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Retrograde Cerebral Perfusion with Moderate Versus Deep Hypothermia in Elective Hemiarch Replacement
Bo Chang B. Wu1, Catherine Eccleston2, Branson Taheri3, Arjune S. Dhanekula2, Pavan Guttipatti1, Argudit Chauhan1, Gregory Fishberger1, Andrea Steely4, Fernando Fleischmann5, Jason Glotzbach4, Anthony D. Caffarelli6, Scott C. DeRoo2, Christopher Burke2, Fenton McCarthy7, T. Brett Reece1
1Cardiothoracic Surgery, University of Colorado Anschutz Medical Campus School of Medicine, Aurora, CO, 2Cardiothoracic Surgery, University of Washington, Seattle, WA, 3Vascular Surgery, University of Colorado Anschutz Medical Campus School of Medicine, Aurora, CO, 4. Cardiothoracic Surgery, The University of Utah School of Medicine, Salt Lake City, UT 5. Cardiothoracic Surgery, University of Southern California Keck School of Medicine, Los Angeles, CA 6. Cardiac Surgery, Providence Heart Institute, Missoula, MT 7. Cardiac Surgery, Providence Sacred Heart Medical Center, Spokane, WA
Objective: Retrograde cerebral perfusion (RCP) in conjunction with deep hypothermic circulatory arrest (DHCA) is an established and safe technique for cerebral perfusion in aortic arch surgery. The use of RCP with moderate hypothermic circulatory arrest (MHCA) is novel and controversial. This study compares RCP in DHCA versus MHCA in patients undergoing elective hemiarch surgery. We hypothesize that RCP with MHCA will have similar survival and neurologic outcomes compared to those achieved with DHCA.
Methods: A multi-institutional retrospective cohort study was performed on 621 patients who underwent elective hemiarch replacement with RCP from 2018 to 2025. Patients were stratified by nadir temperature using a cutoff of above 24°C for MHCA (mean 27.7 ± 1.3°C) and below 24°C for DHCA (mean 18.5 ± 1.2°C) groups. Postoperative neurologic outcomes included stroke alert, confirmed cerebrovascular event (transient ischemic attack or stroke, as defined by the Society of Thoracic Surgeons), delirium, encephalopathy, and seizure. Follow-up neurologic status was assessed at 3 months and 1 year using a four-point scale (no symptoms, mild residual symptoms, major residual symptoms, death). Comparative analyses utilized Mann-Whitney U, t-test, Chi-square, or Fisher's exact test. Multivariable logistic regression identified predictors of stroke, adverse neurologic events, and postoperative mortality.
Results: Among 621 patients, 332 underwent RCP with MHCA and 289 underwent RCP with DHCA. The MHCA group was older (59.8 vs 56.3 years, p=0.01) and had lower rates of hypertension (p=0.01), peripheral artery disease (p<0.01), and prior stroke (p<0.01). There were no significant differences in postoperative mortality or stroke between MHCA and DHCA. Intraoperatively, MHCA patients had significantly shorter cardiopulmonary bypass (138 vs 193 min), cross-clamp (103 vs 152 min), and circulatory arrest times (9 vs 18 min; p<0.01). Postoperatively, DHCA patients experienced more transient ischemic attacks (2.4% vs 0.3%, p=0.03), longer hospital length of stay (8.9 vs 7.7 days, p<0.01) but less delirium (3.1% vs 9.4%, p<0.01). The rates of postoperative encephalopathy, seizure, and neurologic recovery at 3 months and 1 year did not differ between groups. On multivariable logistic regression, MHCA was not associated with composite adverse neurologic events or postoperative mortality, while showing a marginally lower stroke risk (OR 0.32, p=0.046). Given the difference in circulatory arrest times between the MHCA and DHCA cohorts, a propensity matched sensitivity analysis adjusting for these time differences was performed which did not show a significant difference in neurologic outcomes.
Conclusions: Elective hemiarch replacement using RCP at either DHCA or MHCA temperatures demonstrates comparable rates of stroke, mortality, and neurologic recovery. Moreover, MHCA RCP was associated with shorter cardiopulmonary bypass time, cross-clamp time, and hospital length of stay. Overall, these findings support the neurologic safety of MHCA RCP as compared to DHCA RCP in elective hemiarch surgery.
Table. Operative variables and postoperative outcomes in elective hemiarch replacement with retrograde cerebral perfusion (DHCA vs MHCA).
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