Unilateral Versus Bilateral Antegrade Cerebral Protection During Circulatory Arrest in Aortic Surgery: A Meta-Analysis of 5100 Patients

Study Questions:

Does the use of unilateral (u-ACP) or bilateral antegrade cerebral perfusion (b-ACP) result in different mortality and neurologic outcomes after complex aortic surgery?

Methods:

PubMed, Embase, and the Cochrane Library were searched for studies reporting on postoperative mortality and permanent and temporary neurologic dysfunction in complex aortic surgery requiring circulatory arrest with antegrade cerebral protection. Analysis of heterogeneity was performed with the Cochrane Q statistic.

Results:

Twenty-eight studies were analyzed, which included a total of 1,894 patients receiving u-ACP and 3,206 receiving b-ACP. Pooled analysis showed similar rates of 30-day mortality (8.6% vs. 9.2% for u-ACP and b-ACP, respectively; p = 0.78), permanent neurologic dysfunction (6.1% vs. 6.5%, p = 0.80), and temporary neurologic dysfunction (7.1% vs. 8.8%, p = 0.46). Age, sex, and cardiopulmonary bypass time did not influence effect size estimates. Higher rates of postoperative mortality and permanent neurologic dysfunction were observed among nonelective operations, and for highest temperatures and duration of the circulatory arrest. The Egger test excluded publication bias for the outcomes investigated.

Conclusions:

This meta-analysis suggests that b-ACP and u-ACP are associated with similar postoperative mortality, and similar rates of both permanent and temporary neurologic dysfunction after circulatory arrest for complex aortic surgery.

Perspective:

Temporary and permanent neurologic dysfunction can be a morbid or mortal complication following complex aortic surgery. Hypothermic circulatory arrest is the main cerebral protection used during aortic surgery, but limitations exist. ACP can be used in conjunction with hypothermic circulatory arrest, but the need for deep hypothermia in addition to antegrade perfusion is unclear. This meta-analysis suggests that u-ACP (usually via the right axillary artery) has similar outcomes in terms of mortality and cerebral morbidity compared to b-ACP. The finding that higher rates of permanent neurologic dysfunction were associated with higher temperatures of circulatory arrest supports the importance of hypothermia when performing complex aortic surgery.

Clinical Topics: Arrhythmias and Clinical EP, Cardiac Surgery, Vascular Medicine, Implantable Devices, SCD/Ventricular Arrhythmias, Aortic Surgery, Cardiac Surgery and Arrhythmias

Keywords: Aortic Aneurysm, Thoracic, PubMed, Morbidity, Axillary Artery, Hyperbilirubinemia, Hereditary, Heart Arrest, Publication Bias, Postoperative Period, Perfusion, Temperature, Cardiopulmonary Bypass, Cerebrovascular Circulation, Hypothermia, Induced


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