Aortic arch surgery with hypothermic circulatory arrest and unilateral antegrade cerebral perfusion: Perioperative outcomes

Abstract

Objective: The study objective was to determine the effects of surgical procedures, circulatory management strategies, and cerebral protection strategies on the short-term outcomes of aortic arch surgery based on the 7-year clinical experience of a single center.

Methods: We analyzed the data of 1708 patients who underwent aortic arch surgery with definite hypothermic circulatory arrest and unilateral antegrade cerebral perfusion at Beijing Anzhen Hospital between 2009 and 2015. Logistic regression and random Forest regression analyses were used to determine predictors and their effects on outcomes.

Results: Thirty-day mortality was 6.1%. Permanent neurologic dysfunction incidence was 4.8%. The proportion of patients requiring continuous renal replacement therapy was 7.9%. In multivariable analyses, age, DeBakey type I dissection, New York Heart Association score, coma, coronary artery bypass grafting, extra-anatomic bypass, and cardiopulmonary bypass time were independent risk factors for mortality. Age, DeBakey type I dissection, and cardiopulmonary bypass time were independent risk factors for permanent neurologic dysfunction. In the random Forest regression, the risk for permanent neurologic dysfunction and mortality increased when unilateral antegrade cerebral perfusion time was more than 38 minutes and decreased with an increase in nasopharyngeal temperature when temperature was lower than approximately 24°C. The risk for permanent neurologic dysfunction, continuous renal replacement therapy, and paraplegia increased when temperature was greater than approximately 24°C.

Conclusions: The study showed that the largest reported cohort of patients undergoing aortic arch surgery with hypothermic circulatory arrest and unilateral antegrade cerebral perfusion had reasonable morbidity and mortality rates. As a cerebral protection strategy, unilateral antegrade cerebral perfusion may have a 38-minute safety threshold. Moderate hypothermia should be maintained below 24°C to reduce the risk for permanent neurologic dysfunction, paraplegia, and acute renal dysfunction requiring continuous renal replacement therapy.

Keywords: aortic arch surgery; cerebral protection strategy; unilateral antegrade cerebral perfusion.