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Comparative Study
. 2017 Sep 1;52(3):492-498.
doi: 10.1093/ejcts/ezx133.

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

Brian R Englum  1   2 , Xia He  2 , Brian C Gulack  1   2 , Asvin M Ganapathi  1 , Joseph P Mathew  3 , J Matthew Brennan  2 , T Brett Reece  4 , W Brent Keeling  5 , Bradley G Leshnower  5 , Edward P Chen  5 , Jeffrey P Jacobs  6 , Vinod H Thourani  5 , G Chad Hughes  1
Affiliations
Comparative Study

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

Brian R Englum et al. Eur J Cardiothorac Surg. .

Abstract

Objectives: Hypothermic circulatory arrest is essential to aortic arch surgery, although consensus regarding optimal cerebral protection strategy remains lacking. We evaluated the current use and comparative effectiveness of hypothermia/cerebral perfusion (CP) strategies in aortic arch surgery.

Methods: Using the Society of Thoracic Surgeons Database, cases of aortic arch surgery with hypothermic circulatory arrest from 2011 to 2014 were categorized by hypothermia strategy-deep/profound (D/P; ≤20°C), low-moderate (L-M; 20.1-24°C), and high-moderate (H-M; 24.1-28°C)-and CP strategy-no CP, antegrade (ACP), retrograde (RCP) or both ACP/RCP. After adjusting for potential confounders, strategies were compared by composite end-point (operative mortality or neurologic complication).

Results: Of the 12 521 aortic arch repairs with hypothermic circulatory arrest, the most common combined strategies were straight D/P without CP (25%), D/P + RCP (16%) and D/P + ACP (14%). Overall rates of the primary end-point, operative mortality and stroke were 23%, 12% and 8%, respectively. Among the 7 most common strategies, the 2 not utilizing CP (straight D/P and straight L-M) appeared inferior, associated with significantly higher risk of the composite end-point (odds ratio: 1.6; P < 0.01); there was no significant difference in composite outcome between the remaining strategies (D/P + ACP, D/P + RCP, L-M + ACP, L-M + RCP and H-M + ACP).

Conclusions: 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.

Keywords: Aneurysm; Aortic arch; Aortic dissection; Cardiopulmonary bypass; Hypothermia.

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