Brain Protection During Ascending Aortic Repair for Stanford Type A Acute Aortic Dissection Surgery - Nationwide Analysis in Japan

Background: The optimal brain protection strategy for use during acute type A aortic dissection surgery is controversial. Methods and Results: We reviewed the results for 2 different methods: antegrade cerebral perfusion (ACP) and retrograde cerebral perfusion (RCP), during ascending aortic repair for acute type A aortic dissection for the period between 2008 and 2012 nationwide. Cases involving root repair, arch vessel reconstruction and/or concomitant procedures were excluded. Using the Japan Adult Cardiovascular Surgery Database, a total of 4,128 patients (ACP, n=2,769; RCP, n=1,359; mean age, 69.1 +/- 11.8 years; male 41.9%) were identified. The overall operative mortality was 8.6%. Following propensity score matching, among 1,320 matched pairs, differences in baseline characteristics between the 2 patient groups diminished. Cardiac arrest time (ACP 116 +/- 36 vs. RCP102 +/- 38 min, P<0.001), perfusion time (192 +/- 54 vs. 174 +/- 53 min, P<0.001) and operative time (378 +/- 117 vs. 340 +/- 108 min, P<0.001) were significantly shorter in the RCP group. There were no significant differences between the 2 groups regarding the incidence of operative mortality or neurological complications, including stroke (ACP 11.2% vs. RCP 9.7%). Postoperative ventilation time was significantly longer in the ACP group (ACP 128.9 +/- 355.7 vs. RCP 98.5 +/- 301.7 h, P=0.018). There were no differences in other early postoperative complications, such as re-exploration, renal failure, and mediastinitis. Conclusions: Among patients undergoing dissection repair without arch vessel reconstruction, RCP had similar mortality and neurological outcome to ACP.