Hypothermia and cerebral protection strategies in aortic arch surgery: a comparative effectiveness analysis from the STS Adult Cardiac Surgery Database

Abstract

In a comparative effectiveness study of cerebral protection strategies for aortic arch repair, strategies without adjunctive CP, including the most commonly utilized strategy of straight D/P hypothermia, appeared inferior to those utilizing CP. There was no clearly superior strategy among remaining techniques, and randomized trials are needed to define best practice.

Cerebral protection strategies in aortic arch surgery: A network meta-analysis

“…Our results are in line with those of Englum and associates, 30 who compared all the different combinations of neuroprotection during aortic arch surgery using data of 12,521 patients from the Society of Thoracic Surgeons Database and found that DHCA was associated with the highest risk of the combined end point of operative mortality or neurologic complication.…”

“…A recent survey shows that most European surgeons use ACP and RCP for emergency cases, 29 whereas in the United States, data from the 2017 Society of Thoracic Surgery Database show that DHCA is the most commonly used method. 30 In the past, several meta-analyses have compared the different cerebral protection strategies in pairwise comparisons. Takagi and colleagues 8 compared ACP and RCP in a pooled analysis of 19 studies and 15,365 patients, and found no difference in operative mortality and postoperative stroke (OR, 1.07, 95% CI, 0.90-1.26, P ¼ .46; and OR, 0.92, 95% CI, 0.79-1.08, P ¼ .32, respectively).…”

Hybrid and total endovascular repair of the aortic arch

“…Such outcomes, however, should be seen as the exception, rather than the rule; in a recent report of over 12 500 aortic arch repairs from the American Society of Thoracic Surgeons database 29 , the mortality and stroke rates for the entire cohort were 12 and 8 per cent respectively. Moreover, one-quarter of patients in this database underwent deep or profound hypothermic circulatory arrest (below 20 ∘ C) without adjunctive cerebral perfusion 30 , despite good evidence that moderate hypothermic arrest (20-28 ∘ C) and adjunctive cerebral perfusion are superior operative strategies 31,32 . The composite stroke and death rate in this cohort was 23 per cent, compared with 8 per cent in patients who underwent antegrade cerebral perfusion 30 .…”

“…Moreover, one-quarter of patients in this database underwent deep or profound hypothermic circulatory arrest (below 20 ∘ C) without adjunctive cerebral perfusion 30 , despite good evidence that moderate hypothermic arrest (20-28 ∘ C) and adjunctive cerebral perfusion are superior operative strategies 31,32 . The composite stroke and death rate in this cohort was 23 per cent, compared with 8 per cent in patients who underwent antegrade cerebral perfusion 30 .…”

Simple retrograde cerebral perfusion is as good as complex antegrade cerebral perfusion for hemiarch replacement

“…They found that there was no significant difference between these adjuncts with regard to incidence of 30-day mortality or PND/TND but shorter ICU stay in ACP group. Similarly, Englum and colleagues utilized Society of Thoracic Surgeons database and reviewed aortic arch repair with hypothermic circulatory arrest (36% elective, 8% total arch, median circulatory arrest time of 27 minutes), in which they found 4,418 cases with ACP and 3,149 with RCP for adjunctive cerebral protection strategies, and concluded that outcomes-including operative mortality and neurological complications-were similar between RCP and ACP (29). Thus, studies with patients greater than 1,000 in each arm of RCP and ACP failed to demonstrate the significant difference between the groups after aortic arch repair.…”