Key result
Moderate hypothermic circulatory arrest at 29 ℃ with bilateral selective antegrade cerebral perfusion significantly reduced major adverse events to 4% compared to 30.6% with the conventional 25 ℃ unilateral strategy.
Why the study?
The optimal hypothermic level and superiority of unilateral versus bilateral cerebral perfusion in total arch replacement with stented elephant trunk implantation for acute type A aortic dissection remain unestablished and controversial.
Does moderate hypothermic circulatory arrest at 29℃ with bilateral selective antegrade cerebral perfusion improve early outcomes in patients with acute type A aortic dissection undergoing total arch replacement compared to 25℃ with unilateral perfusion?
Cohort (n=61)
Yes
Does moderate hypothermic circulatory arrest at 29℃ with bilateral selective antegrade cerebral perfusion improve early outcomes in patients with acute type A aortic dissection undergoing total arch replacement compared to 25℃ with unilateral perfusion?
A modified strategy of moderate hypothermic circulatory arrest at 29℃ with bilateral cerebral perfusion may reduce major adverse events, ventilation time, and ICU stay in acute type A aortic dissection surgery compared to deeper hypothermia with unilateral perfusion.
Answers are grounded in this paper and cite their sources.
The modified strategy was associated with fewer major adverse events; observational data leaves open whether it should change practice in acute type A dissection.
Background: The optimal hypothermic level in total arch replacement with stented elephant trunk implantation for acute type A aortic dissection (aTAAD) has not been established, and the superiority of unilateral or bilateral cerebral perfusion remains a controversial issue. Therefore, we evaluated the application of moderate hypothermic circulatory arrest (MHCA) with a core temperature of 29℃ and bilateral selective antegrade cerebral perfusion in aTAAD treated by total arch replacement with stented elephant trunk implantation. Methods: From July 2019 to January 2020, 25 aTAAD patients underwent total arch replacement with stented elephant trunk implantation via MHCA (29℃) and bilateral selective antegrade cerebral perfusion (modified group). Thirty-six patients treated by the same procedure with MHCA (25℃) and unilateral selective antegrade cerebral perfusion during this period were selected as controls. Results: There were no differences between the two groups of patients in terms of age, sex, incidence of hypertension, malperfusion, and pericardial effusion, although the incidence of cardiac tamponade was higher in the modified group (control 2.8%, modified 20%; P = 0.038). The lowest mean circulatory arrest temperature was 24.6±0.9℃ in the control group, and 29±0.8℃ in the modified group (P < 0.001). In-hospital mortality was 4.9% (3/61) for the entire cohort (control 8.3%, modified 0; P = 0.262). The incidence of permanent neurologic deficit was 4.9% (control 8.3%, modified 0; P = 0.262). There were no significant differences in the occurrence of temporary neurological deficit, renal failure, and paraplegia between groups. The rate of major adverse events in the modified group was lower (30.6% vs. 4%, P = 0.019). A shorter duration of ventilation and ICU stay was identified in the modified group, as well as a reduced volume of drainage within the first 48 h and red blood cell transfusion.Conclusions: The early results of MHCA (29℃) and bilateral selective antegrade cerebral perfusion applied in total arch replacement with stented elephant trunk implantation for aTAAD were acceptable, providing similar inferior cerebral and visceral protection compared with that of the conventional strategy. A higher core temperature may account for the shorter duration of ventilation and ICU stay, as well as a reduced volume of drainage and red blood cell transfusion.
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Dong et al. (2020) conducted a cohort in Acute type A aortic dissection (n=61). Moderate hypothermic circulatory arrest (29 ℃) and bilateral selective antegrade cerebral perfusion vs. Moderate hypothermic circulatory arrest (25 ℃) and unilateral selective antegrade cerebral perfusion was evaluated on Major adverse events (composite of in-hospital mortality, permanent neurologic deficit, paraplegia, and new renal failure needing CRRT) (p=0.019). Moderate hypothermic circulatory arrest at 29 ℃ with bilateral selective antegrade cerebral perfusion significantly reduced major adverse events to 4% compared to 30.6% with the conventional 25 ℃ unilateral strategy.
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