Predictors of Outcomes after Correction of Acute Type A Aortic Dissection under Moderate Hypothermic Circulatory Arrest and Antegrade Cerebral Perfusion

Abstract

IntroductionHypothermic circulatory arrest is widely used for correction of acute type A aortic dissection pathology. We present our experience of 45 consecutive patients operated in our unit with bilateral antegrade cerebral perfusion and moderate hypothermic circulatory arrest.MethodsBetween January 2011 and April 2015, 45 consecutive patients were admitted for acute type A aortic dissection and operated emergently under moderate hypothermic circulatory arrest and bilateral antegrade cerebral perfusion. ResultsMean age was 58±11.4 years old. Median circulatory arrest time was 41.5 (30-54) minutes while the 30-day mortality and postoperative permanent neurological deficits rates were 6.7% and 13.3%, respectively. Unadjusted analysis revealed that the factors associated with 30-day mortality were: preoperative hemodynamic instability (OR: 14.8, 95% CI: 2.41, 90.6, P=0.004); and postoperative requirement for open sternum management (OR: 5.0, 95% CI: 1.041, 24.02, P=0.044) while preoperative hemodynamic instability (OR: 8.8, 95% CI: 1.41, 54.9, P=0.02) and postoperative sepsis or multiple organ dysfunction (OR: 13.6, 95% CI: 2.1, 89.9, P=0.007) were correlated with neurological dysfunction. By multivariable logistic regression analysis, postoperative sepsis and multiple organ dysfunction independently predicted (OR: 15.9, 95% CI: 1.05, 96.4, P=0.045) the incidence of severe postoperative neurological complication. During median follow-up of 6 (2-12) months, the survival rate was 86.7%.ConclusionBilateral antegrade cerebral perfusion and direct carotid perfusion for cardiopulmonary bypass, in the surgical treatment for correction of acute aortic dissection type A, is a valuable technique with low 30-day mortality rate. However, postoperative severe neurological dysfunctions remain an issue that warrants further research.

Meta-analysis: Bilateral and Unilateral Cerebral Perfusion in Type A Dissection

“…However, ACP is generally favored in cases involving longer periods of body circulatory arrest, especially when total aortic arch replacement is necessary. 2,6 ACP encompasses two main techniques 11 : bilateral cerebral perfusion (BCP) 12 and unilateral cerebral perfusion (UCP). 9 BCP provides antegrade perfusion to both cerebral hemispheres, whereas UCP involves antegrade perfusion to only one side (typically the right side), with the other side receiving perfusion through collateral vessels, including the circle of Willis.…”