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Thorac Cardiovasc Surg
DOI: 10.1055/a-2576-7627
Original Cardiovascular

Normothermic Circulatory Arrest with Antegrade Cerebral Perfusion for Type A Aortic Dissection

Laura Rings
1   Department of Cardiac Surgery, University Hospital Zurich, Zurich, Switzerland
2   Department of Cardiac Surgery, City Hospital of Zurich - Site Triemli, Zurich, Switzerland
,
Rasha Boulos
1   Department of Cardiac Surgery, University Hospital Zurich, Zurich, Switzerland
3   Center for Translational and Experimental Cardiology (CTEC), Zurich, Switzerland
,
Vasileios Ntinopoulos
1   Department of Cardiac Surgery, University Hospital Zurich, Zurich, Switzerland
2   Department of Cardiac Surgery, City Hospital of Zurich - Site Triemli, Zurich, Switzerland
,
Achim Haeussler
1   Department of Cardiac Surgery, University Hospital Zurich, Zurich, Switzerland
2   Department of Cardiac Surgery, City Hospital of Zurich - Site Triemli, Zurich, Switzerland
,
Hector Rodriguez Cetina Biefer
1   Department of Cardiac Surgery, University Hospital Zurich, Zurich, Switzerland
2   Department of Cardiac Surgery, City Hospital of Zurich - Site Triemli, Zurich, Switzerland
3   Center for Translational and Experimental Cardiology (CTEC), Zurich, Switzerland
,
Omer Dzemali
1   Department of Cardiac Surgery, University Hospital Zurich, Zurich, Switzerland
2   Department of Cardiac Surgery, City Hospital of Zurich - Site Triemli, Zurich, Switzerland
3   Center for Translational and Experimental Cardiology (CTEC), Zurich, Switzerland
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Abstract

Background

Deep hypothermic circulatory arrest is the standard approach for the surgical repair of acute type A aortic dissection. This study aimed to evaluate the feasibility and outcomes of normothermic circulatory arrest using antegrade cerebral perfusion as an alternative technique.

Methods

A retrospective propensity score-matched analysis was conducted on patients undergoing surgery for acute type A aortic dissection between 2007 and 2023 at a single center. Outcomes were compared between patients who underwent normothermic (>35°C) versus mild hypothermic (28–34°C) circulatory arrest. The primary outcomes were 30-day mortality, new neurological deficits, and the intraoperative and postoperative parameters.

Results

After propensity score matching, 20 pairs were analyzed. The normothermic group (NTCA) had significantly shorter aortic cross-clamp times (47.5 vs. 66.5 minutes, p = 0.013) and trends toward shorter cardiopulmonary bypass times (68 vs. 95 minutes, p = 0.066), ICU stays (4.5 vs. 5 days, p = 0.4), and intubation times (6 vs. 8 hours, p = 0.4). There were no significant differences in new neurological deficits (n = 6 [NTCA] vs. 4, p = 0.7), delirium (n = 5 [NTCA] vs. 6, p = 0.6), or mortality (n = 1 [NTCA] vs. 3, p = 0.6) between the groups. The normothermic group required less prothrombin complex concentrate (p = 0.0012).

Conclusion

In this pilot study, NTCA with antegrade cerebral perfusion appears feasible and safe for hemiarch repair in acute type A aortic dissection, with potential benefits of shorter operative times and improved coagulation profiles compared with mild hypothermia. Larger prospective studies are needed to confirm these findings.

Keywords

aorta/aortic - cardiac - hypothermia/circulatory arrest - outcomes (includes mortality morbidity)

Supplementary Material



Publication History

Received: 24 November 2024

Accepted: 07 April 2025

Article published online:
02 May 2025

© 2025. Thieme. All rights reserved.

