroke epidemiology and how it influenced decision making.

Haga Braincare Strategy 2017.pdf