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ORIGINAL ARTICLE
Year : 2021  |  Volume : 34  |  Issue : 3  |  Page : 1170-1175

Is deep hypothermic circulatory arrest inferior to antegrade cerebral perfusion for brain protection?


1 Department of Cardiothoracic Surgery, Menoufia University, Menoufia, Egypt; Madinah Cardiac Center, King Fahd Hospital, Madina, Cardiac Surgery Department, KSA
2 Madinah Cardiac Center, King Fahd Hospital, Madina, Cardiac Surgery Department, KSA; Department of Cardiothoracic Surgery, Minia University, Minia, Egypt
3 Madinah Cardiac Center, King Fahd Hospital, Madina, Cardiac Surgery Department, KSA
4 Department of Cardiology, National Heart Institute, Minia, Egypt
5 Department of Cardiothoracic Surgery, Menoufia University, Menoufia, Egypt

Date of Submission28-Jan-2021
Date of Decision15-Apr-2021
Date of Acceptance19-Apr-2021
Date of Web Publication18-Oct-2021

Correspondence Address:
Ayman R Abdelrehim
Department of Cardiothoracic Surgery, Faculty of Medicine, Menoufia University, Menoufia

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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_29_21

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  Abstract 


Objective
This study aims to compare the deep hypothermic circulatory arrest (DHCA) and antegrade cerebral perfusion (ACP) with moderate hypothermia for cerebral protection during aortic arch surgery.
Background
Aortic arch surgery is a complicated technical operation due to the risk of cerebral insults and the need for cerebral protection.
Materials and methods
Forty patients performed aortic arch surgery with cerebral protection either by, DHCA (18°C) in 20 patients and ACP (22 °C) in the others. Data were collected including; preoperative risks factors, intraoperative finding and postoperative neurological examination and brain computed tomography (CT)when indicated.
Results
Neurological insults were higher in ACP group (30%) than in DHCA group (10%) without statistical significance. Cardiopulmonary bypass (CPB) time was lower in DHCA group (133.05 ± 28.04) than in ACP group (177.65 ± 53.3), and significantly p-value is (< 0.01).
Conclusion
Techniques for cerebral protection (DHCA or ACP)during aortic arch surgery have no statistical significant difference, and each technique has its own advantages and disadvantages.

Keywords: antegrade cerebral perfusion, cerebral protection, deep hypothermic circulatory arrest


How to cite this article:
Abdelrehim AR, Mubarak Y, Sandogji H, Farkooh S, Soliman RF. Is deep hypothermic circulatory arrest inferior to antegrade cerebral perfusion for brain protection?. Menoufia Med J 2021;34:1170-5

How to cite this URL:
Abdelrehim AR, Mubarak Y, Sandogji H, Farkooh S, Soliman RF. Is deep hypothermic circulatory arrest inferior to antegrade cerebral perfusion for brain protection?. Menoufia Med J [serial online] 2021 [cited 2024 Mar 29];34:1170-5. Available from: http://www.mmj.eg.net/text.asp?2021/34/3/1170/328326




  Introduction Top


Aortic arch surgery is associated with a non-negligible rate of mortality and neurologic deficits despite advancements in surgical techniques and cerebral monitoring technologies [1],[2].

Currently, three different cerebral protection strategies are available: isolated deep hypothermic circulatory arrest (DHCA), circulatory arrest coupled with retrograde cerebral perfusion (RCP) and circulatory arrest coupled with antegrade cerebral perfusion (ACP). The advantages and disadvantages of these cerebral protection techniques have been extensively studied, but consensus on the optimal strategy is still lacking [3],[4].

The optimal cerebral protection strategy during aortic arch surgery remains controversial [5].

DHCA has the main advantage of simplicity and does not need any additional cannulation, but relies only on hypothermia for neuroprotection. RCP is fast and easy to establish, but its efficacy in reaching the brain parenchyma is debated. ACP ensures direct cerebral perfusion at the expense of a more complex cannulation and perfusion setup [6],[7].

These techniques revealed some limitations. For instance, there are difficulties in the application of ACP; besides, it cannot be performed every time as aortic dissection patients could show comorbid occlusive and stenotic lesions of the brachio-cephalic arteries. Also, insufficient neurological protection can occur as a result of the lack of an accurate estimation of perfusion volume that is not allowed by the RCP [8].