Georg Thieme Verlag KG
Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany

 

  • References

  • 1 Di Marco L, Leone A, Murana G. et al. Acute type A aortic dissection: rationale and outcomes of extensive repair of the arch and distal aorta. Int J Cardiol 2018; 267: 145-149
    CrossrefPubMedSearch in Google Scholar
  • 2 Yu W, Liang Y, Gao J, Xiong J. Study on risk factors and treatment strategies of hypoxemia after acute type A aortic dissection surgery. J Cardiothorac Surg 2024; 19 (01) 273
    PubMedSearch in Google Scholar
  • 3 Toia P, Pennisi L, Taravella R. et al. Post-operative computed tomography imaging evaluation of ascending aorta surgery. Pol J Radiol 2021; 86: e246-e254
    PubMedSearch in Google Scholar
  • 4 Appoo JJ, Ralley F, Baslaim G, de Varennes B. Anesthesia for deep hypothermic circulatory arrest in adults: experience with the first 50 patients. J Cardiothorac Vasc Anesth 1998; 12 (03) 260-265
    PubMedSearch in Google Scholar
  • 5 Liu Y, Wu Z, Dai L. et al. Deep hypothermic circulatory arrest does not show better protection for vital organs compared with moderate hypothermic circulatory arrest in pig model. BioMed Res Int 2019; 2019: 1420216
    PubMedSearch in Google Scholar
  • 6 Amir G, Ramamoorthy C, Riemer RK, Reddy VM, Hanley FL. Neonatal brain protection and deep hypothermic circulatory arrest: pathophysiology of ischemic neuronal injury and protective strategies. Ann Thorac Surg 2005; 80 (05) 1955-1964
    PubMedSearch in Google Scholar
  • 7 Troncone MJ, Hong JC. Descending thoracic and thoracoabdominal aortic aneurysm repair using deep hypothermic circulatory arrest. Vessel Plus 2023; 7: 14
    PubMedSearch in Google Scholar
  • 8 Cooper WA, Duarte IG, Thourani VH. et al. Hypothermic circulatory arrest causes multisystem vascular endothelial dysfunction and apoptosis. Ann Thorac Surg 2000; 69 (03) 696-702 , discussion 703
    PubMedSearch in Google Scholar
  • 9 Tian DH, Wan B, Bannon PG. et al. A meta-analysis of deep hypothermic circulatory arrest versus moderate hypothermic circulatory arrest with selective antegrade cerebral perfusion. Ann Cardiothorac Surg 2013; 2 (02) 148-158
    PubMedSearch in Google Scholar
  • 10 Rajagopalan S, Mascha E, Na J, Sessler DI. The effects of mild perioperative hypothermia on blood loss and transfusion requirement. Anesthesiology 2008; 108 (01) 71-77
    CrossrefPubMedSearch in Google Scholar
  • 11 Schmied H, Kurz A, Sessler DI, Kozek S, Reiter A. Mild hypothermia increases blood loss and transfusion requirements during total hip arthroplasty. Lancet 1996; 347 (8997) 289-292
    CrossrefPubMedSearch in Google Scholar
  • 12 Manoly I, Uzzaman M, Karangelis D. et al. Neuroprotective strategies with circulatory arrest in open aortic surgery—a meta-analysis. Asian Cardiovasc Thorac Ann 2022; 30 (06) 635-644
    PubMedSearch in Google Scholar
  • 13 Jassar AS, Vallabhajosyula P, Bavaria JE. et al. Direct innominate artery cannulation: an alternate technique for antegrade cerebral perfusion during aortic hemiarch reconstruction. J Thorac Cardiovasc Surg 2016; 151 (04) 1073-1078
    PubMedSearch in Google Scholar
  • 14 Ma M, Liu L, Feng X. et al. Moderate hypothermic circulatory arrest with antegrade cerebral perfusion for rapid total arch replacement in acute type A aortic dissection. Thorac Cardiovasc Surg 2016; 64 (02) 124-132
    PubMedSearch in Google Scholar
