Implications from neurologic assessment of brain protection for total arch replacement from a randomized trial

• Published in: The Journal of thoracic and cardiovascular surgery Vol. 150; no. 5; pp. 1140 - 1147.e11
• Main Authors: Svensson, Lars G., MD, PhD, Blackstone, Eugene H., MD, Apperson-Hansen, Carolyn, MStat, Ruggieri, Paul M., MD, Ainkaran, Ponnuthurai, MS, Naugle, Richard I., PhD, Lima, Brian, MD, Roselli, Eric E., MD, Cooper, Maxwell, BS, Somogyi, David, CCP, Tuzcu, E. Murat, MD, Kapadia, Samir, MD, Clair, Daniel G., MD, Sabik, Joseph F., MD, Lytle, Bruce W., MD
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01.11.2015
• Subjects: Aged; Aorta, Thoracic - physiopathology; Aorta, Thoracic - surgery; aortic arch; Blood Vessel Prosthesis Implantation - adverse effects; Blood Vessel Prosthesis Implantation - methods; Blood Vessel Prosthesis Implantation - mortality; Brain Injuries - diagnosis; Brain Injuries - etiology; Brain Injuries - mortality; Brain Injuries - physiopathology; Brain Injuries - prevention & control; brain protection; Cardiothoracic Surgery; Cerebrovascular Circulation; circulatory arrest; Cognition; Cytoprotection; Female; Humans; Magnetic Resonance Imaging; Male; Middle Aged; Neurologic Examination - methods; Neuropsychological Tests; Ohio; Perfusion - adverse effects; Perfusion - methods; Perfusion - mortality; Predictive Value of Tests; Reproducibility of Results; Single-Blind Method; Time Factors; Tomography, X-Ray Computed; Treatment Outcome; Ohio; computed tomography; electroencephalography; RBP; magnetic resonance imaging; 26; MRI; antegrade brain perfusion; EEG; retrograde brain perfusion; TAVR; ABP; CT; brain protection; circulatory arrest; transcatheter aortic valve replacement; aortic arch
• ISSN: 0022-5223; 1097-685X
• DOI: 10.1016/j.jtcvs.2015.07.054

Abstract Objective The study objective was to perform a randomized trial of brain protection during total aortic arch replacement and identify the best way to assess brain injury. Methods From June 2003 to January 2010, 121 evaluable patients were randomized to retrograde (n = 60) or antegrade (n = 61) brain perfusion during hypothermic circulatory arrest. We assessed the sensitivity of clinical neurologic evaluation, brain imaging, and neurocognitive testing performed preoperatively and 4 to 6 months postoperatively to detect brain injury. Results A total of 29 patients (24%) experienced neurologic events. Clinical stroke was evident in 1 patient (0.8%), and visual changes were evident in 2 patients; all had brain imaging changes. A total of 14 of 95 patients (15%) undergoing both preoperative and postoperative brain imaging had evidence of new white or gray matter changes; 10 of the 14 patients had neurocognitive testing, but only 2 patients experienced decline. A total of 17 of 96 patients (18%) undergoing both preoperative and postoperative neurocognitive testing manifested declines of 2 or more reliable change indexes; of these 17, 11 had neither imaging changes nor clinical events. Thirty-day mortality was 0.8% (1/121), with no neurologic deaths and a similar prevalence of neurologic events after retrograde and antegrade brain perfusion (22/60, 37% and 15/61, 25%, respectively; P  = .2). Conclusions Although this randomized clinical trial revealed similar neurologic outcomes after retrograde or antegrade brain perfusion for total aortic arch replacement, clinical examination for postprocedural neurologic events is insensitive, brain imaging detects more events, and neurocognitive testing detects even more. Future neurologic assessments for cardiovascular procedures should include not only clinical examination but also brain imaging studies, neurocognitive testing, and long-term assessment.