Different hypothermic and cerebral perfusion strategies in extended arch replacement for acute type a aortic dissection: a retrospective comparative study

Abstract

Background The optimal hypothermic level in total arch replacement with stented elephant trunk implantation for acute type A aortic dissection (aTAAD) has not been established, and the superiority of unilateral or bilateral cerebral perfusion remains a controversial issue. Therefore, we evaluated the application of moderate hypothermic circulatory arrest (MHCA) with a core temperature of 29 °C and bilateral selective antegrade cerebral perfusion in aTAAD treated by total arch replacement with stented elephant trunk implantation. Methods From July 2019 to January 2020, 25 aTAAD patients underwent total arch replacement with stented elephant trunk implantation via MHCA (29 °C) and bilateral selective antegrade cerebral perfusion (modified group). Thirty-six patients treated by the same procedure with MHCA (25 °C) and unilateral selective antegrade cerebral perfusion during this period were selected as controls. Results There were no differences between the two groups of patients in terms of age, sex, incidence of hypertension, malperfusion, and pericardial effusion, although the incidence of cardiac tamponade was higher in the modified group (control 2.8%, modified 20%; P = 0.038). The lowest mean circulatory arrest temperature was 24.6 ± 0.9 °C in the control group, and 29 ± 0.8 °C in the modified group (P < 0.001). In-hospital mortality was 4.9% (3/61) for the entire cohort (control 8.3%, modified 0; P = 0.262). The incidence of permanent neurologic deficit was 4.9% (control 8.3%, modified 0; P = 0.262). There were no significant differences in the occurrence of temporary neurological deficit, renal failure, and paraplegia between groups. The rate of major adverse events in the modified group was lower (30.6% vs. 4%, P = 0.019). A shorter duration of ventilation and ICU stay was identified in the modified group, as well as a reduced volume of drainage within the first 48 h and red blood cell transfusion. Conclusions The early results of MHCA (29 °C) and bilateral selective antegrade cerebral perfusion applied in total arch replacement with stented elephant trunk implantation for aTAAD were acceptable, providing similar inferior cerebral and visceral protection compared with that of the conventional strategy. A higher core temperature may account for the shorter duration of ventilation and ICU stay, as well as a reduced volume of drainage and red blood cell transfusion.

Unilateral versus bilateral anterograde cerebral perfusion in acute type A aortic dissection repair: A systematic review and meta-analysis

“…Detailed study selection process is presented inSupplemental Figure 1 . Ultimately, 8 studies reporting on cumulatively 2416 patients, 843 patients undergoing UACP and 1573 patients undergoing BACP were included in this metaanalysis 6,7,[16][17][18][19][20][21] . Study characteristics are reported in Table 1 .…”

“…ICU stay duration was reported in five studies 7,16,17,19,20 . UACP demonstrated increased ICU stay length compared to BACP (SMD: 0.16, 95%CI: [0.01] -[0.31], p =0.04, I 2 =28.56%).…”

“…Re-exploration for bleeding was available in 6 studies 6,7,[17][18][19][20] . No statistically significant difference was observed between the UACP group and the BACP group in terms of re-exploration for bleeding (OR: 0.77, 95%CI: [0.48] - [1.22].…”

“…6,[16][17][18][19][20][21] and no difference was noted between UACP and BACP groups (SMD: -0.04, 95%CI: [-0.38] -[0.29], p =0.79, I 2 =91.29%). CPB duration was reported in 7 studies6,7,16,17,[19][20][21] .…”

“…6,[16][17][18][19][20][21] and no difference was noted between UACP and BACP groups (SMD: -0.04, 95%CI: [-0.38] -[0.29], p =0.79, I 2 =91.29%). CPB duration was reported in 7 studies6,7,16,17,[19][20][21] . CPB time did not differ significantly between the groups (SMD: 0.11, 95%CI: [-0.22] -[0.44], p =0.52, I 2 =89.65%).…”