Unilateral versus Bilateral Antegrade Cerebral Protection

Unilateral versus Bilateral Antegrade Cerebral Protection

During Circulatory Arrest in Aortic Surgery:

A Meta-Analysis of 5462 patients

Emiliano Angeloni, Umberto Benedetto, Ivan Stigliano,

Simone Refice, Giovanni Melina, and Riccardo Sinatra

Department of Cardiac Surgery,

“Sapienza” University of Rome, S. Andrea Hospital,

Rome, Italy

Sapienza, Università di RomaOspedale Sant’AndreaDipartimento di Cardiochirurgia


Background

• During complex aortic surgery cerebral protection can be achieved with

different strategies

• In the current practice hypothermic circulatory arrest (CA) associated to

cerebral perfusion is widely used

• Antegrade cerebral perfusion (ACP) has been reported to grant longer “safe

period” and lowest rates of postoperative mortality and neurologic events

• In this setting, the use of bilateral (b-ACP) or unilateral (u-ACP) cannulation of

the supra-aortic vessels remains controversial

To determine whether cerebral protection achieved by means of bACP or

uACP results in different clinical outcomes in terms of Mortality, Permanent

Neurologic Disease (PND), and Transient Neurologic Disease (TND)

Objective


Methods

• A systematic review and meta-analysis was performed with the use of the

Meta-analysis of Observational Studies in Epidemiology guidelines

• PubMed, Embase and Cochrane library were searched for studies reporting on

postoperative mortality, permanent neurologic disease and transient neurologic

disease after aortic surgery performed with the use of ACP

QUORUM on 17/07/2011:

antegrade[All Fields] AND ("cerebrum"[MeSH Terms] OR "cerebrum"[All Fields] OR "cerebral"[All Fields] OR "brain"[MeSH Terms] OR

"brain"[All Fields]) AND ("perfusion"[MeSH Terms] OR "perfusion"[All Fields]) AND protection[All Fields]


Methods

• Comparison between bACP and uACP by means of analysis of

heterogeneity (Cochrane Q-statistic)

• Causes for heterogeneity explored throughout subgroup analyses

• Publication bias detected by Egger’s regression test


Results

• A total of 136 studies were identified, and only 35 were finally included

Case reports (n=11)

Pediatric papers (n=2)

Multiple publications (n=33)

Data not available (n=14)

Animal studies (n=18)

Review articles (n=16)

Alternative techniques (n=7)

136 papers

35 papers


Results


uACP bACP p value

Time frame, years 2002-2011 1998-2011 na

Patients, n 1761 3791 na

Age, years 59.8±2.6 62.2±5.6 0.35

Male sex, n (%) 926 (54.6) 2422 (63.9) 0.92

CPB time, mins 181.5±45.7 203.9±40.6 0.16

Xclamp time, mins 124.8±37.9 121.6±35.9 0.84

CA time, mins 40.6±14.5 42.9±18.6 0.71

CA temp, celsius° 24.2±2.6 26.2±3.8 0.12

Emergency, n (%) 751 (55.4)* 1415 (48.9)** 0.53

* Total of 1355 pts ** Total of 2895 pts

Study population

Results


Mortality p=0.92

PND p=0.37

TND p=0.03

8.0% (95CI 6.3-10.1)

7.8% (95CI 5.4-11.2)

7.1% (95CI 4.2-11.8)

4.5% (95CI 1.9-10.6)

12.1% (95CI 7.7-18.5)

4.5% (95CI 1.9-10.1)

Meta-analysis of outcomes

Results

• Meta-regression analysis showed that age, emergency, CPB time, CA time,

and CA temperature did not influence effect size estimatesRegression of ACC time on Logit event rate

ACC time

Lo

git

eve

nt

rate

3,30 12,54 21,78 31,02 40,26 49,50 58,74 67,98 77,22 86,46 95,70

4,00

2,80

1,60

0,40

-0,80

-2,00

-3,20

-4,40

-5,60

-6,80

-8,00

Regression of ACC temp on Logit event rate

ACC temp

Lo

git

eve

nt

rate

18,40 20,32 22,24 24,16 26,08 28,00 29,92 31,84 33,76 35,68 37,60

4,00

2,80

1,60

0,40

-0,80

-2,00

-3,20

-4,40

-5,60

-6,80

-8,00

Regression of CA time for Mortality

Regression of CA temp for Mortality

Regression of ACC time on Logit event rate

ACC time

Lo

git

eve

nt

rate

4,40 13,52 22,64 31,76 40,88 50,00 59,12 68,24 77,36 86,48 95,60

2,00

1,00

0,00

-1,00

-2,00

-3,00

-4,00

-5,00

-6,00

-7,00

-8,00

Regression of CA time for TND

Regression of ACC temp on Logit event rate

ACC temp

Lo

git

eve

nt

rate

18,40 20,32 22,24 24,16 26,08 28,00 29,92 31,84 33,76 35,68 37,60

2,00

1,00

0,00

-1,00

-2,00

-3,00

-4,00

-5,00

-6,00

-7,00

-8,00

Regression of CA temp for TND


Q-model 0.07p=0.79

Q-model 0.16p=0.43

Q-model 0.08p=0.66

Q-model 0.06p=0.74

Regression of CA temp for PND

Results

• As expected, longer CA times and lower CA temperatures were associated

with higher rates of PND, but as shown in Table 1 there was no difference in

their prevalence between uACP and bACP groups

• Egger’s test excluded publication bias for mortality (p=0.36), PND (p=0.31),

and TND (p=0.48)

Regression of ACC time on Logit event rate

ACC time

Lo

git

eve

nt

rate

3,30 12,54 21,78 31,02 40,26 49,50 58,74 67,98 77,22 86,46 95,70

1,00

0,10

-0,80

-1,70

-2,60

-3,50

-4,40

-5,30

-6,20

-7,10

-8,00

Regression of CA time for PNDRegression of ACC temp on Logit event rate

ACC temp

Lo

git

eve

nt

rate

18,40 20,32 22,24 24,16 26,08 28,00 29,92 31,84 33,76 35,68 37,60

1,00

0,10

-0,80

-1,70

-2,60

-3,50

-4,40

-5,30

-6,20

-7,10

-8,00


Q-model 42.0p<0.0001

Q-model 16.5P<0.0001

Conclusions

• This meta-analysis shows that both bACP and uACP have similar postoperative

mortality and PND rates following CA for complex aortic surgery

• The statistically significant lower rate of TND shown in uACP group may be due

to the different definitions adopted to make diagnosis of such a heterogeneous

cohort of neurologic alterations

• Grade of hypothermia, CA time, CPB time, age, and emergency status did not

affect results


Conclusions

• Even if resulting from an accurate, large meta-analysis, these findings

should be interpreted with some caution because the design of the

studies analyzed lacks of random allocation and the indication for the

different ACP strategies is not univocal


Documents

Unilateral versus Bilateral Antegrade Cerebral Protection