A recent survey shows that most European surgeons use ACP for emergency cases, whereas in the United States, data from the 2017 Society of Thoracic Surgery Database show that DHCA is the most commonly used method [9].

Over the past 15 years, eight meta-analyses have reported pairwise comparisons of DHCA, RCP and ACP in different combinations [10],[11].


  Materials and methods Top


This review of medical records and computerized hospital data was approved by the Ethical Committee of number (2021 R27) the Medina Cardiac Center MCC and a written informed consent was obtained from all patients in this study. We retrospectively reviewed data of patients who underwent cardiac operations. A total of 40 patients underwent aortic arch operations between May 2014 and March 2020; they were divided into 20 patients who underwent DHCA for cerebral protection and 20 patients who underwent ACP with moderate hypothermia for cerebral protection.

Inclusion criteria

Patients with aortic dissection with a need for surgical replacement of the ascending aorta and aortic arch and patients with a total arch replacement were included in this study.

Exclusion criteria

Patients with a brain trauma and neuroinfection history, patients with neurological complaints and patients who had undergone a previous cardiovascular surgery were excluded from the study.

Preoperative data

Preoperative data and demographic data including age, sex, status on admission, initial diagnosis and central nervous system (CNS) problem were collected.

  1. Data for investigation were computed tomography (CT) chest, CT brain and Carotid duplex.
  2. CNS examination.
  3. Cardiopulmonary bypass data included the total bypass time, the aortic clamping time, circulatory arrest time, temperature during arrest and time of antegrade perfusion.
  4. Postoperative assessment included determination of CNS problems, ICU stay, time of ventilation, outcome, CT brain, and CNS clinical examination.


The endpoints of this study are first, evaluation of postoperative functional brain status, and second, review of postoperative CT scans of brain.

In the DHCA group, the core cooling was instituted during cardiopulmonary bypass (CPB) to produce profound hypothermia (18°C); the head was packed in ice. Circulation was arrested and the distal repair was carried out. Central warming was usually discontinued at a nasopharyngeal temperature of 35°C.

In the ACP group, the patients were cooled to 22°C (nasopharyngeal temperature) and the diseased aorta was opened. Under direct visual control, ACP with selective perfusion by cannulation of the right subclavian artery in 12 patients or direct carotid artery cannulation in eight patients was performed using coronary cardioplegic cannulas with silk snare fixation; see [Figure 1]. Then, all this was connected to the oxygenator with a separate single-roller pump head with a perfusion rate of 10 ml/min/kg and adjusted to maintain a right radial arterial pressure between 40 and 70 mmHg.
Figure 1: Intraoperative picture for Aoric arch repair: A) Directing ACP cannula to left Carotid artery B) Finishing the distal anastomosis with the presence of cannula.

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Statistical analysis

Statistical analysis was carried out using SPSS version 20.0 (SPSS, IBM Ink, Chicago, Illinois, USA). Mean values were expressed as average ± SD. Statistical analysis was carried out using the χ2-test and an unpaired Student's t-test. P values less than 0.05 were considered statistically significant.


  Results Top


The clinical and demographic data of both groups are shown in [Table 1].
Table 1: Demographic and preoperative data

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In the DHCA group, there were 10 men (50%) and 10 women (50%) whose age ranged from 48 to 80 years (mean 65.8 ± 08.5 years); nine patients (45%) were operated on electively and 11 (55%) underwent an urgent operation (seven patients 35% sustained acute dissection). Preoperative complications included a history of cerebrovascular problems in six patients (30%) and coronary artery disease in five patients (25%). Aortic dissection-related complications included cardiac tamponade in one patient (5%). Preoperative CNS diseases included in six (30%) patients, while 14 (70%) patients were free. Also, the preoperative CT of the brain showed no significant changes in five (25%) patients, whereas four (20%) patients showed significant findings.

