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

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Abstract

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 μg/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.

Section snippets

Patients and methods

From June 1, 1997 to April 9, 1999, 84 patients had a total replacement of the transverse aortic arch in the National Cardiovascular Center, Osaka, Japan. Seventeen patients who underwent an emergent surgery because of acute aortic dissection or rupture of the aneurysm were excluded. Two patients who had a total aortic arch replacement via a left thoracotomy were also excluded from the analysis. Sixty consecutive patients who had a total arch replacement via a midsternotomy on an elective basis

Results

Total duration of the operation (RCP 365 ± 131, SCP 467 ± 218, p = 0.03 minutes; p = 0.03) and bypass time (175 ± 58, 215 ± 83 minutes; p = 0.03) were significantly longer in the SCP group. Duration of cardiac ischemia (99.8 ± 44.3, 106 ± 58 minutes; p = 0.6) and of circulatory arrest of the lower body (44.3 ± 13.9, 54.1 ± 26.3 minutes; p = 0.07) were similar. In the RCP group, the duration of the total circulatory arrest was 44.3 ± 13.9 minutes, and the duration of RCP was 33.1 ± 11.4 minutes.

Comment

Although brain complication remains a rare event after cardiac surgery, it is a major cause of postoperative mortality and morbidity in thoracic aortic surgery [2]. An alarming prevalence (1% to 83%) 3, 4 of postoperative neuropsychological dysfunction has been reported after cardiopulmonary bypass. Improvement of methods to assess the postoperative neuropsychiatric status has been achieved recently; however, there is no simple method to determine the incidence or severity of brain injury after

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