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Ann Thorac Surg 2007;84:759-767
© 2007 The Society of Thoracic Surgeons

Original Articles: Cardiovascular

Straight Deep Hypothermic Arrest: Experience in 394 Patients Supports Its Effectiveness as a Sole Means of Brain Preservation

Arjet Gega, MDa, John A. Rizzo, PhDc,d, Michele H. Johnson, MDb, Maryann Tranquilli, RNa, Emily A. Farkas, MDa, John A. Elefteriades, MDa,*

a Section of Cardiothoracic Surgery, Yale University School of Medicine, New Haven, Connecticut
b Department of Diagnostic Imaging, Yale University School of Medicine, New Haven, Connecticut
c Department of Preventive Medicine, State University of New York, Stony Brook, Stony Brook, New York
d Department of Economics, State University of New York, Stony Brook, Stony Brook, New York

Accepted for publication April 24, 2007.

* Address correspondence to Dr Elefteriades, Section of Cardiothoracic Surgery, FMB, 333 Cedar St, New Haven, CT 06510 (Email: john.elefteriades{at}yale.edu).

Presented at the Forty-third Annual Meeting of The Society of Thoracic Surgeons, San Diego, CA, Jan 29–31, 2007.

Background: The three methods of brain preservation for aortic arch surgery— straight deep hypothermic circulatory arrest (DHCA) without perfusion adjuncts, retrograde cerebral perfusion, and antegrade cerebral perfusion—remain controversial. Patients in this report underwent surgery solely with DHCA.

Methods: Straight DHCA at 19°C was used in 394 patients (267 males, 127 females) during a 10-year period. Mean age was 61.3 years (range, 15 to 88 years). Eighty-seven cases (22.1%) were urgent or emergencies. Thirty-eight (9.6%) were performed for descending or thoracoabdominal pathology and the rest for ascending/arch (102 hemiarch, 49 total arch). Ninety-one patients (23.1%) had dissections. The head was packed in ice. No barbiturate coma was used.

Results: DHCA lasted a mean of 31.0 minutes (range, 10 to 66 minutes). Reexploration for bleeding was required in 4.5% (18/394). Overall mortality was 6.3% (25/394). Mortality was 3.6% (11/307) for elective cases and 16% (14/87) for emergency cases. The stroke rate was 4.8% (19/394). The seizure rate was 3.1% (12/394). Forty-five patients with high professional cognitive demands (MD, PhD, attorney, etc) performed without detriment postoperatively. Among patients with DHCA exceeding 40 minutes, the stroke rate was 13.1% (8/61); a neuroradiologist’s review of brain computed tomography scans found 62.5% of these strokes (5/8) to be embolic and 37.5% (3/8) hypoperfusion related. By multivariable logistic regression, emergency operation and descending location increased morbidity and mortality.

Conclusions: Straight DHCA without adjunctive perfusion suffices as a sole means of cerebral protection. Stroke and seizure rates are low. Cognitive function, by clinical assessment, is excellent. Especially for straightforward ascending/arch reconstructions, there is little need for the added complexity of brain perfusion strategies.




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