The Standardized Concept of Moderate-to-Mild (≥28°C) Systemic Hypothermia During Selective Antegrade Cerebral Perfusion for All-Comers in Aortic Arch Surgery: Single-Center Experience in 587 Consecutive Patients Over a 15-Year Period

Abstract

Background: Whether selective antegrade cerebral perfusion (ACP) during moderate-to-mild systemic hypothermia (≥28°C) is applicable to aortic arch surgery without restrictions including the emergency setting of an acute type A aortic dissection or extensive total arch procedures such as elephant and frozen elephant trunk techniques is an ongoing subject of controversy.

Methods: Between January 2000 and January 2015, 587 consecutive all-comers underwent aortic arch surgery at our institution uniformly applying selective ACP (unilateral: n = 393 [67%]; bilateral: n = 194 [33%]) during moderate-to-mild systemic hypothermia (28.7 ± 0.6°C). Patients' mean age was 68 ± 16 years, 405 patients (69%) were men, and 219 patients (37%) had acute type A aortic dissection. Hemiarch replacement was performed in 386 patients (66%) whereas the remaining 201 patients (34%) underwent total arch replacement including elephant trunk (n = 74 [13%]) and frozen elephant trunk (n = 37 [6%]) procedures. Fifty-six patients (10%) have had previous aortic arch surgery. Clinical data were prospectively entered into our institutional database.

Results: Cardiopulmonary bypass time accounted for 183 ± 67 min and myocardial ischemic time reached 110 ± 45 min. Mean duration of selective ACP was 48 ± 21 (range, 12 to 135) min. Chest tube drainage during the first 24 h accounted for 597 ± 438 mL. Mean ventilation time was 31 ± 18 h. Reexploration for bleeding and postoperative renal replacement therapy was necessary in 74 patients (13%) and 49 patients (8%), respectively. Mean intensive care unit stay was 4 ± 5 days. We observed new postoperative permanent neurologic deficits in 34 patients (6%; stroke: n = 33 [6%]; paraplegia: n = 1 [0.17%]) and transient neurologic deficits in 29 patients (5%). Thirty-day mortality was 6% (n = 36).

Conclusions: Current data suggest that selective ACP in combination with moderate-to-mild systemic hypothermia offers sufficient neurologic and visceral organ protection to all-comers requiring aortic arch surgery without pathological or procedural limitations.