Antegrade cerebral perfusion with mild hypothermia for aortic arch replacement: single-center experience in 245 consecutive patients.

Background: Aortic arch replacement remains a surgical challenge because of prolonged operative times, bleeding complications, and a considerable risk of neurologic morbidity and mortality. This study investigates our clinical results after modification of perfusion technique for cardiopulmonary bypass as well as temperature management for these high- risk patients.

Methods: Between January 2000 and January 2009, 245 consecutive patients underwent aortic arch repair during selective antegrade cerebral perfusion (ACP) with mild systemic hypothermia (30.5°C±1.4°C). Mean age was 63±12 years, 175 patients (71%) were men and 141 patients (58%) had acute type A dissection. Hemiarch replacement was performed in 152 patients (62%) while the remaining 93 patients (38%) underwent total arch replacement.

Results: Cardiopulmonary bypass time accounted for 168±62 minutes, and myocardial ischemic time was 103±45 minutes. Isolated ACP was performed for 38±27 (range 12 to 135) minutes. Chest tube drainage during the first 24 hours was 563±248 mL. Mean ventilation time was 44±22 hours. Serum lactate levels at 1, 12, and 24 hours postoperatively rose to 19±11, 33±14, and 20±8 mg/dL, respectively. We observed new postoperative permanent neurologic deficits in 14 patients (6%) and transient neurologic deficits in 12 patients (5%). The operative mortality rate was 8% (n=20). Among patients with ACP times 60 minutes or greater (n=28; 92±29 minutes), permanent neurologic deficits occurred in 2 individuals (n=2 of 28; 7%) and operative mortality was 7% (n=2 of 28). At late follow-up (3.8±3.2 years, 98% complete), 196 patients (80%) were still alive.

Conclusions: Selective ACP in combination with mild hypothermia offered sufficient cerebral as well as distal organ protection in our patient cohort. Thus, current data suggest that this standardized perfusion and temperature management protocol can safely be applied to complex aortic arch surgery requiring up to 90 minutes of isolated ACP times.