Moderate Hypothermic Circulatory Arrest with Antegrade Cerebral Perfusion for Rapid Total Arch Replacement in Acute Type A Aortic Dissection

Abstract

Background The optimal hypothermic level during circulatory arrest is controversial. The aim of our study was to comprehensively assess the impact of moderate hypothermic circulatory arrest with antegrade cerebral perfusion (ACP) on total aortic arch replacement.

Methods From 2010 to 2013, data were collected from 99 consecutive patients with acute type A aortic dissection. All patients underwent total arch replacement plus frozen elephant trunk procedure. There were 51 patients in the deep hypothermia circulatory arrest (DHCA) group and 47 in the moderate hypothermia circulatory arrest (MHCA) group. Either unilateral or bilateral ACP was applied for cerebral protection. Perioperative data and measured outcomes were compared.

Results Overall mean circulatory arrest time was 29.9 ± 6.0 minutes. Temporary neurologic dysfunction incidence was lower in the MHCA group compared with the DHCA group (21.3 vs. 40.4%, p = 0.041). The total 30-day mortality was 17.2% (14.9 vs. 19.2%, p = 0.568) and permanent neurologic dysfunction morbidity was 3.0% overall. In MHCA, less blood products were used than in DHCA. Moderate hypothermia was a protective factor for the composite outcome of temporary and permanent neurologic dysfunctions (odds ratio = 0.385; 95% confidence interval = 0.162–0.919). Hypothermic level did not significantly affect the perioperative alanine aminotransferase and serum creatinine levels.

Conclusion Within a short circulatory arrest time, MHCA combined with ACP seemed to be a safe and effective method to protect cerebral and visceral organs during total aortic arch replacement.

Keywords

acute type A aortic dissection - cerebral protection - frozen elephant trunk procedure - moderate hypothermia - total aortic arch replacement

• References

• 1 Algarni KD, Yanagawa B, Rao V, Yau TM. Profound hypothermia compared with moderate hypothermia in repair of acute type A aortic dissection. J Thorac Cardiovasc Surg 2014; 148 (6) 2888-2894
• 2 McCullough JN, Zhang N, Reich DL , et al. Cerebral metabolic suppression during hypothermic circulatory arrest in humans. Ann Thorac Surg 1999; 67 (6) 1895-1899 , discussion 1919–1921
• 3 Englum BR, Andersen ND, Husain AM, Mathew JP, Hughes GC. Degree of hypothermia in aortic arch surgery - optimal temperature for cerebral and spinal protection: deep hypothermia remains the gold standard in the absence of randomized data. Ann Cardiothorac Surg 2013; 2 (2) 184-193
• 4 Harrington DK, Lilley JP, Rooney SJ, Bonser RS. Nonneurologic morbidity and profound hypothermia in aortic surgery. Ann Thorac Surg 2004; 78 (2) 596-601
• 5 Yan TD, Bannon PG, Bavaria J , et al. Consensus on hypothermia in aortic arch surgery. Ann Cardiothorac Surg 2013; 2 (2) 163-168
• 6 Griepp RB, Stinson EB, Hollingsworth JF, Buehler D. Prosthetic replacement of the aortic arch. J Thorac Cardiovasc Surg 1975; 70 (6) 1051-1063
• 7 Ziganshin BA, Rajbanshi BG, Tranquilli M, Fang H, Rizzo JA, Elefteriades JA. Straight deep hypothermic circulatory arrest for cerebral protection during aortic arch surgery: safe and effective. J Thorac Cardiovasc Surg 2014; 148 (3) 888-898 , discussion 898–900
• 8 Stecker MM, Cheung AT, Pochettino A , et al. Deep hypothermic circulatory arrest: I. Effects of cooling on electroencephalogram and evoked potentials. Ann Thorac Surg 2001; 71 (1) 14-21
• 9 Cooper WA, Duarte IG, Thourani VH , et al. Hypothermic circulatory arrest causes multisystem vascular endothelial dysfunction and apoptosis. Ann Thorac Surg 2000; 69 (3) 696-702 , discussion 703
• 10 Cavus E, Hoffmann G, Bein B , et al. Cerebral metabolism during deep hypothermic circulatory arrest vs moderate hypothermic selective cerebral perfusion in a piglet model: a microdialysis study. Paediatr Anaesth 2009; 19 (8) 770-778
• 11 Numata S, Tsutsumi Y, Monta O , et al. Aortic arch repair with antegrade selective cerebral perfusion using mild to moderate hypothermia of more than 28°C. Ann Thorac Surg 2012; 94 (1) 90-95 , discussion 95–96
• 12 Qian H, Hu J, Du L, Xue Y, Meng W, Zhang EY. Modified hypothermic circulatory arrest for emergent repair of acute aortic dissection type a: a single-center experience. J Cardiothorac Surg 2013; 8: 125
• 13 Tsai JY, Pan W, Lemaire SA , et al. Moderate hypothermia during aortic arch surgery is associated with reduced risk of early mortality. J Thorac Cardiovasc Surg 2013; 146 (3) 662-667
• 14 Ma WG, Zheng J, Zhang W , et al. Frozen elephant trunk with total arch replacement for type A aortic dissections: does acuity affect operative mortality?. J Thorac Cardiovasc Surg 2014; 148 (3) 963-970 , discussion 970–972
• 15 Zierer A, Aybek T, Risteski P, Dogan S, Wimmer-Greinecker G, Moritz A. Moderate hypothermia (30 degrees C) for surgery of acute type A aortic dissection. Thorac Cardiovasc Surg 2005; 53 (2) 74-79
• 16 Kunihara T, Grün T, Aicher D , et al. Hypothermic circulatory arrest is not a risk factor for neurologic morbidity in aortic surgery: a propensity score analysis. J Thorac Cardiovasc Surg 2005; 130 (3) 712-718
• 17 Kamiya H, Hagl C, Kropivnitskaya I , et al. The safety of moderate hypothermic lower body circulatory arrest with selective cerebral perfusion: a propensity score analysis. J Thorac Cardiovasc Surg 2007; 133 (2) 501-509
• 18 Numata S, Thomson DS, Seah P, Singh T. Simplified cerebral protection using unilateral antegrade cerebral perfusion and moderate hypothermic circulatory arrest. Heart Lung Circ 2009; 18 (5) 334-336
• 19 Pacini D, Pantaleo A, Di Marco L , et al. Visceral organ protection in aortic arch surgery: safety of moderate hypothermia. Eur J Cardiothorac Surg 2014; 46 (3) 438-443
• 20 Vallabhajosyula P, Szeto WY, Pulsipher A , et al. Antegrade thoracic stent grafting during repair of acute Debakey type I dissection promotes distal aortic remodeling and reduces late open distal reoperation rate. J Thorac Cardiovasc Surg 2014; 147 (3) 942-948