Type-A Aortic Dissection and Cerebral Perfusion: The Society of Thoracic Surgeons Database Analysis

Background: The optimal cerebral perfusion strategy during hypothermic circulatory arrest for acute type A aortic dissection repair is controversial. This study used a national clinical registry to evaluate cerebral protection strategies. Methods: Using the Society of Thoracic Surgeons Adult Cardiac Surgical Database, study investigators identified 6387 patients with aortic dissection (mean age, 60.4 years, SD 13.5 years) who underwent total arch (n = 872; 13.7%) or ascending or hemiarch (n = 5515; 86.3%) replacement with circulatory arrest between 2014 and 2016 in the United States. Multivariable analysis adjusted for potential confounders, including demographics and comorbidity. Outcomes were compared according to the following: use of retrograde, antegrade, or no cerebral perfusion; nadir temperature; and duration of circulatory arrest. The primary end point was a composite of 30-day and in-hospital mortality or stroke. Results: The rate of death or stroke was 25.5% (n = 1627). Antegrade cerebral perfusion was used in 46.2% (n = 2950) patients, retrograde cerebral perfusion was used in 22.6% (n = 1445), and no cerebral perfusion was used in 31.2% (n = 1992). In multivariable analysis, death or stroke risk increased with longer circulatory arrest duration (adds ratio [OR], 1.11 per 10-minute increment; 95% confidence interval [CI], 1.08 to 1.14). Multivariate analysis stratified by temperature showed improved outcomes with cerebral perfusion (antegrade or retrograde) and deep (OR, 0.86; 95% CI, 0.74 to 0.98), or moderate (OR, 0.78; 95% CI, 0.65 to 0.95) hypothermic circulatory arrest vs circulatory arrest without cerebral perfusion. There was a slight correlation between nadir temperature and the primary outcome. Conclusions: Cerebral perfusion should be used during arch repair for aortic dissection because antegrade and retrograde cerebral perfusion strategies are associated with reduced death and stroke risk compared with hypothermic circulatory arrest without cerebral perfusion.