The Standardized Concept of Moderate-to-Mild (≥28°C) Systemic Hypothermia During Selective Antegrade Cerebral Perfusion for All-Comers in Aortic Arch Surgery: Single-Center Experience in 587 Consecutive Patients Over a 15-Year Period

• Published in: The Annals of thoracic surgery Vol. 104; no. 1; pp. 49 - 55
• Main Authors: El-Sayed Ahmad, Ali, MD, Papadopoulos, Nestoras, MD, Risteski, Petar, MD, Moritz, Anton, MD, Zierer, Andreas, MD
• Format: Journal Article
• Language: English
• Published: Netherlands Elsevier Inc 01.07.2017
• Subjects: Aged; Aneurysm, Dissecting - physiopathology; Aneurysm, Dissecting - surgery; Aorta, Thoracic - surgery; Aortic Aneurysm, Thoracic - physiopathology; Aortic Aneurysm, Thoracic - surgery; Body Temperature; Brain Ischemia - physiopathology; Brain Ischemia - prevention & control; Cardiothoracic Surgery; Cerebrovascular Circulation - physiology; Female; Follow-Up Studies; Forecasting; Humans; Hypothermia, Induced - methods; Male; Perfusion - methods; Retrospective Studies; Surgery; Treatment Outcome; Vascular Surgical Procedures - methods
• ISSN: 0003-4975; 1552-6259
• DOI: 10.1016/j.athoracsur.2016.10.024

Background Whether selective antegrade cerebral perfusion (ACP) during moderate-to-mild systemic hypothermia (≥28°C) is applicable to aortic arch surgery without restrictions including the emergency setting of an acute type A aortic dissection or extensive total arch procedures such as elephant and frozen elephant trunk techniques is an ongoing subject of controversy. Methods Between January 2000 and January 2015, 587 consecutive all-comers underwent aortic arch surgery at our institution uniformly applying selective ACP (unilateral: n = 393 [67%]; bilateral: n = 194 [33%]) during moderate-to-mild systemic hypothermia (28.7 ± 0.6°C). Patients’ mean age was 68 ± 16 years, 405 patients (69%) were men, and 219 patients (37%) had acute type A aortic dissection. Hemiarch replacement was performed in 386 patients (66%) whereas the remaining 201 patients (34%) underwent total arch replacement including elephant trunk (n = 74 [13%]) and frozen elephant trunk (n = 37 [6%]) procedures. Fifty-six patients (10%) have had previous aortic arch surgery. Clinical data were prospectively entered into our institutional database. Results Cardiopulmonary bypass time accounted for 183 ± 67 min and myocardial ischemic time reached 110 ± 45 min. Mean duration of selective ACP was 48 ± 21 (range, 12 to 135) min. Chest tube drainage during the first 24 h accounted for 597 ± 438 mL. Mean ventilation time was 31 ± 18 h. Reexploration for bleeding and postoperative renal replacement therapy was necessary in 74 patients (13%) and 49 patients (8%), respectively. Mean intensive care unit stay was 4 ± 5 days. We observed new postoperative permanent neurologic deficits in 34 patients (6%; stroke: n = 33 [6%]; paraplegia: n = 1 [0.17%]) and transient neurologic deficits in 29 patients (5%). Thirty-day mortality was 6% (n = 36). Conclusions Current data suggest that selective ACP in combination with moderate-to-mild systemic hypothermia offers sufficient neurologic and visceral organ protection to all-comers requiring aortic arch surgery without pathological or procedural limitations.