In the ACP group, there were 14 men (70%) and six women (30%) whose age ranged from 48 to 78 years (mean: 63.1 ± 9.8 years); 16 patients (80%) were operated on electively and four patients (20%) underwent an urgent operation (four patients (20%) underwent acute dissection). Preoperative complications included a history of cerebrovascular problems in four patients (20%) and coronary artery disease in three patients (15%). Aortic dissection-related complications included cardiac tamponade in five patients (25%). Preoperative CNS diseases included in four (20%) patients while 16 (80%) patients were free. Also, the preoperative CT of the brain showed no significant changes in eight (40%) patients, whereas three (15%) patients showed significant findings.

There was a significant difference in the number of patients in terms of the state of admission; significantly higher number of patients in the ACP group were admitted on emergency bases (P < 0.05).

The neurological outcomes in different cerebral protection are shown in [Table 2].
Table 2: Neurological outcome in different cerebral protection operations

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In the ACP group, six patients (30%) developed new neurological problems, while in the DHCA group, only two patients (10%) developed new neurological problems.

The relations between carotid Duplex and the neurological outcome are shown in [Table 3].
Table 3: Relation between carotid duplex and the neurological outcome

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In the ACP group, there were duplex changes (>60% stenosis) in nine patients (56%), while in the DHCA group, there were Duplex changes (>60% stenosis) in one patient (6%).

This reveals a highly significant relation between the carotid Duplex positive finding and the selected type of cerebral protection used, which was high in the ACP group.

The different CPB data and neurological outcomes are shown in [Table 4]. The mean ± SD value of CPB total bypass time was highly significantly lower in the DHCA group (133.05 ± 28.04) than in the ACP group (177.65 ± 53.3), and the P value is less than 0.01. Also, the mean value of the aortic cross clamping time was significantly lower in the DHCA group than in the DHCA group (87.25 ± 23.15 vs. 111.8 ± 41.76, respectively), and the P value is less than 0.05; the circulatory arrest time was nonsignificantly lower in the DHCA group than in the ACP group (26.4 ± 6.13 vs. 26.9 ± 9.44, respectively). In addition, the CPB Temp during arrest showed a highly significantly lower value in the DHCA group than in the ACP group (18.3 ± 0.66, vs. 20.25 ± 1.99, respectively). CPB Time of antegrade perfusion also showed a highly significantly lower value in the DHCA group (not used at all) than the ACP group (0.0 ± 0.0 and 54.25 ± 13.15, respectively), and the P value is less than 0.01.
Table 4: CPB data and the neurological outcome

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From [Table 5], it is clear that there is a highly statistically significant difference in postoperative neurological problems in the DHCA group if circulatory arrest time was more than 30 min (two patients, 10%).
Table 5: Relation of CNS problems and circulatory arrest time in DHCA

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[Table 6] shows the relation of ICU data and type of method used for cerebral protection. The duration of ICU stay in the DHCA group showed a higher mean ± SD value (4.2 ± 2.9) than in the ACP group (3.6 ± 2.35). Similarly, the mean ± SD value of the time of ventilation was higher in the DHCA group than in the ACP group (42.6 ± 28.2 vs. 35.4 ± 25.7, respectively). The time taken to regain full conscious was very similar in the two groups (22.94 ± 11.7 vs. 22.8 ± 28.2), while the mean value of the time to discharge was lower in the DHCA group than the ACP group (10.9 ± 5.2 vs. 18.25 ± 27.7, respectively).
Table 6: Relation between type of cerebral protection and ICU data

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  Discussion Top


DHCA with or without RCP or ACP is currently being used as a method for protection of the brain. Technical simplicity and avoidance of manipulation of the aorta and arch vessels as well as a bloodless operative field make DHCA an attractive method of brain protection, especially during ascending aorta and hemi arch replacement, when a short period of circulatory arrest is anticipated. However, hypothermia-associated coagulopathy, and pulmonary, renal and microembolic complications are major disadvantages associated with DHCA [12].

ACP provides several advantages: the circulatory arrest time can safely be extended up to 90 min, allowing more complex aortic repair to be performed and moderate (nasopharyngeal, 25°C) instead of profound hypothermia. Criticisms against ACP include technical complexity, reduced surgical visibility and manipulation of the aortic arch and arch vessels, especially in the case of acute dissections [13].

