Prospective comparative study of brain protection in total aortic arch replacement: Deep hypothermic circulatory arrest with retrograde cerebral perfusion or selective antegrade cerebral perfusion

Background. The purpose of this study was to compare the results of total a ortic arch replacement using two different methods of brain protection, par ticularly with respect to neurologic outcome. Methods. From June 1997, 60 consecutive patients who underwent total arch r eplacement through a midsternotomy were alternately allocated to one of two methods of brain protection: deep hypothermic circulatory arrest with retr ograde cerebral perfusion (RCP: 30 patients) or with selective antegrade ce rebral perfusion (SCP: 30 patients). Preoperative and postoperative (3 week s) brain CT scan, neurological examination, and cognitive function tests we re performed. Serum 100b protein was assayed before and after the cardiopul monary bypass, as well as 24 hours and 48 hours after the operation. Results. Hospital mortality occurred in 2 patients in the RCP group (6.6%) and 2 in the SCP group (6.6%). New strokes occurred in 1(3.3%) of the RCP g roup and in 2 (6.6%) of the SCP group (p = 0.6). The incidence of transient brain dysfunction was significantly higher in the RCP group than in the SC P group (10, 33.3% vs 4, 13.3%, p = 0.05). Except in patients with strokes, S-100b values showed no significant differences in the two groups (RCP: SC P, prebypass 0.01 +/- 0.34: 0.05 +/- 0.16, postbypass 2.17 +/- 0.94: 1.97 /- 1.00, 24 hours 0.61 +/- 0.36: 0.60 +/- 0.37, 48 hours 0.36 +/- 0.45: 0.4 6 +/- 0.40 mug/L, p = 0.7). There were no intergroup differences in the sco res of memory decline (RCP 0.74 +/- 0.99; SCP 1.55 +/- 1.19, p = 0.6), orie ntation (RCP 1.11 +/- 1.29; SCP 0.50 +/- 0.76, p = 0.08), or intellectual f unction (RCP 1.21 +/- 1.27; SCP 1.05 +/- 1.15, p = 0.7). Conclusions. Both methods of brain protection for patients undergoing total arch replacement resulted in acceptable levels of mortality and morbidity. However, the prevalence of transient brain dysfunction was significantly h igher in patients with the RCP. (C) 2001 by The Society of Thoracic Surgeon s.