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Comment
. 2020 Sep;160(3):617-625.e5.
doi: 10.1016/j.jtcvs.2019.07.108. Epub 2019 Sep 5.

Unilateral is comparable to bilateral antegrade cerebral perfusion in acute type A aortic dissection repair

Elizabeth L Norton  1 , Xiaoting Wu  2 , Karen M Kim  2 , Himanshu J Patel  2 , G Michael Deeb  2 , Bo Yang  3
Affiliations
Comment

Unilateral is comparable to bilateral antegrade cerebral perfusion in acute type A aortic dissection repair

Elizabeth L Norton et al. J Thorac Cardiovasc Surg. 2020 Sep.

Abstract

Objective: To compare the short- and long-term outcomes of unilateral and bilateral antegrade cerebral perfusion (uni-ACP and bi-ACP) in acute type A aortic dissection (ATAAD) repair.

Methods: From 2001 to 2017, 307 patients underwent surgical repair of an ATAAD using uni-ACP (n = 140) and bi-ACP (n = 167). Data were collected through the Department of Cardiac Surgery Data Warehouse, medical record review, and the National Death Index database.

Results: The demographics and preoperative comorbidities were similar between the uni-ACP and bi-ACP groups. Both groups had similar rates of procedures for aortic valve/root, ascending aorta, frozen elephant trunk, and other concomitant procedures. Perioperative outcomes were not significantly different between the 2 groups (30-day mortality: uni-ACP 3.4% vs bi-ACP 7.8%, P = .12) except reoperation for bleeding was significantly lower in uni-ACP (5% vs 12%, P = .03). Between the uni-ACP and bi-ACP groups, overall postoperative stroke rate (6% vs 9%, P = .4) and left brain stroke rate (0.7% vs 3.0%, P = .23) were not significantly different. The odds ratio of uni-ACP versus bi-ACP was 0.87 (P = .80) for postoperative stroke and 0.86 (P = .81) for operative mortality. The mid-term survival was better in the uni-ACP group, P = .027 (5-year: 84% vs 76%). The hazard ratio of all-time mortality for uni-ACP versus bi-ACP was 0.74 (95% confidence interval, 0.33-1.65), P = .46.

Conclusions: In ATAAD, both uni-ACP and bi-ACP are equally effective to protect the brain with low postoperative stroke rates and mortality in hemiarch to zone 3 arch replacement. Uni-ACP is recommended for its simplicity and less manipulation of arch branch vessels.

Keywords: antegrade cerebral perfusion; aortic arch replacement; aortic dissection; stroke; survival.

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Conflict of interest statement

Conflict of Interest: None related to this study.

Figures

Figure 1:
Figure 1:
A) The distribution of new-onset postoperative stroke after ATAAD repair with unilateral or bilateral ACP. Only one patient had an embolic isolated left cerebral stroke, and no patients had an isolated left cerebral stroke due to hypoperfusion in the uni-ACP group. B) Survival (Kaplan-Meier analysis) of all patients with acute type A aortic dissection (ATAAD) repair utilizing unilateral and bilateral antegrade cerebral perfusion (uni-ACP or bi-ACP). The 5-year survival was better in the uni-ACP group compared to the bi-ACP group (84% vs. 76%). C) Cox proportional hazard regression model: Survival of a 60-year old male without comorbidities (including coronary artery disease, preoperative renal failure, acute myocardial infarction, acute paralysis, or cardiogenic shock), operated in 2017 utilizing uni-ACP vs. bi-ACP [HR=0.74 (95% CI: 0.33, 1.65, p=0.46)]. The curve was truncated at 10 years.
Central Picture:
Central Picture:
New-onset postoperative stroke after ATAAD repair with unilateral or bilateral ACP. Central Message: Unilateral ACP provides adequate cerebral protection and achieves favorable short-term outcomes and mid-term survival in acute type A aortic dissection repair as effectively as bilateral ACP.
See this image and copyright information in PMC

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References

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