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Temporary neurological dysfunction after surgery of the thoracic aorta: a predictor of poor outcome and impaired quality of life

Department of Cardiovascular Surgery, University Hospital, 3010 Berne, Switzerland

Received 20 September 2007; received in revised form 22 January 2008; accepted 28 January 2008.

^_* Corresponding author. Tel.: +41 31 632 04 77; fax: +41 31 632 44 43. (Email: franz.immer{at}insel.ch).

Background: Transient neurological dysfunction (TND) consists of postoperative confusion, delirium and agitation. It is underestimated after surgery on the thoracic aorta and its influence on long-term quality of life (QoL) has not yet been studied. This study aimed to assess the influence of TND on short- and long-term outcome following surgery of the ascending aorta and proximal arch. Methods: Nine hundred and seven patients undergoing surgery of the ascending aorta and the proximal aortic arch at our institution were included. Two hundred and ninety patients (31.9%) underwent surgery because of acute aortic dissection type A (AADA) and 617 patients because of aortic aneurysm. In 547 patients (60.3%) the distal anastomosis was performed using deep hypothermic circulatory arrest (DHCA). TND was defined as a Glasgow coma scale (GCS) value <13. All surviving patients had a clinical follow up and QoL was assessed with an SF-36 questionnaire. Results: Overall in-hospital mortality was 8.3%. TND occurred in 89 patients (9.8%). As compared to patients without TND, those who suffered from TND were older (66.4 vs 59.9 years, p < 0.01) underwent more frequently emergent procedures (53% vs 32%, p < 0.05) and surgery under DHCA (84.3% vs 57.7%, p < 0.05). However, duration of DHCA and extent of surgery did not influence the incidence of TND. In-hospital mortality in the group of patients with TND compared to the group without TND was similar (12.0% vs 11.4%; p = ns). Patients with TND suffered more frequently from coronary artery disease (28% vs 20.8%, p = ns) and were more frequently admitted in a compromised haemodynamic condition (23.6% vs 9.9%, p < 0.05). Postoperative course revealed more pulmonary complications such as prolonged mechanical ventilation. Additional to their transient neurological dysfunction, significantly more patients had strokes with permanent neurological loss of function (14.6% vs 4.8%, p < 0.05) compared to the patients without TND. ICU and hospital stay were significantly prolonged in TND patients (18 ± 13 days vs 12 ± 7 days, p < 0.05). Over a mean follow-up interval of 27 ± 14 months, patients with TND showed a significantly impaired QoL. Conclusion: The neurological outcome following surgery of the ascending aorta and proximal aortic arch is of paramount importance. The impact of TND on short- and long-term outcome is underestimated and negatively affects the short- and long-term outcome.

Key Words: Thoracic aorta • Neurological dysfunction • Outcome