Prospective comparative study of brain protection in total aortic arch replacement: deep hypothermic circulatory arrest with retrograde cerebral perfusion or selective antegrade cerebral perfusion.

BACKGROUND The purpose of this study was to compare the results of total aortic arch replacement using two different methods of brain protection, particularly with respect to neurologic outcome. METHODS From June 1997, 60 consecutive patients who underwent total arch replacement through a midsternotomy were alternately allocated to one of two methods of brain protection: deep hypothermic circulatory arrest with retrograde cerebral perfusion (RCP: 30 patients) or with selective antegrade cerebral perfusion (SCP: 30 patients). Preoperative and postoperative (3 weeks) brain CT scan, neurological examination, and cognitive function tests were performed. Serum 100b protein was assayed before and after the cardiopulmonary bypass, as well as 24 hours and 48 hours after the operation. RESULTS Hospital mortality occurred in 2 patients in the RCP group (6.6%) and 2 in the SCP group (6.6%). New strokes occurred in 1 (3.3%) of the RCP group and in 2 (6.6%) of the SCP group (p = 0.6). The incidence of transient brain dysfunction was significantly higher in the RCP group than in the SCP group (10, 33.3% vs 4, 13.3%, p = 0.05). Except in patients with strokes, S-100b values showed no significant differences in the two groups (RCP: SCP, prebypass 0.01+/-0.04: 0.05+/-0.16, postbypass 2.17+/-0.94: 1.97+/-1.00, 24 hours 0.61+/-0.36: 0.60+/-0.37, 48 hours 0.36+/-0.45: 0.46+/-0.40 microg/L, p = 0.7). There were no intergroup differences in the scores of memory decline (RCP 0.74+/-0.99; SCP 0.55+/-1.19, p = 0.6), orientation (RCP 1.11+/-1.29; SCP 0.50+/-0.76, p = 0.08), or intellectual function (RCP 1.21+/-1.27; SCP 1.05+/-1.15, p = 0.7). CONCLUSIONS Both methods of brain protection for patients undergoing total arch replacement resulted in acceptable levels of mortality and morbidity. However, the prevalence of transient brain dysfunction was significantly higher in patients with the RCP.

[1]  S. Westaby,et al.  Proximal aortic perfusion for complex arch and descending aortic disease. , 1998, The Journal of thoracic and cardiovascular surgery.

[2]  C. Bodian,et al.  Hypothermic circulatory arrest in operations on the thoracic aorta. Determinants of operative mortality and neurologic outcome. , 1994, The Journal of thoracic and cardiovascular surgery.

[3]  C. Miller,et al.  Impact of retrograde cerebral perfusion on ascending aortic and arch aneurysm repair. , 1997, The Annals of thoracic surgery.

[4]  K. Tabayashi,et al.  Brain damage after aortic arch repair using selective cerebral perfusion. , 1998, The Annals of thoracic surgery.

[5]  J. Bavaria,et al.  Retrograde cerebral perfusion (RCP) in aortic arch surgery: efficacy and possible mechanisms of brain protection. , 1997, Seminars in thoracic and cardiovascular surgery.

[6]  H. Matsuo,et al.  Aortic arch operation using selective cerebral perfusion for nondissecting thoracic aneurysm. , 1997, The Annals of thoracic surgery.

[7]  J. Coselli,et al.  Surgical treatment of aneurysm and/or dissection of the ascending aorta, transverse aortic arch, and ascending aorta and transverse aortic arch. Factors influencing survival in 717 patients. , 1989, The Journal of thoracic and cardiovascular surgery.

[8]  F. Loop,et al.  Atheroembolism from the ascending aorta. An emerging problem in cardiac surgery. , 1992, The Journal of thoracic and cardiovascular surgery.

[9]  Y. Okita,et al.  Surgical treatment of aneurysm or dissection involving the ascending aorta and aortic arch, utilizing circulatory arrest and retrograde cerebral perfusion. , 1990, The Journal of cardiovascular surgery.

[10]  Y. Okita,et al.  Mortality and cerebral outcome in patients who underwent aortic arch operations using deep hypothermic circulatory arrest with retrograde cerebral perfusion: no relation of early death, stroke, and delirium to the duration of circulatory arrest. , 1998, The Journal of thoracic and cardiovascular surgery.

[11]  N. Kouchoukos,et al.  Management of the severely atherosclerotic ascending aorta during cardiac operations. A strategy for detection and treatment. , 1992, The Journal of thoracic and cardiovascular surgery.

[12]  C. Alling,et al.  The appearance of S-100 protein in serum during and immediately after cardiopulmonary bypass surgery: a possible marker for cerebral injury. , 1997, Journal of cardiothoracic and vascular anesthesia.

[13]  G. Dreyfus,et al.  Cold cerebroplegia. A new technique of cerebral protection during operations on the transverse aortic arch. , 1991, The Journal of thoracic and cardiovascular surgery.

[14]  A. Moritz,et al.  Neuropsychological changes after cardiopulmonary bypass for coronary artery bypass grafting. , 1998, The Thoracic and cardiovascular surgeon.

[15]  J. Coselli,et al.  Deep hypothermia with circulatory arrest. Determinants of stroke and early mortality in 656 patients , 1993 .

[16]  H. Mohri,et al.  Aortic arch aneurysm repair using selective cerebral perfusion. , 1994, The Annals of thoracic surgery.

[17]  H. Koyanagi,et al.  Medium-term results after surgery for aortic arch aneurysm with hypothermic cerebral perfusion. , 1995, European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery.

[18]  T. Kazui,et al.  Selective cerebral perfusion during operation for aneurysms of the aortic arch: a reassessment. , 1992, The Annals of thoracic surgery.

[19]  C. Alling,et al.  Serum S100 protein: a potential marker for cerebral events during cardiopulmonary bypass. , 1996, The Annals of thoracic surgery.

[20]  M. Jurmann,et al.  Tactics and Techniques of Aortic Arch Replacement , 1994, Journal of cardiac surgery.

[21]  C. Duyckaerts,et al.  The prevalence of ulcerated plaques in the aortic arch in patients with stroke. , 1992, The New England journal of medicine.

[22]  M. Mittlböck,et al.  Surgical treatment of aortic arch aneurysms in profound hypothermia and circulatory arrest. , 1997, The Annals of thoracic surgery.

[23]  Y. Okita,et al.  Predictive factors for mortality and cerebral complications in arteriosclerotic aneurysm of the aortic arch. , 1999, The Annals of thoracic surgery.

[24]  R. P. Cochran,et al.  Variations in Annuloplasty Ring and Sizer Dimensions May Alter Outcome in Mitral Valve Repair , 1997, Journal of cardiac surgery.

[25]  R A Kahn,et al.  Neuropsychologic outcome after deep hypothermic circulatory arrest in adults. , 1999, The Journal of thoracic and cardiovascular surgery.

[26]  S. Folstein,et al.  "Mini-mental state". A practical method for grading the cognitive state of patients for the clinician. , 1975, Journal of psychiatric research.

[27]  K. Bergström,et al.  Adverse effects on the brain in cardiac operations as assessed by biochemical, psychometric, and radiologic methods. , 1984, The Journal of thoracic and cardiovascular surgery.