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 aortic arch replacement using two different methods of brain protection, particularly with respect to neurologic outcome. Methods. From June 1997, 60 consecutive patients who underwent total arch replacement through a midsternotomy were alternately allocated to one of two methods of brain protection: deep hypothermic circulatory arrest with retrograde cerebral perfusion (RCP: 30 patients) or with selective antegrade cerebral perfusion (SCP: 30 patients). Preoperative and postoperative (3 weeks) brain CT scan, neurological examination, and cognitive function tests were performed. Serum 100b protein was assayed before and after the cardiopulmonary 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 group 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 SCP 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: SCP, prebypass 0.01 ± 0.04: 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: 0.46 ± 0.40 μg/L, p = 0.7). There were no intergroup differences in the scores of memory decline (RCP 0.74 ± 0.99; SCP 0.55 ± 1.19, p = 0.6), orientation (RCP 1.11 ± 1.29; SCP 0.50 ± 0.76, p = 0.08), or intellectual function (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 higher in patients with the RCP.