Impact of perfusion strategy on neurologic recovery in acute type A aortic dissection.
BACKGROUND
The optimal perfusion strategy during surgery of acute type A aortic dissection is controversial. The purpose of this study was to determine the impact of retrograde cerebral perfusion during hypothermic circulatory arrest on short-term and long-term outcome in this specific patient population.


METHODS
Between 1984 and 2005, 175 consecutive patients underwent repair of an acute type A dissection. Three different surgical approaches were used: aortic cross-clamping without hypothermic circulatory arrest in 50 (29%), hypothermic circulatory arrest alone in 69 (39%), and hypothermic circulatory arrest with supplemental retrograde cerebral perfusion in 56 (32%).


RESULTS
Operative mortality was 18% +/- 3% (+/- 70% confidence interval), and adverse outcomes (death or cerebrovascular accident) occurred in 21% +/- 3% of patients (p = 0.97 between groups). Multivariate analysis identified valve replacement (p = 0.04), preoperative flow complications (p = 0.03), and non-Marfan syndrome (p = 0.04) as predictors of operative mortality. Intraoperative dissection (p < 0.001) and history of cerebrovascular disease (p = 0.02) were predictors for permanent neurologic deficit, and retrograde cerebral perfusion was shown to have a protective effect on transient neurologic deficits (p = 0.008). Kaplan-Meier survival was 75% +/- 3% at 1 year (131 patients at risk), 63% +/- 4% at 5 years (87 patients at risk), and 49% +/- 4% at 10 years (48 patients at risk) and was independent of surgical approach (p = 0.37). Long-term survival was diminished with increased age (p < 0.001), earlier operative year (p < 0.001), and coronary artery disease (p = 0.02).


CONCLUSIONS
The current investigation suggests improved neurologic recovery with circulatory arrest and supplemental retrograde cerebral perfusion. Operative mortality and long-term survival were comparable among groups.
Zierer
Andreas
A
Division of Cardiothoracic Surgery and the Center for Diseases of the Thoracic Aorta, Washington University School of Medicine, Barnes Jewish Hospital, St. Louis, Missouri 63110-1013, USA.
Moon
Marc R
MR
Melby
Spencer J
SJ
Moazami
Nader
N
Lawton
Jennifer S
JS
Kouchoukos
Nicholas T
NT
Pasque
Michael K
MK
Damiano
Ralph J
RJ
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000784:Aortic Dissection / Q000150:complications / Q000601:surgery*; D001013:Aorta, Thoracic / Q000601:surgery; D017545:Aortic Aneurysm, Thoracic / Q000150:complications / Q000601:surgery*; D001927:Brain Diseases / Q000209:etiology / Q000517:prevention & control*; D002560:Cerebrovascular Circulation; D050792:Circulatory Arrest, Deep Hypothermia Induced / Q000009:adverse effects / Q000379:methods*; D003250:Constriction; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010477:Perfusion / Q000379:methods; D012189:Retrospective Studies; D016019:Survival Analysis