The impact of temperature in aortic arch surgery patients receiving antegrade cerebral perfusion for >30 minutes: How relevant is it really?

• Published in: The Journal of thoracic and cardiovascular surgery Vol. 153; no. 4; pp. 767 - 776
• Main Authors: Preventza, Ourania, MD, Coselli, Joseph S., MD, Akvan, Shahab, MD, Kashyap, Sarang A., MD, Garcia, Andrea, MD, Simpson, Katherine H., MS, Price, Matt D., MS, Mayor, Jessica, MD, de la Cruz, Kim I., MD, Cornwell, Lorraine D., MD, Omer, Shuab, MD, Bakaeen, Faisal G., MD, Haywood-Watson, Ricky J.L., MD, Rammou, Athina, BS, CCP
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01-04-2017
• Subjects: Aged; antegrade cerebral perfusion; Aorta, Thoracic - physiopathology; Aorta, Thoracic - surgery; aortic arch surgery; Blood Vessel Prosthesis Implantation - adverse effects; Blood Vessel Prosthesis Implantation - methods; Blood Vessel Prosthesis Implantation - mortality; Cardiothoracic Surgery; Cerebrovascular Circulation; Circulatory Arrest, Deep Hypothermia Induced - adverse effects; Circulatory Arrest, Deep Hypothermia Induced - methods; Circulatory Arrest, Deep Hypothermia Induced - mortality; Databases, Factual; deep hypothermia; Female; Hospital Mortality; Humans; Hypothermia, Induced - adverse effects; Hypothermia, Induced - methods; Hypothermia, Induced - mortality; hypothermic circulatory arrest; Male; Middle Aged; moderate hypothermia; patient outcomes; Perfusion - adverse effects; Perfusion - methods; Perfusion - mortality; Postoperative Hemorrhage - etiology; Postoperative Hemorrhage - surgery; Reoperation; Retrospective Studies; Risk Assessment; Risk Factors; Stroke - etiology; Stroke - prevention & control; Time Factors; Treatment Outcome; ECMO; near-infrared spectroscopy; MOF; CI; deep hypothermic circulatory arrest; patient outcomes; ACP; ET; antegrade cerebral perfusion; elephant trunk; CPB; deep hypothermia; cardiopulmonary bypass; NIRS; hypothermic circulatory arrest; confidence interval; extracorporeal membrane oxygenation; multiorgan failure; aortic arch surgery; CABG; DHCA; moderate hypothermia; coronary artery bypass grafting
• ISSN: 0022-5223; 1097-685X
• DOI: 10.1016/j.jtcvs.2016.11.059

Abstract Objective We examined the early outcomes and the long-term survival associated with different degrees of hypothermia in patients who received antegrade cerebral perfusion (ACP) for >30 minutes. Methods During a 10-year period, 544 consecutive patients underwent proximal and total aortic arch surgery and received ACP for >30 minutes and 1 of 3 levels of hypothermia: deep (14.1°C-20°C; n = 116 [21.3%]), low-moderate (20.1°C-23.9°C; n = 262 [48.2%]), and high-moderate (24°C-28°C; n = 166 [30.5%]). A variable called “predicted temperature” was used in propensity-score analysis. Multivariate analysis was done to evaluate the effect of actual temperature on outcomes. Results The operative mortality rate was 12.5% (n = 68) overall and was 15.5%, 11.8%, and 11.5% in the deep, low-moderate, and high-moderate hypothermia patients, respectively ( P  = .54). The persistent stroke rate was 6.6% overall and 12.2%, 4.6%, and 6.0% in these 3 groups, respectively ( P  = .024 on univariate analysis). On multivariate analysis, actual temperature was not associated with mortality, but lower temperatures predicted persistent stroke and reoperation for bleeding. In the propensity-matched subgroups, the patients with predicted deep hypothermia had (nonsignificantly) greater rates of persistent stroke (12.2% vs 4.9%; relative risk, 1.08; 95% CI, 0.87-1.15) and reoperation for bleeding (14.6% vs 2.4%; relative risk, 1.14; 95% CI, 0.87-1.15) than the patients with predicted moderate hypothermia. On long-term follow-up (mean duration, 5.12 years), 4- and 8-year survival rates were 62.3% and 55.7% in the deep hypothermia group and 75.4% and 74.2% in the moderate hypothermia group ( P  = .0015). Conclusions In proximal and arch operations involving ACP for >30 minutes, greater actual temperatures were associated with less stroke and reoperation for bleeding. There were no significant differences among the predicted hypothermia levels, although a trend toward a higher rate of adverse events was noticed in the deep hypothermia group. Long-term survival was better in the moderate hypothermia group.