  • 15 Risteski P, Radacki I, Zierer A, Lenos A, Moritz A, Urbanski PP. Reoperative aortic arch surgery under mild systemic hypothermia: two-center experience. Aorta (Stamford) 2021; 9 (02) 60-66
    PubMedSearch in Google Scholar
  • 16 Zierer A, Aybek T, Risteski P, Dogan S, Wimmer-Greinecker G, Moritz A. Moderate hypothermia (30 degrees C) for surgery of acute type A aortic dissection. Thorac Cardiovasc Surg 2005; 53 (02) 74-79
    PubMedSearch in Google Scholar
  • 17 Bakhtiary F, Dogan S, Zierer A. et al. Antegrade cerebral perfusion for acute type A aortic dissection in 120 consecutive patients. Ann Thorac Surg 2008; 85 (02) 465-469
    PubMedSearch in Google Scholar
  • 18 Leshnower BG, Thourani VH, Halkos ME. et al. Moderate versus deep hypothermia with unilateral selective antegrade cerebral perfusion for acute type A dissection. Ann Thorac Surg 2015; 100 (05) 1563-1568 , discussion 1568–1569
    PubMedSearch in Google Scholar
  • 19 Raja SG. Off-pump coronary artery bypass grafting in octogenarians. J Thorac Dis 2016; 8 (Suppl. 10) S799-S807
    PubMedSearch in Google Scholar
  • 20 Anthony A, Sendelbach S. Postoperative complications of coronary artery bypass grafting surgery. Crit Care Nurs Clin North Am 2007; 19 (04) 403-415 , vi
    PubMedSearch in Google Scholar
  • 21 Wang J, Wang T, Zhang H. et al. Effect of mild hypothermia vs normothermia cardiopulmonary bypass on postoperative bleeding in patients undergoing coronary artery bypass grafting: protocol of a multi-center, randomized, controlled trial. BMC Surg 2024; 24 (01) 323
    PubMedSearch in Google Scholar
  • 22 Elmore JR, Franklin DP, Youkey JR, Oren JW, Frey CM. Normothermia is protective during infrarenal aortic surgery. J Vasc Surg 1998; 28 (06) 984-992 , discussion 992–994
    PubMedSearch in Google Scholar
  • 23 Zierer A, Risteski P, El-Sayed Ahmad A, Moritz A, Diegeler A, Urbanski PP. The impact of unilateral versus bilateral antegrade cerebral perfusion on surgical outcomes after aortic arch replacement: a propensity-matched analysis. J Thorac Cardiovasc Surg 2014; 147 (04) 1212-1217 , discussion 1217–1218
    CrossrefPubMedSearch in Google Scholar
  • 24 Risteski P, Radwan M, Boshkoski G. et al. Minimally invasive aortic arch repair: technical considerations and mid-term outcomes. Heart Surg Forum 2020; 23 (06) E803-E808
    PubMedSearch in Google Scholar
  • 25 R Core Team. 2023 R: A language and environment for statistical## computing. R Foundation for Statistical Computing, Vienna, Austria. [Internet]. 2023. Accessed at: https://www.R-project.org/
    PubMedSearch in Google Scholar
  • 26 Ho DE, Imai K, King G, Stuart EA. MatchIt: nonparametric preprocessing for parametric causal inference. J Stat Softw 2011;42(08):
    PubMed
  • 27 Smith PK, Carrier M, Chen JC. et al. Effect of pexelizumab in coronary artery bypass graft surgery with extended aortic cross-clamp time. Ann Thorac Surg 2006; 82 (03) 781-788 , discussion 788–789
    PubMedSearch in Google Scholar
  • 28 Gaillard D, Bical O, Paumier D, Trivin F. A review of myocardial normothermia: its theoretical basis and the potential clinical benefits in cardiac surgery. Cardiovasc Surg 2000; 8 (03) 198-203
    PubMedSearch in Google Scholar
  • 29 Bianco V, Kilic A, Aranda-Michel E. et al. Mild hypothermia versus normothermia in patients undergoing cardiac surgery. JTCVS Open 2021; 7: 230-242
    CrossrefPubMedSearch in Google Scholar
