Risk-adjusted and Case-matched Comparative Study Comparing Antegrade and Retrograde Cerebral Perfusion in Aortic Arch Surgery Based on the Japan Adult Cardiovascular Surgery Database

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Risk-adjusted and Case-matched Comparative Study
Comparing Antegrade and Retrograde Cerebral
Perfusion in Aortic Arch Surgery Based on the
Japan Adult Cardiovascular Surgery Database

• The Japan Cardiovascular Surgery Database
  Organization
• Usui A, Miyata H, Ueda Y
• Motomura N, Takamoto S

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Objective

• Antegrade cerebral perfusion (ACP) and retrograde
  cerebral perfusion (RCP) are two techniques for
  brain protection in aortic arch surgery.
• We conducted a large-scaled, comparative clinical
  study between ACP and RCP to evaluate up-to-date
  clinical outcomes based upon Japan Adult
  Cardiovascular Surgery Database (JACVSD).

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Patients selection
2005-2007 116 institutes
8470 aortic surgery
Use of ACP or RCP
3359 ACP 1232 RCP
Ascending or arch AO Elective surgery No-dissectio
n 10 pt./year lt (65 institutes)
Statistical analysis
1185 ACP 392 RCP
Risk adjusted analysis
463 ACP 304 RCP
Matched pair analysis
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End points

• Mortality
• 30 days mortality
• Operative mortality
• In-hospital complications
• CNS dysfunction (Stroke, TIA, Coma)
• Paraparesis / paraplegia
• Reoperation for any reason
• Prolonged ventilation 24lt hours
• Renal failure required dialysis
• Deep sternal wound infection

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Patients Characteristics for Risk Adjusted
Analysis
variables ACP RCP P value
No. of patients 1185 392
Sex (male) 74.3 69.1 0.049
Smoking 52.4 42.1 0.000
Renal failure 7.7 3.6 0.003
Cerebrovascular accident 16.6 11.5 0.015
Congestive heart failure 3.5 11.5 0.000
Range of replacement (root) 6.1 17.3 0.000
(Ascending) 50.7 74.2 0.000
(Arch) 84.6 37.5 0.000
Age 71 /- 9 67 /- 12 0.000
Annual volume 34 /-19 39 /- 23 0.000
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Risk Adjusted Analysis
ACP RCP Odds ratio (95CI) P value
No. of patients No. of patients No. of patients 1185 392
30-day mortality 30-day mortality 30-day mortality 3.21 2.00 0.63(0.25-1.58) 0.324
Operative mortality Operative mortality Operative mortality 5.15 3.83 0.74(0.37-1.49) 0.401
Morbidity Morbidity Morbidity
Stroke Stroke 5.65 2.81 0.61(0.29-1.28) 0.189
Prolonged ventilation Prolonged ventilation 15.02 12.24 1.00(0.67-1.50) 0.996
Reoperation Reoperation 7.76 7.40 0.98(0.59-1.65) 0.948
Dialysis required Dialysis required 2.53 3.06 2.51(1.04-6.03) 0.04
Deep sternal infection Deep sternal infection 1.69 1.79 1.12(0.39-3.24) 0.837
Paraparesis Paraparesis 3.29 2.04 0.96(0.41-2.28) 0.934
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Patient Characteristics by Propensity-matched
Pairs
variables ACP RCP P value
No. of patients 463 304
Sex (male) 71.7 68.1 0.295
Smoking 45.8 44.7 0.824
Renal failure 3.4 4.6 0.325
Cerebrovascular accident 11.9 12.5 0.822
Congestive heart failure 5.0 5.3 0.868
Range of replacement (root) 11.2 12.2 0.730
(Ascending) 65.0 70.1 0.158
(Arch) 62.4 48.4 0.000
Age 69 /-10 68 /- 11 0.253
Annual volume 36 /- 19 34 /- 21 0.229
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Propensity-matched Analysis
ACP RCP Odds ratio (95CI) P value
No. of patients No. of patients No. of patients 463 304
30-day mortality 30-day mortality 30-day mortality 2.81 2.30 0.721(0.28-1.85) 0.497
Operative mortality Operative mortality Operative mortality 3.67 3.95 0.991(0.46-2.12) 0.981
Morbidity Morbidity Morbidity
Stroke 4.54 2.96 0.610(0.27-1.36) 0.228
Transient 3.90 5.90 1.536(0.785-3.006) 0.21
Continuous Coma 1.30 1.00 0.683(0.168-2.774) 0.594
Prolonged ventilation 13.6 13.5 0.939(0.61-1.14) 0.774
Reoperation 7.56 8.88 1.129(0.66-1.92) 0.654
Dialysis required 1.30 3.29 2.556(0.92-7.13) 0.073
Deep sternal infection 1.10 1.64 1.480(0.42-5.17) 0.539
Paraparesis 3.02 2.30 0.752(0.30-1.89) 0.543
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Effect of RCP in subgroups of patients
Range of replacement Range of replacement Operative mortality Odds ratio (95CI) p value
Root 89 5.62 0.418 (0.42-4.19) 0.458
Ascending 514 2.14 1.203(0.36-4.03) 0.764
Arch 436 2.98 0.395(0.10-1.50) 0.172
Distal 227 5.29 1.113(0.32-3.88) 0.867
Range of replacement showed no significant effect
of RCP for operative mortality.
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Effect of RCP in subgroups of patients
Cross clamp time (min) Cross clamp time (min) Cross clamp time (min)
lt 120 403 3.47 1.036(0.348-3.083) 0.949
gt-120 355 4.23 1.071(0.363-3.158 0.9
Perfusion time (min) Perfusion time (min)
lt200 421 5.46 0.891(0.369-2.1519 0.798
gt-200 337 1.78 1.457(0.288-7.359) 0.649
Lowest core tempreture ? Lowest core tempreture ? Lowest core tempreture ?
lt22 392 3.83 1.165(0.235-5.772) 0.851
gt-22 368 3.80 1.486(0.448-4.937) 0.518
Operation time (min) Operation time (min)
lt400 381 6.30 0.918(0.376-2.224) 0.851
gt-400 385 1.30 1.716(0.282-10.427) 0.558
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Effect of RCP for Mortality and Neurologic
dysfunction
Risk adjusted analysis Propensity-matched analysis
30 day mortality
Operative mortality
Stroke
Transient neurologic dysfunction
Coma
Paraparesis
RCP showed no significant effect for operative
mortality and neurologic dysfunction.
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Conclusion

• This is the first clinical study based on a large
  scaled database.
• Both RCP and ACP provide excellent and comparable
  clinical outcomes including mortality, stroke and
  other morbidity.
• Brain protection has been applied for aortic arch
  surgery in reasonable selection criteria in
  Japan.