Changes Of Regional Cerebral Oxygen Saturation,S100β Protein,Neuron Specific Enolase And Their Relationship With Early Perioperative Neurocognitive Disorders After Total Aortic Arch Replacement And Trunk Stenting

Objective:Perioperative neurocognitive disorders（PND）are common complications after anesthesia and surgery.It is characterized by impaired memory and decreased information processing ability.PND seriously affects the quality of life and prognosis of patients,and even leads to increased mortality.The incidence of PND in cardiac surgery under CPB is very high,especially in total arch replacement and trunk stent,deep hypothermia and circulatory arrest（DHCA）technology is used,which is prone to cerebral ischemia and hypoxia,and is more likely to be complicated with PND.Early prediction of the occurrence of PND and intervention measures remain to be solved.Studies have shown a significant correlation between decreased regional cerebral oxygen saturation（r Sc O₂）during cardiac surgery and postoperative neurological complications.Intraoperative changes in r Sc O₂are more clinically significant in predicting the occurrence of PND than changes in baseline values.There are few reports on the relationship between PND and r Sc O₂after total arch replacement and trunk stenting.The purpose of this study was to investigate the predictive value of r Sc O₂monitoring for PND during total arch replacement and stent trunk surgery,and the relationship between the changes of nerve injury marker S100βprotein and neuron-specific enolase（NSE）concentrations and PND,and to analyze the risk factors of PND.To provide reference basis for preventing and reducing the occurrence of PND after cardiac surgery in DHCA.Methods:Sixty-five Stanford type A aortic dissection patients who were to undergo total arch replacement and stent elephantism were selected.r Sc O₂was continuously monitored during the operation and r Sc O₂and MAP values were recorded after induction（T₁）,the beginning of CPB（T₂）,cryogenic stop circulation（T₃）,rewarming to 36℃（T₄）,CPB stop for 1h（T₅）,and after surgery（T₆）,respectively.The mean value of intraoperative r Sc O₂,the minimum value of intraoperative r Sc O₂(r Sc O_2min),the maximum percentage of r Sc O₂decline from the base value(r Sc O_2%max)and the duration were calculated.Central venous blood was collected after induction（T_a）,rewarming to 36℃（T_b）,stopping CPB for 1h（T_c）,6h（T_d）,and 24h（T_e）,respectively.The concentrations of S100βprotein and NSE were detected by ELISA.Cognitive function was assessed by mini-mental-state-examination（MMSE）scale before surgery,on the day of extubation and 7 days after surgery.All patients were divided into PND group and non-PND group for comparison.The dynamic changes of r Sc O₂value,MAP value and concentration levels of two biochemical indicators at any point in time were analyzed,and the differences between PND group and non-PND group were analyzed,so as to evaluate the value of r Sc O₂in predicting early PND after total arch replacement and trunk support.The basic data and perioperative variables of patients with total aortic arch replacement and stent elephantism were collected to screen the risk factors of early PND after total aortic arch replacement and stent elephantism.Results:1.A total of 136 Stanford Type A aortic dissection patients who were to undergo total arch replacement and stent elephantism were collected.In strict accordance with the inclusion and exclusion criteria,65 patients were finally included in this study,including 29 patients in the PND group and 36 patients in the non-PND group,with an incidence of PND of 44.6%.2.There was no significant difference in preoperative MMSE scores between the two groups（P>0.05）,and the MMSE scores of the PND group on the day of extubation and 7 days after surgery were lower than those of the non-PND group（P<0.01）.3.r Sc O₂value at T₂was significantly lower than that at T₁（P<0.05）;r Sc O₂in T₃and T₆groups was significantly lower than that in T₁and non-PND groups（P<0.05）.The mean value of r Sc O₂and r Sc O_2minin PND group were significantly lower than those in non-PND group,and r Sc O_2%maxwas significantly higher than that in non-PND group（P<0.05）,but there was no significant difference in the duration of r Sc O₂decline between the two groups（P>0.05）.The ROC curve determined that the critical value of r Sc O_2%maxwas>9.89%,the predicted area under the curve of PND was 0.658（95%CI:0.525～0.791,P<0.05）,and the sensitivity and specificity were 48.3%and75.0%,respectively.4.The concentrations of S100βprotein and NSE at T_cand T_dpoints in PND group were significantly higher than those in non-PND group（P<0.01）,and the concentrations of S100βprotein and NSE in PND group peaked at T_c.Compared with T_a,S100βprotein concentration in T_cand T_dpatients in PND group was significantly increased（P<0.001）.The protein concentration of S100βin non-PND group was higher in T_dthan in T_a（P<0.05）.Compared with T_a,NSE concentration in T_b,T_c,T_dand T_ein PND group was significantly increased（P<0.01）.The concentration of NSE in T_dand T_ein non-PND group was higher than that in Ta group（P<0.05）.5.There was no statistical significance in MAP between the two groups（P>0.05）;MAP at T₂,T₃and T₄was significantly lower than that at T₁（P<0.001）.In PND group,MAP at T₆was higher than that at T₁（P<0.05）.6.Univariate analysis showed that there were statistically significant differences between PND group and non-PND group in whether patients smoked or tookβ-blockers（P<0.05）.The duration of anesthesia,operation,mechanical ventilation and CPB in PND group was significantly longer than that in non-PND group（P<0.05）.7.Multivariate Logistic regression analysis showed that smoking（OR=3.412,95%CI:1.412～11.258,P<0.05）and CPB time（OR=1.011,95%CI:1.001～1.022,P<0.05）were independent risk factors for the occurrence of PND.Hosmer-Lemeshow test showed that the model had good goodness of fit（χ²=3.160,P=0.870）.The ROC curve showed that CPB time>215 min was significant in predicting PND.The area under the curve（AUC）of predicting PND was 0.695（95%CI:563～826,P<0.01）,the sensitivity was 72.4%,and the specificity was 61.1%.Conclusions:1.The decrease of r Sc O₂during total arch replacement and trunk stent operation may predict central nervous system injury,and the maximum percentage decrease of r Sc O₂from the base value during operation is>9.89%,which can be used as a potential predictor of PND occurrence.2.The increased concentration of S100βprotein and NSE may be helpful in the diagnosis of early PND after total aortic arch replacement and trunk stenting.3.Smoking,takingβ-blockers,anesthesia duration,operation duration,CPB duration and mechanical ventilation duration had an effect on the occurrence of PND.Smoking and CPB duration were independent risk factors for the occurrence of PND,and CPB duration>215min was significant in predicting the occurrence of PND.