Impact of Cerebral Perfusion on Outcomes of Aortic Surgery: The Society of Thoracic Surgeons Adult Cardiac Surgery Database Analysis.

BACKGROUND

Limited data inform cerebral protection during circulatory arrest. This study was designed to identify optimal approaches from a national clinical registry.

METHODS

A total of 7830 adults (mean age, 63.1 years, SD 13.1 years) who underwent hemiarch (n = 6891; 88.0%) or total arch (n = 939; 12.0%) replacement with hypothermic circulatory arrest between 2014 and 2016 were identified from The Society of Thoracic Surgeons Adult Cardiac Surgery Database (version 2.81). Aortic dissections were excluded from the analysis. Multivariable logistic regression was used to adjust for 29 baseline and operative variables, including demographics, comorbidity, surgery, and nadir temperature, comparing outcomes according to protection strategy. The primary end point was a composite of 30-day and in-hospital mortality or major permanent neurologic complications.

RESULTS

The rate of death or permanent neurologic complication was 10.9% (n = 850). Antegrade cerebral perfusion was most commonly used (n = 3369; 43%; median nadir temperature 23°C; median arrest time 30 minutes) compared with retrograde cerebral perfusion (n = 1898; 24%; 20°C; 24 minutes) and no cerebral perfusion (n = 2563; 33%; 20°C, 22 minutes). In multivariable analysis, deep hypothermia with antegrade (odds ratio [OR], 0.65; 95% confidence interval [CI], 0.52 to 0.81) or retrograde (OR, 0.57; 95% CI, 0.45 to 0.71) perfusion and moderate hypothermia with antegrade perfusion (OR, 0.61; 95% CI, 0.46 to 0.79) were associated with significant reductions in death and stroke compared with deep hypothermia without cerebral perfusion. Risk reduction was greatest in circulatory arrest lasting longer than 30 minutes.

CONCLUSIONS

For patients without aortic dissection and who require more than 30 minutes of circulatory arrest, optimal cerebral protection strategies are deep hypothermia with either antegrade or retrograde cerebral perfusion and moderate hypothermia with antegrade cerebral perfusion.