title: Effect of cerebral protection strategy on outcome of patients with Stanford type A aortic dissection.
abstract: OBJECTIVE
  The aim of the present study was to assess the efficacy and mid- to long-term results of different cerebral protection techniques in the treatment of acute type A aortic dissection.
  
  
  METHODS
  Between April 1987 and January 2011, 329 patients (220 male patients; median age, 60 years; range, 16-87) with type A aortic dissection underwent replacement of the ascending aorta or aortic arch with an open distal anastomosis. Either hypothermic circulatory arrest alone at 18 °C (n = 116; 35%) or combined with retrograde cerebral perfusion (n = 122; 37%) or antegrade cerebral perfusion at 25 °C (n = 91; 28%) was used.
  
  
  RESULTS
  The median circulatory arrest time was 30 minutes (range, 12-92). The overall 30-day mortality was 19% (62 of 329). The 30-day mortality stratified by group was 26% (30 patients) in the hypothermic circulatory arrest group, 16% in the retrograde cerebral perfusion group (20 patients), and 13% (12 patients) in the antegrade cerebral perfusion group (P = .047). Permanent neurologic dysfunction occurred in 53 patients (16%), with statistically significant differences among the 3 groups (23% for hypothermic circulatory arrest, 12% for retrograde cerebral perfusion, and 12% for antegrade cerebral perfusion; P = .033). Univariate analysis showed a significant effect of the brain protection strategy on 30-day mortality and neurologic outcome. Multivariate analysis revealed preoperative hemodynamic instability, preoperative resuscitation, age, and operative year as independent predictors of 30-day mortality. Regarding permanent neurologic dysfunction, the multivariate analysis could not identify any independent predictors. Kaplan-Meier analyses revealed statistically significant differences among the 3 groups with a 1-, 3-, and 5-year survival rate of 84%, 79%, and 77% with antegrade cerebral perfusion, 75%, 72%, and 66% with retrograde cerebral perfusion, and 66%, 62%, and 60% with hypothermic circulatory arrest alone.
  
  
  CONCLUSIONS
  Patients in the antegrade cerebral perfusion group had the best short- and long-term survival rates. However, during the study period, several significant improvements in the treatment of patients with type A aortic dissection were achieved; therefore, independent predictors of mortality and permanent neurologic dysfunction were difficult to identify.
authors.affiliation: Department of Cardiac Surgery, Vienna Medical University, Vienna, Austria. dominik.wiedemann@meduniwien.ac.at
authors.forename: Dominik
authors.initials: D
authors.lastname: Wiedemann
authors.forename: Alfred
authors.initials: A
authors.lastname: Kocher
authors.forename: Marion
authors.initials: M
authors.lastname: Dorfmeister
authors.forename: Amit
authors.initials: A
authors.lastname: Vadehra
authors.forename: Stephane
authors.initials: S
authors.lastname: Mahr
authors.forename: Günther
authors.initials: G
authors.lastname: Laufer
authors.forename: Marek
authors.initials: M
authors.lastname: Ehrlich
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000784:Aortic Dissection / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D001014:Aortic Aneurysm / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D001317:Austria; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000401:mortality; D002560:Cerebrovascular Circulation; D002561:Cerebrovascular Disorders / Q000209:etiology / Q000401:mortality / Q000503:physiopathology / Q000517:prevention & control*; D016009:Chi-Square Distribution; D005260:Female; D006324:Heart Arrest, Induced / Q000009:adverse effects / Q000401:mortality; D017052:Hospital Mortality; D006801:Humans; D007036:Hypothermia, Induced / Q000009:adverse effects / Q000401:mortality; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D016017:Odds Ratio; D010477:Perfusion / Q000009:adverse effects / Q000401:mortality; D012189:Retrospective Studies; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D055815:Young Adult