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Optimal Degree of Hypothermia in Total Arch Replacement for Type A Aortic Dissection
Jinlin Wu1,2, Juntao Qiu2, Zhongrong Fang3
1Department of Cardiac Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China.
Insights
Mild hypothermic cardiac arrest (MHCA) may be superior to deep hypothermic cardiac arrest (DHCA) for type A aortic dissection (TAAD) arch repair, particularly in older patients. Lower temperatures (DHCA) were associated with worse outcomes and increased complications.
Area of Science:
- Cardiovascular Surgery
- Thoracic Surgery
- Aortic Dissection Research
Background:
- Investigating optimal hypothermic cardiac arrest (HCA) temperatures for type A aortic dissection (TAAD) total arch replacement.
- Analyzing a cohort of 1,018 patients undergoing TAAD arch repair between 2013 and 2018.
Purpose of the Study:
- To determine the ideal degree of hypothermic cardiac arrest (HCA) for type A aortic dissection (TAAD) total arch replacement.
- To compare outcomes between deep hypothermic cardiac arrest (DHCA) and moderate hypothermic cardiac arrest (MHCA).
Main Methods:
- Cohort divided into DHCA (≤24°C) and MHCA (>24°C) groups.
- Primary endpoints included mortality, stroke, paraplegia, and continuous renal replacement therapy (CRRT), summarized as composite major outcomes (CMO).
- Analysis included propensity score matching and sensitivity analyses.
Main Results:
- MHCA showed a trend towards reduced composite major outcomes (CMO) compared to DHCA (adjusted OR 0.6; p=0.055).
- DHCA was associated with longer cardiopulmonary bypass time, hospital stay, and ICU stay, alongside greater blood loss and transfusion requirements.
- MHCA demonstrated a significant protective effect (60% risk reduction) in patients over 60 years old (OR 0.4; p=0.009).
- Lower temperatures (DHCA) correlated with significantly higher mortality and worse outcomes.
Conclusions:
- A shift towards moderate hypothermic cardiac arrest (MHCA) may be beneficial for type A aortic dissection (TAAD) arch operations.
- MHCA appears particularly advantageous for elderly patients undergoing TAAD arch repair.
- Findings suggest that lower temperatures during HCA may be associated with poorer surgical outcomes.
Abstract:
Background: We sought to investigate the best degree of hypothermic cardiac arrest (HCA) in type A aortic dissection (TAAD) with a cohort of 1,018 cases receiving total arch replacement from 2013 to 2018 in Fuwai Hospital. Method: The cohort was divided by DHCA (≤24°C, n = 580) vs. MHCA (>24°C, n = 438), and interquartile range (Q1-Q4). Primary endpoints included mortality, stroke, paraplegia, and continuous renal replacement therapy (CRRT), which were summarized as composite major outcomes (CMO). Results: The Odds Ratio (OR) of CMO for MHCA was 0.7 (95% CI: 0.5-1.0, p = 0.06) (unadjusted) and 0.6 (95% CI: 0.4-1.0, p = 0.055) (adjusted). DHCA group tended to have a significantly longer CPB time (175.6 ± 45.6 vs. 166.8 ± 49.8 min, p = 0.003), longer hospital stay (16.0 ± 13.6 vs. 13.5 ± 6.8 days, p < 0.001), and ICU stay [5.0 (3.9-6.6) vs. 3.8 (2.0-5.6) days]. A significantly greater blood loss was observed in DHCA group, with a greater requirement for RBC and platelet transfusion. Of note, MHCA showed a significant protective effect (60% risk reduction) for older patients (above 60 years) (OR 0.4; 95% CI: 0.2-0.8; p = 0.009). By quartering, Q1 had significantly higher mortality (10.9%) than Q4 (5.2%) (p = 0.035). For other comparisons, the gap was significantly widened in quartering between Q1 and Q4, i.e., the lower the temperature, the worse the outcomes, and vice versa. Propensity score matching and sensitivity analyses confirmed the above findings. Conclusions: A paradigm change from DHCA to MHCA may be encouraged in TAAD arch operation, especially for the elderly.
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