Antegrade cerebral protection in thoracic aortic surgery: lessons from the past decade

Objective: Prolonged deep hypothermic circulatory arrest (DHCA) adversely affects outcome and quality of life in thoracic aortic surgery. Several techniques of antegrade cerebral perfusion are routinely used: bilateral selective antegrade cerebral protection (SACP) by introducing catheters in the innominate and left carotid artery, unilateral perfusion through the right axillary antegrade cerebral perfusion (RAACP) or a combination of right axillary perfusion with an additional catheter in the left carotid artery (RAACCP), resulting also in bilateral perfusion. The aim of the present study was to analyse the impact of the different approaches on the quality of life (QoL). Methods: The data of 292 patients who underwent surgery of the thoracic aorta using DHCA at our hospital between January 2004 and December 2007 have been analysed and a follow-up was performed focussing on QoL, assessed with the Short Form-36 Health Survey Questionnaire (SF-36). Results were analysed according to the type of cerebral perfusion and the duration of DHCA. Results: Patients' characteristics were similar in all groups. Of the total, 3.4% patients underwent DHCA (average 8.3 +/- 6.4 min) without ACP, 45.9% underwent SACP (average DHCA of 15.6 +/- 7.1 min), 40.4% had RAACP (average DHCA of 28.1 +/- 11.6 min) and 9.4% bilateral perfusion (RAACCP) (average DHCA of 43.1 +/- 16.7 min). The average follow-up was 23.2 +/- 15.1 months. QoL was preserved in all groups. For DHCA above 40 min, bilateral ACP provides superior midterm QoL than unilateral RAACP (average SF-36 95.1 + 44.4 vs 87.6 +/- 31.3; p = 0.072). Conclusions: When midterm QoL is assessed, bilateral SACP provides the best cerebral protection for prolonged DHCA (>40 min). (C) 2010 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.