Neurologic injury is still a frequent cause of mortality, morbidity, and long-lasting disability in patients undergoing an aortic arch operation with hypothermic circulatory arrest. The aim of this analysis was to evaluate short- and long-term outcomes in neurologic and cognitive functions in this group of high-risk patients.
A total of 333 patients undergoing an aortic arch operation between February 2004 and June 2010 were retrospectively reviewed. Cerebral protection was obtained with deep hypothermic circulatory arrest in 220 patients (66%) or with moderate hypothermic circulatory arrest in 113 cases (34%). Straight deep hypothermic circulatory arrest was adopted in 35 cases (11%), while the association with antegrade cerebral perfusion was adopted in 271 cases (81%) and with retrograde cerebral perfusion in 27 cases (8%). Seventy-eight patients were enrolled in a case control prospective study (mean follow-up time = 42 months) and underwent neuropsychologic evaluations; data were compared with those of a matched-control group of hypertensive patients without history of cardiac operations.
Forty-one out of 333 patients experienced permanent neurologic dysfunction (12%) and 83 experienced temporary neurologic dysfunctions (25%). Acute aortic dissection and deep hypothermic circulatory arrest were significant predictors of mortality and permanent neurologic dysfunction. Acute aortic dissection and hypothermic circulatory arrest duration >30 minutes were significant predictors of temporary neurologic dysfunction, while antegrade cerebral perfusion was protective on mortality. Neuropsychologic evaluations showed no significant differences between the groups. The operative group showed worse verbal and working memory (P = .003), worse semantic fluency (P = .036), higher degree of alexithymia (P = .004), and a lower quality of life (P = .007).
Although moderate hypothermic circulatory arrest with antegrade cerebral perfusion demonstrated a lower mortality compared with deep hypothermic arrest, neurocognitive testing demonstrated no difference between the groups. Additionally, patients undergoing an aortic arch operation demonstrated long-term cognitive deficits and psychological dysfunction when compared to a matched cohort of nonoperative patients.
To read this article in full you will need to make a payment
Purchase one-time access:Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
One-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:Subscribe to Surgery
Already a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
- Contemporary results for proximal aortic replacement in North America.J Am Coll Cardiol. 2012; 60: 1156-1162
- Temporary neurologic dysfunction after deep hypothermic circulatory arrest: a clinical marker of long-term functional deficit.Ann Thorac Surg. 1999; 67: 1887-1894
- New frontiers in aortic therapy: focus on deep hypothermic circulatory arrest.J Cardiothorac Vasc Anesth. 2014; 28: 1171-1175
- Consensus on hypothermia in aortic arch surgery.Ann Cardiothorac Surg. 2013; 2: 163-168
- Some new inequalities for the range distribution, with application to the determination of optimum significance levels of multiple range tests.J Am Stat Assoc. 1990; 85: 191-194
- On a monotonicity problem in step-down multiple test procedures.J Am Stat Assoc. 1993; 88: 920-923
- Is surgery always mandatory for type A aortic dissection?.Ann Thorac Surg. 2006; 82: 1658-1663
- Surgical outcome of aortic arch aneurysms using selective cerebral perfusion.Ann Thorac Surg. 1994; 57: 904-911
- Brain protection using antegrade selective cerebral perfusion: a multicenter study.Ann Thorac Surg. 2003; 76: 1181-1188
- Total arch replacement using antegrade cerebral perfusion.J Thorac Cardiovasc Surg. 2013; 145: S63-S71
- Antegrade cerebral perfusion for acute type A aortic dissection in 120 consecutive patients.Ann Thorac Surg. 2008; 85: 465-469
- What is the best strategy for brain protection in patients undergoing aortic arch surgery? A single center experience of 636 patients.Ann Thorac Surg. 2012; 93: 1502-1508
- Selective antegrade cerebral perfusion and mild (28°C-30°C) systemic hypothermic circulatory arrest for aortic arch replacement: results from 1002 patients.J Thorac Cardiovasc Surg. 2012; 144: 1042-1049
- Contemporary results of surgery in acute type A aortic dissection: The International Registry of Acute Aortic Dissection experience.J Thorac Cardiovasc Surg. 2005; 129: 112-122
- Aortic arch replacement with a trifurcated graft.Ann Thorac Surg. 2007; 83: S791-S795
- Total arch replacement using aortic arch branched grafts with the aid of antegrade selective cerebral perfusion.Ann Thorac Surg. 2000; 70: 3-8
- Evolving selective cerebral perfusion for aortic arch replacement: high flow rate with moderate hypothermic circulatory arrest.Ann Thorac Surg. 2008; 86: 1827-1831
- The safety of moderate hypothermic lower body circulatory arrest with selective cerebral perfusion: a propensity score analysis.J Thorac Cardiovasc Surg. 2007; 133: 501-509
- Impact of hypothermic selective cerebral perfusion compared with hypothermic cardiopulmonary bypass on cerebral hemodynamics and metabolism.Eur J Cardiothorac Surg. 2003; 24: 807-816
- Selective cerebral perfusion during operation for aneurysms of the aortic arch: a reassessment.Ann Thorac Surg. 1992; 53: 109-114
- A meta-analysis of deep hypothermic circulatory arrest versus moderate hypothermic circulatory arrest with selective antegrade cerebral perfusion.Ann Cardiothorac Surg. 2013; 2: 148-158
- Cerebral metabolic suppression during hypothermic circulatory arrest in humans.Ann Thorac Surg. 1999; 67: 1895-1899
- Deep hypothermia with circulatory arrest. Determinants of stroke and early mortality in 656 patients.J Thorac Cardiovasc Surg. 1993; 106: 19-28
- Predictors of adverse outcome and transient neurologic dysfunction after ascending aorta/hemiarch replacement.Ann Thorac Surg. 2000; 69: 1755-1763
- Surgical treatment of aortic arch aneurysms in profound hypothermia and circulatory arrest.Ann Thorac Surg. 1997; 64: 1067-1071
- Cognitive outcomes three years after coronary artery bypass surgery: a comparison of on-pump coronary artery bypass graft surgery and nonsurgical controls.Ann Thorac Surg. 2005; 79: 1201-1209
- Surgery of the thoracic aorta using deep hypothermic total circulatory arrest. Are there neurologic consequences other than frank cerebral defects?.Eur J Cardiothorac Surg. 1997; 11: 650-656
- Neuropsychologic outcome after deep hypothermic circulatory arrest in adults.J Thorac Cardiovasc Surg. 1999; 117: 156-163
Published online: April 02, 2016
Accepted: February 4, 2016
© 2016 Elsevier Inc. All rights reserved.