A retrospective comparative study of deep hypothermic circulatory arrest, retrograde, and antegrade cerebral perfusion in aortic arch surgery.

OBJECTIVE

Despite theoretical advantages of antegrade (ACP) and retrograde cerebral perfusion (RCP) in addition to deep hypothermic arrest (DHA) in aortic arch surgery, there is still controversy about the best method of cerebral protection. We reviewed our experience with neurological outcome after aortic arch repair over the last five years.

METHODS

Sixty-two patients undergoing aortic arch repair were reviewed. Five patients (8.1%) had Marfan's syndrome, 11 (17.7%) had previous cardiac operations, and 13 (21.0%) also received coronary bypass grafting (CABG). The extent of arch replacement was proximal level in 40 (64.5%), distal level in 18 (29.0%), and total in 13 (21.0%). The method of cerebral protection was DHA alone in 14 patients, DHA with RCP in 23, and DHA with ACP in 25. Pre-, intra-, and postoperative variables in the three categories of cerebral protection were compared. Specifically, the independent predictors of mortality, stroke, and temporary neurological dysfunction (TND) were examined.

RESULTS

Overall hospital mortality was 5 (8.0%). Stroke occurred in 4 patients (6.4%), and TND in 5 (8.0%). There were no significant differences among the groups in mortality or neurological dysfunction. Total brain exclusion time (TBET) was significantly longer in ACP (DHA, 25.2+/-12.0 min; ACP, 61.8+/-44.1 min; RCP, 36.4+/-20.5 min; p=0.023). Multivariate analysis showed a trend for TBET of longer than 90 minutes as a predictor of stroke (p=0.06; odds ratio, 7.9). The actuarial survival rate was 88.7% at five years (DHA, 85.7%; ACP, 80.0%; RCP, 100%; no significant difference).

CONCLUSIONS

Despite more complicated arch repairs requiring a significantly longer cerebral exclusion time which were performed in the group receiving ACP, there was no significant increase in stroke or death rates. Increasing confidence in the ability of ACP has led us to perform the most appropriate arch repair without compromising the extent of replacement for fear of exceeding the "safe" period of circulatory arrest.