In our study, we compared DHCA and ACP in terms of neurological outcome in patients undergoing aortic arch surgery. Patients with CNS problems preoperative (clinical or brain CT finding), in ACP group. 30% had variable CNS problems vary from transient ischemic attack (TIA) and old stroke, from them 33% complicated with new CNS events with no a statistical significant relation. In DHCA group there are 20% had CNS problems preoperative, however no patients complicated from them by new CNS catastrophes.

Also, we found that 14 patients (70%) were older than 65 years of age in the ACP group (mean ± SD is 65.8 ± 8.5 years); see [Table 1]. Among them, three (21.3%) patients developed complications with permanent neurological deficit (PND), and among them, two patients died, with a statistically significant relation between older age and PND.

In terms of the emergency states in [Table 1], there were 11 patients (55%) in the ACP group; among them, three patients (27%) developed complications with PND and two patients (18%) developed complications with TND, with a presence of a significant relation.

On the basis of the carotid duplex scanning results presented in [Table 3] (16 patients in the ACP group and 15 patients in the DHCA group), we found that nine patients had significant lesions (>60% carotid artery stenosis) in the ACP group; among them, three patients (33.3%) had PND postoperatively.

By studying our hospital mortality in this study we found 2/40 patients (5 % in all patients) and (2/20) 10% from ACP group and 0.0% in DHCA group. Patients with neurological deficits post operative were high in ACP group but most of them were urgent cases, with no statistical significant difference between DHCA and ACP groups for cerebral protection.

Tian and colleagues compared DHCA with ACP in a meta-analysis of nine observational studies (1783 patients) and found a significantly higher risk of stroke in the DHCA group, but similar operative mortality [2],[3],[4],[5],[6],[7],[8],[9],[10],[11],[12],[13],[14].

Kamenskaya and his group showed that the neurological complications outcomes as well as the postoperative complications were reduced in ACP group compared to DHCA group[15].

In our study, the course of ICU was not statistically significantly different between both groups; it was longer in the DHCA group (which may be due to the long ventilation time related to brain edema).

Kazui and colleagues reported an overall hospital mortality of 4.1% in a study of 266 patients. Independent predictors of in-hospital mortality were renal impairment, pump time, increasing age, history of cerebrovascular accident and previous ascending or arch operation [16].

In our CPB data from [Table 4], we found that the total bypass time in the ACP group (mean ± SD177.65 ± 53.3) was longer than that in the DHCA group (mean ± SD 133.05 ± 28.04), and the aortic cross clamping time is longer in the ACP group (mean ± SD 111.8 ± 41.76) than the DHCA group (mean ± SD 87.25 ± 23.15); this may be due to the time needed for selective cannulation and de-cannulation and difficult local anatomy in the patients of the ACP group.

In DHCA group, [Table 5], we found that after 30 minutes of circulatory arrest (Mean ±SD 26.4 ± 6.13) in DHCA,the patients were more vulnerable to CNS problems than before 30 minutes.

Gega and colleagues reported that DHCA lasted a mean of 31.0 min (range: 10–66 min) (study carried out on 394 patients). The overall mortality was 6.3% (25/394). Mortality was 3.6% (11/307) for elective cases and 16% (14/87) for emergency cases. The stroke rate was 4.8% (19/394). Among patients with DHCA exceeding 40 min, the stroke rate was 13.1% (8/61) [17].


  Conclusion Top


Conclusion the utilization of DHCA and ACP resulted in acceptable outcomes during aortic arch surgery. Preoperative risk factorslike;emergency, age >65 years,previous history of Stroke/TIA and significant carotid duplex affected the neurological outcome. In DHCA group a circulatory arrest time of more than 30 min. was associatedwith an increased risk of neurological problems.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Pacini D, Di Marco L, Leone A, Tonon C, Pettinato C, Fonti C, et al. Cerebral functions and metabolism after antegrade selective cerebral perfusion in aortic arch surgery. Eur J Cardiothorac Surg. 2010; 37:1322-1331.  Back to cited text no. 1
    
2.
Tian DH, Weller J, Hasmat S, Oo A, Forrest P, Kiat H, et al. Adjunct retrograde cerebral perfusion provides superior outcomes compared with hypothermic circulatory arrest alone: a meta-analysis. J Thorac Cardiovasc Surg. 2018; 156:1339-1348.  Back to cited text no. 2
    
