title: A study of brain protection during total arch replacement comparing antegrade cerebral perfusion versus hypothermic circulatory arrest, with or without retrograde cerebral perfusion: analysis based on the Japan Adult Cardiovascular Surgery Database.
abstract: OBJECTIVE
  Antegrade cerebral perfusion and hypothermic circulatory arrest, with or without retrograde cerebral perfusion, are 2 major types of brain protection that are used during aortic arch surgery. We conducted a comparative study of these methods in patients undergoing total arch replacement to evaluate the clinical outcomes in Japan, based on the Japan Adult Cardiovascular Surgery Database.
  
  
  METHODS
  A total of 16,218 patients underwent total arch replacement between 2009 and 2012. Patients with acute aortic dissection or ruptured aneurysm, or who underwent emergency surgery were excluded, leaving 8169 patients for analysis. For the brain protection method, 7038 patients had antegrade cerebral perfusion and 1141 patients had hypothermic circulatory arrest/retrograde cerebral perfusion. A nonmatched comparison was made between the 2 groups, and propensity score analysis was performed among 1141 patients.
  
  
  RESULTS
  The matched paired analysis showed that the minimum rectal temperature was lower in the hypothermic circulatory arrest/retrograde cerebral perfusion group (21.2°C ± 3.7°C vs 24.2°C ± 3.2°C) and that the duration of cardiopulmonary bypass and cardiac ischemia was longer in the antegrade cerebral perfusion group. There were no significant differences between the antegrade cerebral perfusion and hypothermic circulatory arrest/retrograde cerebral perfusion groups with regard to 30-day mortality (3.2% vs 4.0%), hospital mortality (6.0% vs 7.1%), incidence of stroke (6.7% vs 8.6%), or transient neurologic disorder (4.1% vs 4.4%). There was no difference in a composite outcome of hospital death, bleeding, prolonged ventilation, need for dialysis, stroke, and infection (antegrade cerebral perfusion 28.4% vs hypothermic circulatory arrest 30.1%). However, hypothermic circulatory arrest/retrograde cerebral perfusion resulted in a significantly higher rate of prolonged stay in the intensive care unit (>8 days: 24.2% vs 15.6%).
  
  
  CONCLUSIONS
  Hypothermic circulatory arrest/retrograde cerebral perfusion and antegrade cerebral perfusion provide comparable clinical outcomes with regard to mortality and stroke rates, but hypothermic circulatory arrest/retrograde cerebral perfusion resulted in a higher incidence of prolonged intensive care unit stay. Antegrade cerebral perfusion might be preferred as the brain protection method for complicated aortic arch procedures.
authors.affiliation: Department of Cardiovascular Surgery, Kobe University, Kobe, Japan. Electronic address: yokita@med.kobe-u.ac.jp.
authors.forename: Yutaka
authors.initials: Y
authors.lastname: Okita
authors.affiliation: Health Care Quality Assessment, University of Tokyo, Tokyo, Japan.
authors.forename: Hiroaki
authors.initials: H
authors.lastname: Miyata
authors.affiliation: Department of Cardiovascular Surgery, Toho University Medical Center Sakura Hospital, Chiba, Japan.
authors.forename: Noboru
authors.initials: N
authors.lastname: Motomura
authors.affiliation: Mitsui Memorial Hospital, Tokyo, Japan.
authors.forename: Shinichi
authors.initials: S
authors.lastname: Takamoto
mesh_terms: D000208:Acute Disease; D000368:Aged; D000369:Aged, 80 and over; D000784:Aortic Dissection / Q000175:diagnosis / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D001013:Aorta, Thoracic / Q000503:physiopathology / Q000601:surgery*; D017545:Aortic Aneurysm, Thoracic / Q000175:diagnosis / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D001019:Aortic Rupture / Q000175:diagnosis / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000401:mortality; D002560:Cerebrovascular Circulation; D050792:Circulatory Arrest, Deep Hypothermia Induced / Q000009:adverse effects / Q000401:mortality; D016208:Databases, Factual; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D007362:Intensive Care Units; D007564:Japan; D007902:Length of Stay; D008297:Male; D016555:Matched-Pair Analysis; D008875:Middle Aged; D010477:Perfusion / Q000009:adverse effects / Q000379:methods* / Q000401:mortality; D011183:Postoperative Complications / Q000401:mortality / Q000628:therapy; D057216:Propensity Score; D012189:Retrospective Studies; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome