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A meta-analysis of deep hypothermic circulatory arrest alone versus with adjunctive selective antegrade cerebral
David H Tian1, Benjamin Wan, Paul G Bannon
1Collaborative Research (CORE) Group, Sydney, Australia;
Insights
Deep hypothermic circulatory arrest with selective antegrade cerebral perfusion (DHCA + SACP) improves survival outcomes in aortic arch surgery compared to DHCA alone. This meta-analysis found no significant neurological differences between the neuroprotection strategies.
Area of Science:
- Cardiovascular Surgery
- Neurosurgery
- Medical Technology
Background:
- Deep hypothermic circulatory arrest (DHCA) is crucial for neuroprotection during aortic arch surgery by reducing cerebral metabolic activity.
- Selective antegrade cerebral perfusion (SACP) is an adjunct to DHCA for extended procedures, but carries risks of embolism and perfusion abnormalities.
- The optimal neuroprotection strategy for aortic arch surgery remains a subject of investigation.
Purpose of the Study:
- To compare postoperative outcomes between DHCA alone and DHCA with SACP (DHCA + SACP) in aortic arch surgery.
- To evaluate the efficacy of these neuroprotection strategies in reducing neurological injury and improving survival.
- To synthesize evidence from existing comparative studies through a meta-analysis.
Main Methods:
- A systematic literature search was conducted across six databases up to January 2013.
- Two independent reviewers identified and selected comparative studies of DHCA alone versus DHCA + SACP.
- Data from nine identified studies involving 648 patients (DHCA alone) and 370 patients (DHCA + SACP) were extracted and meta-analyzed.
Main Results:
- No significant differences were observed in temporary or permanent neurological outcomes between the two groups.
- DHCA + SACP demonstrated significantly better survival outcomes (P=0.008) compared to DHCA alone, despite longer cardiopulmonary bypass times.
- Analysis of other systemic outcomes was precluded due to inconsistent reporting in the included studies.
Conclusions:
- DHCA + SACP is associated with superior mortality outcomes in aortic arch surgery.
- While neurological outcomes were similar, the survival benefit suggests DHCA + SACP may be a preferred neuroprotection strategy.
- Further research with consistent reporting of systemic outcomes is warranted.
Introduction:
Recognizing the importance of neuroprotection in aortic arch surgery, deep hypothermic circulatory arrest (DHCA) now underpins operative practice as it minimizes cerebral metabolic activity. When prolonged periods of circulatory arrest are required, selective antegrade cerebral perfusion (SACP) is supplemented as an adjunct. However, concerns exist over the risks of SACP in introducing embolism and hypo- and hyper-perfusing the brain. The present meta-analysis aims to compare postoperative outcomes in arch surgery using DHCA alone or DHCA + SACP as neuroprotection strategies.
Methods:
Electronic searches were performed using six databases from their inception to January 2013. Two reviewers independently identified all relevant studies comparing DHCA alone with DHCA + SACP. Data were extracted and meta-analyzed according to pre-defined clinical endpoints.
Results:
Nine comparative studies were identified in the present meta-analysis, with 648 patients employing DHCA alone and 370 utilizing DHCA + SACP. No significant differences in temporary or permanent neurological outcomes were identified. DHCA + SACP was associated with significantly better survival outcomes (P=0.008, I(2)=0%), despite longer cardiopulmonary bypass time. Infrequent and inconsistent reporting of other clinical results precluded analysis of systemic outcomes.
Conclusions:
The present meta-analysis indicate the superiority of DHCA + SACP in terms of mortality outcomes.
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