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Takagi H, Mitta S, Ando T. A contemporary meta-analysis of antegrade versus retrograde cerebral perfusion for thoracic aortic surgery. Thorac Cardiovasc Surg. 2019; 67:351-362.  Back to cited text no. 3
    
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Cheung AT, Bavaria JE, Pochettino A, Weiss SJ, Barclay DK, Stecker MM. Oxygen delivery during retrograde cerebral perfusion in humans. Anesth Analg. 1999; 88:8-15.  Back to cited text no. 6
    
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De Paulis R, Czerny M, Weltert L, Bavaria J, Borger MA, Carrel TP, et al. Current trends in cannulation and neuroprotection during surgery of the aortic arch in Europe. Eur J Cardiothorac Surg. 2015; 47:917-923.  Back to cited text no. 7
    
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Perreas K, Samanidis G, Thanopoulos A, Georgiopoulos G, Antoniou T, Khoury M, et al. Antegrade or retrograde cerebral perfusion in ascending aorta and hemiarch surgery? A propensity-matched analysis. Ann Thorac Surg 2016; 101:146-152.  Back to cited text no. 8
    
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Englum BR, He X, Gulack BC, Ganapathi AM, Mathew JP, Brennan JM, et al. Hypothermia and cerebral protection strategies in aortic arch surgery: a comparative effectiveness analysis from the STS adult cardiac surgery database. Eur J Cardiothorac Surg. 2017; 52:492-498.  Back to cited text no. 9
    
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Guo S, Sun Y, Ji B, Liu J, Wang G, Zheng Z. Similar cerebral protective effectiveness of antegrade and retrograde cerebral perfusion during deep hypothermic circulatory arrest in aortic surgery: a meta-analysis of 7023 patients. Artif Organs. 2015; 39:300-308.  Back to cited text no. 10
    
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Hu Z, Wang Z, Ren Z, Wu H, Zhang M, Zhang H, et al. Similar cerebral protective effectiveness of antegrade and retrograde cerebral perfusion combined with deep hypothermia circulatory arrest in aortic arch surgery: a meta-analysis and systematic review of 5060 patients. J Thorac Cardiovasc Surg. 2014; 148:544-560.  Back to cited text no. 11
    
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Di Eusanio M, Schepens AM, Morshuis WJ, Di Bartolomeo R, Pierangeli A, Dossche KM. Brain protection using antegrade selective cerebral perfusiona multicenter study. Ann Thorac Surg 2003; 76:1181.  Back to cited text no. 12
    
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Di Eusanio M, Schepens MA, Morshuis WJ, Di Bartolomeo R, Pierangeli A, Dossche KM. Antegrade selective cerebral perfusion during operations on the thoracic aorta factors influencing survival and neurologic outcome in 413 patients. J Thorac Cardiovasc Surg 2002; 124:1080-1086.  Back to cited text no. 13
    
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Tian DH, Wan B, Bannon PG, Misfeld M, LeMaire SA, Kazui T, et al. A metaanalysis of deep hypothermic circulatory arrest versus moderate hypothermic circulatory arrest with selective antegrade cerebral perfusion. Ann Cardiothorac Surg. 2013; 2:148-158.  Back to cited text no. 14
    
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Kamenskaya OV, Klinkova AS, Chernyvsky AM, Lomivorotov VV, Meshkov IO, Georgiopoulos G, Antoniou T, et al. Deep hypothermic circulatory arrest vs. antegrade cerebral perfusion in cerebral protection during the surgical treatment of chronic dissection of the ascending and arch aorta. J Extra Corpor Technol 2017; 49:16.  Back to cited text no. 15
    
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Kazui T, Yamashita K, Washiyama N, Muhammad Bashar A, Kazuchika S, Suzuki T. Aortic arch replacement using selective cerebral perfusion. Ann Thorac Surg. 2007; 83:S796-S798.  Back to cited text no. 16
    
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Gega A, Rizzo J, Johnson M, Tranquilli M, Farkas EA, Elefteriades J. Straight deep hypothermic arrest: experience in 394 patients supports its effectiveness as a sole means of brain preservation. Ann Thorac Surg 2007; 84:759-767.  Back to cited text no. 17
    


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