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Original Articles: Adult Cardiac

What Is the Best Strategy for Brain Protection in Patients Undergoing Aortic Arch Surgery? A Single Center Experience of 636 Patients

Department of Cardiac Surgery, Heart Center, University of Leipzig, Leipzig, Germany

Accepted for publication January 31, 2012.

^_* Address correspondence to Dr Leontyev, Universität Leipzig, Herzzentrum, Klinik für Herzchirurgie, Strümpellstr 39, Leipzig 04289, Germany (Email: sergey.leontyev{at}med.uni-leipzig.de).

Background: Cerebral protection during aortic arch surgery can be performed using various surgical strategies. We retrospectively analyzed our results of different brain protection modalities during aortic arch surgery.

Methods: Between January 2003 and November 2009, 636 consecutive patients underwent aortic arch replacement surgery using unilateral antegrade cerebral perfusion (UACP [n = 123]), bilateral antegrade cerebral perfusion (BACP [n = 242]), retrograde cerebral perfusion (RCP [n = 51]), or deep hypothermia and circulatory arrest (DHCA [n = 220]). Mean age of patients was 62 ± 14 years, 64% were male, 15% were reoperations, and 37% were performed for acute type A dissections. Mean follow-up was 4.9 ± 0.1 years and was 97% complete.

Results: Circulatory arrest time was 22 ± 17 minutes UACP, 23 ± 21 minutes BACP, 18 ± 12 minutes RCP, and 15 ± 13 minutes DHCA; p < 0.001). Early mortality was 11% (n = 72) and was not different between the surgical groups. Stroke rate was 9% for ACP patients (n = 33) versus 15% (n = 39) for patients who did not receive ACP (p = 0.035). Independent predictors of stroke were type A aortic dissection (odds ratio [OR], 1.9; 95% confidence interval [CI], 1.3 to 3.2; p < 0.001), age (OR, 1.04; 95% CI, 1.01 to 1.06; p = 0.001), duration of circulatory arrest (OR, 1.01, 95% CI, 1.002 to 1.03; p = 0.02), and total aortic arch replacement (OR, 2.7; 95% CI, 1.3 to 5.7; p = 0.005). Five year survival was 68% ± 4% and was not significantly different between groups.

Conclusions: Antegrade cerebral perfusion is associated with significantly less neurologic complications than RCP and DHCA, despite longer circulatory arrest times. Medium-term survival is worse for patients with postoperative permanent neurologic deficit and preoperative type A aortic dissection.

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Invited Commentary

Y. Joseph Woo
Ann. Thorac. Surg. 2012 93: 1508-1509. [Extract] [Full Text] [PDF]

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