Improved Outcomes of Total Arch Replacement: Does Cerebral Protection Strategy Matter?

P0166 

Abstract Submission 

Defne Ergi (1), Alberto Pochettino (1), Austin Todd (1), Gabor Bagameri (1), Juan Crestanello (1), Kevin Greason (1), Hartzell Schaff, MD (1), Joseph Dearani (2), Nishant Saran (3)

(1) Mayo Clinic, Rochester, MN, (2) Mayo Clinic, United States, (3) N/A, Rochester, MN

Defne Gunes Ergi    -  Contact Me
Mayo Clinic

*Alberto Pochettino    -  Contact Me
Mayo Clinic

Austin Todd    -  Contact Me
Mayo Clinic

Gabor Bagameri    -  Contact Me
Mayo Clinic

*Juan Crestanello    -  Contact Me
Mayo Clinic

*Kevin Greason    -  Contact Me
Mayo Clinic

*Hartzell Schaff, MD    -  Contact Me
Mayo Clinic

*Joseph Dearani    -  Contact Me
Mayo Clinic

Nishant Saran    -  Contact Me
N/A

Defne Gunes Ergi    -  Contact Me
N/A

Objective: We reviewed our experience with total arch replacement (TAR) to understand the impact of surgical methods on short- and long-term outcomes.
Methods: We analyzed all adult patients (n=334) undergoing TAR at our institution from 1/1993 through 6/2023; the median age was 64.8 years (Interquartile range [IQR], 55.6-73.4), and 214 (64.1 %) were males. Patients who underwent endovascular arch repair were not included.
Results: The number of patients undergoing TAR significantly increased with each successive decade (1993-2002, n=16, 4.8 %, 2003-2012, n=90, 26.9 %, 2013-2023: n=228, 68.3 %; p<0.001) (Figure 1). The majority had previous cardiac surgery and underwent a repeat sternotomy (n=204, 61.1 %) for TAR. Among patients undergoing repeat sternotomy, the most common indication for operation was dissecting aneurysm (n=97, 51.5%), followed by aneurysmal degeneration (n=70, 37.2 %); aneurysmal degeneration (n=120, 92.3%) followed by Type A dissection (n=78, 23.3 %) were the most common indications in patients having TAR as a primary procedure. Frozen elephant trunk was used in 118 patients (35.2 %), and classic elephant trunk in 116 (34.7 %). All 3 arch vessels were re-implanted in 241 (72.2 %) patients, while 2 and single vessel reimplantations were done in 77 (23.1 %) and 16 (4.8 %), respectively. Deep hypothermia was used in 316 (94.6 %) cases, and moderate in 18 (5.4 %). The most common cerebral protection strategy was combined retrograde cerebral perfusion (RCP) and antegrade cerebral perfusion (ACP) (n=183, 64.4 %). The typical sequence involved a median RCP time of 8.0 minutes (IQR, 6.0-10.0), followed by a median ACP time of 41.0 minutes (IQR, 33.8-49.2). The median cardiopulmonary bypass, cross-clamp, and circulatory arrest times were 275.0 min. (IQR, 231.5-317.0), 183.0 mins (IQR, 134.0-238.0), and 47.0 mins (IQR, 37.0-60.0), respectively. Postoperative stroke occurred in 11 (3.2 %) patients; all were observed in re-operative cases (p<0.001), and it was not associated with any specific cerebral protection strategy (p=0.109). Overall, early mortality was 9.3 % (n=30), which improved with each successive decade (1993-2002, n=4, 26.7 % vs 2003-2012, n=11, 12.2 % vs 2013-2023, n=15, 6.6 %). In the univariate analysis, years (2013-2023) were associated with lower early mortality (OR 0.21; 95 % CI 0.06-0.83). Use of ACP alone (OR 3.14; 95 % CI 1.27-7.99) and RCP alone (OR 9.67; 95 % CI 2.59-34.04) were associated with higher early mortality compared to the combined perfusion strategy. Median follow-up was 5.7 (IQR, 2.8-10.2) years, and survival at 5 and 10 years was 70.8 % (95% CI 65.5 % - 76.5 %) and 54.1% (95% CI 47 %- 62.2 %), respectively. Older age was the only factor independently associated with poorer long-term survival (HR 1.05; 95 % CI 1.03-1.06). Freedom from reoperation was 96 % (95 % CI 93.1%-99 %) at 5 years and 92 % (95 % CI 86 %- 98.3 %) at 10 years.
Conclusion: Over the last three decades, early outcomes of TAR have improved with declining early mortality rates. Improved results may relate to the use of a combined cerebral protection strategy utilizing RCP and ACP.

Cerebral Protection