Neuroprotective strategies with circulatory arrest in open aortic surgery - A meta-analysis

Abstract

Objective: Deep hypothermic circulatory arrest (DHCA) in aortic surgery is associated with morbidity and mortality despite evolving strategies. With the advent of antegrade cerebral perfusion (ACP), moderate hypothermic circulatory arrest (MHCA) was reported to have better outcomes than DHCA. There is no standardised guideline or consensus regarding the hypothermic strategies to be employed in open aortic surgery. Meta-analysis was performed comparing DHCA with MHCA + ACP in patients having aortic surgery.

Methods: A systematic review of the literature was undertaken. Any studies with DHCA versus MHCA + ACP in aortic surgeries were selected according to specific inclusion criteria and analysed to generate summative data. Statistical analysis was performed using STATS Direct. The primary outcomes were hospital mortality and post-operative stroke. Secondary outcomes were cardiopulmonary bypass time (CPB), post-operative blood transfusion, length of ICU stay, respiratory complications, renal failure and length of hospital stay. Subgroup analysis of primary outcomes for Arch surgery alone was also performed.

Results: Fifteen studies were included with a total of 5869 patients. There was significantly reduced mortality (Pooled OR = +0.64, 95% CI = +0.49 to +0.83; p = 0.0006) and stroke rate (Pooled OR = +0.62, 95% CI = +0.49 to +0.79; p < 0.001) in the MHCA group. MHCA was associated significantly with shorter CPB times, shorter duration in ICU, less pulmonary complications, and reduced rates of sepsis. There was no statistical difference between the two groups in terms of circulatory arrest times, X-Clamp times, total operation duration, transfusion requirements, renal failure and post-op hospital stay.

Conclusion: MHCA + ACP are associated with significantly better post-operative outcomes compared with DHCA for both mortality and stroke and majority of the secondary outcomes.

Keywords: Cerebral protection; aortic disease; aortic surgery; hypothermic circulatory arrest; selective antegrade cerebral protection.

Figure 1.

Quorum chart showing study selection for meta-analysis.

Figure 2.

(A) Forest plot of the odds ratio (OR) of post-operative mortality comparing aortic arch surgeries using deep hypothermic circulatory arrest (DHCA) or using moderate hypothermic circulatory arrest with selective antegrade cerebral protection (MHCA + SACP) as cerebral protection strategies. (B) Forest plot of the odds ratio (OR) of post-operative stroke comparing aortic arch surgeries using deep hypothermic circulatory arrest (DHCA) or using moderate hypothermic circulatory arrest with selective antegrade cerebral protection (MHCA + SACP) as cerebral protection strategies.

Figure 3.

Forest plot of the weighted mean differences (wmd) of peri-operative operative continuous variables including (A) CPB (B) circulatory arrest time (C) cross clamp time and (4) operation time during aortic arch surgeries using DHCA or using moderate MHCA + SACP as cerebral protection strategies.

Figure 4.

Forest plot of the weighted mean differences (wmd) of post-operative operative continuous variables including (A) blood transfusion (B) intubation (C) ICU stay and (4) LOS, during aortic arch surgeries using DHCA or using moderate MHCA + SACP as cerebral protection strategies.