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 OrganizationUsui A, Miyata H, Ueda YMotomura N, Takamoto S

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).

Patients selection

Ascending or arch AOElective surgeryNo-dissection10 pt./year < (65 institutes)Risk adjusted analysis

Matched pair analysis

1185 ACP 392 RCP

463 ACP 304 RCP

3359 ACP1232 RCP

8470 aortic surgery

Use of ACP or RCP

2005-2007116 institutes

Statistical analysis

End points Mortality

30 days mortality Operative mortality

In-hospital complications: CNS dysfunction (Stroke, TIA, Coma) Paraparesis / paraplegia Reoperation for any reason Prolonged ventilation 24< hours Renal failure required dialysis Deep sternal wound infection

Patients Characteristics for Risk Adjusted Analysis

variables ACP RCP P valueNo. 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

Risk Adjusted Analysis　 　 ACP RCP Odds ratio

(95%CI)P

valueNo. of patients 1185 392 　 　30-day mortality 3.21% 2.00% 0.63(0.25-1.58)0.324Operative mortality 5.15% 3.83% 0.74(0.37-1.49)0.401Morbidity

Stroke 5.65% 2.81% 0.61(0.29-1.28)0.189Prolonged ventilation 15.02% 12.24% 1.00(0.67-1.50)0.996Reoperation 7.76% 7.40% 0.98(0.59-1.65)0.948Dialysis required 2.53% 3.06% 2.51(1.04-6.03) 0.04Deep sternal infection 1.69% 1.79% 1.12(0.39-3.24)0.837

　 Paraparesis 3.29% 2.04% 0.96(0.41-2.28)0.934

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

Propensity-matched Analysis　　 ACP RCP Odds ratio (95%CI) P valueNo. of patients 463 304 　 　30-day mortality 2.81% 2.30% 0.721(0.28-1.85) 0.497Operative mortality 3.67% 3.95% 0.991(0.46-2.12) 0.981Morbidity

Stroke 4.54% 2.96% 0.610(0.27-1.36) 0.228Transient 3.90% 5.90% 1.536(0.785-3.006) 0.21Continuous Coma 1.30% 1.00% 0.683(0.168-2.774) 0.594Prolonged ventilation 13.6% 13.5% 0.939(0.61-1.14) 0.774Reoperation 7.56% 8.88% 1.129(0.66-1.92) 0.654Dialysis required 1.30% 3.29% 2.556(0.92-7.13) 0.073Deep sternal infection 1.10% 1.64% 1.480(0.42-5.17) 0.539Paraparesis 3.02% 2.30% 0.752(0.30-1.89) 0.543

Effect of RCP in subgroups of patients

Range of replacement Operative mortality

Odds ratio (95%CI) 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.

Effect of RCP in subgroups of patients

Cross clamp time (min) 　 　< 120 403 3.47% 1.036(0.348-3.083) 0.949>-120 355 4.23% 1.071(0.363-3.158 0.9

Perfusion time (min) 　 　 　<200 421 5.46% 0.891(0.369-2.1519 0.798>-200 337 1.78% 1.457(0.288-7.359) 0.649

Lowest core tempreture ℃ 　 　<22 392 3.83% 1.165(0.235-5.772) 0.851>-22 368 3.80% 1.486(0.448-4.937) 0.518

Operation time (min) 　 　 　<400 381 6.30% 0.918(0.376-2.224) 0.851>-400 385 1.30% 1.716(0.282-10.427) 0.558

Effect of RCP for Mortality and Neurologic dysfunction

30 day mortalityOperative mortality

StrokeTransient neurologic dysfunction

ComaParaparesis

Risk adjusted analysisPropensity-matched analysis

RCP showed no significant effect for operative mortality and neurologic dysfunction.

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.