  • 30 Stiru O, Geana RC, Tulin A. et al. ARCH replacement in acute aortic dissection type a in normothermia. Rev Chim. 2001; 71 (03) 282-286
    PubMedSearch in Google Scholar
  • 31 Okita Y, Minatoya K, Tagusari O, Ando M, Nagatsuka K, Kitamura S. Prospective comparative study of brain protection in total aortic arch replacement: deep hypothermic circulatory arrest with retrograde cerebral perfusion or selective antegrade cerebral perfusion. Ann Thorac Surg 2001; 72 (01) 72-79
    PubMedSearch in Google Scholar
  • 32 Cho HJ, Kyong YY, Oh YM, Choi SM, Choi KH, Oh JS. Therapeutic hypothermia complicated by spontaneous brain stem hemorrhage. Am J Emerg Med 2013; 31 (01) 266.e1-266.e3
    PubMedSearch in Google Scholar
  • 33 Schanche T, Filseth OM, Østerud B, Kondratiev TV, Sieck GC, Tveita T. Enhanced blood clotting after rewarming from experimental hypothermia in an intact porcine model. Front Physiol 2022; 13: 901908
    PubMedSearch in Google Scholar
  • 34 Shimokawa M, Kitaguchi K, Kawaguchi M, Sakamoto T, Kakimoto M, Furuya H. The influence of induced hypothermia for hemostatic function on temperature-adjusted measurements in rabbits. Anesth Analg 2003; 96 (04) 1209-1213
    PubMedSearch in Google Scholar
  • 35 Oddo M, Frangos S, Milby A. et al. Induced normothermia attenuates cerebral metabolic distress in patients with aneurysmal subarachnoid hemorrhage and refractory Fever. Stroke 2009; 40 (05) 1913-1916
    PubMedSearch in Google Scholar
  • 36 Mizushima Y, Wang P, Cioffi WG, Bland KI, Chaudry IH. Should normothermia be restored and maintained during resuscitation after trauma and hemorrhage?. J Trauma 2000; 48 (01) 58-65
    PubMedSearch in Google Scholar
  • 37 Amer GF, Elawady MS, ElDerie A, Sanad M. Normothermia versus hypothermia during cardiopulmonary bypass in cases of repair of atrioventricular septal defect. Anesth Essays Res 2020; 14 (01) 112-118
    CrossrefPubMedSearch in Google Scholar
  • 38 Grimm M, Czerny M, Baumer H. et al. Normothermic cardiopulmonary bypass is beneficial for cognitive brain function after coronary artery bypass grafting—a prospective randomized trial. Eur J Cardiothorac Surg 2000; 18 (03) 270-275
    PubMedSearch in Google Scholar
  • 39 Touati GD, Marticho P, Farag M. et al. Totally normothermic aortic arch replacement without circulatory arrest. Eur J Cardiothorac Surg 2007; 32 (02) 263-268 , discussion 268
    PubMedSearch in Google Scholar
  • 40 Pouard P, Mauriat P, Ek F. et al. Normothermic cardiopulmonary bypass and myocardial cardioplegic protection for neonatal arterial switch operation. Eur J Cardiothorac Surg 2006; 30 (05) 695-699
    PubMedSearch in Google Scholar
  • 41 Ohki S, Oshima K, Takeyoshi I, Matsumoto K, Morishita Y. Endotoxin removal with a polymyxin B-immobilized hemoperfusion cartridge improves cardiopulmonary function after cardiopulmonary bypass. J Surg Res 2008; 145 (01) 74-79
    PubMedSearch in Google Scholar
  • 42 Pupovac SS, Hemli JM, Giammarino AT. et al. Deep versus moderate hypothermia in acute type A aortic dissection: a propensity-matched analysis. Heart Lung Circ 2022; 31 (12) 1699-1705
    PubMedSearch in Google Scholar
  • 43 Nakai Y, Yamada T, Ogawa S, Kamiya S, Saitoh Y, Suda H. Surgical outcomes of acute type A aortic dissection in septuagenarians and octogenarians. Asian Cardiovasc Thorac Ann 2022; 30 (07) 772-778
    PubMedSearch in Google Scholar