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Sapienza, Università di Roma Ospedale Sant’Andrea Dipartimento di Cardiochirurgia. Unilateral versus Bilateral Antegrade Cerebral Protection During Circulatory Arrest in Aortic Surgery: A Meta-Analysis of 5462 patients. Emiliano Angeloni, Umberto Benedetto, Ivan Stigliano,

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Sapienza, Università di Roma

Ospedale Sant’Andrea

Dipartimento di Cardiochirurgia

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

DepartmentofCardiacSurgery,

“Sapienza” Universityof Rome, S. Andrea Hospital,

Rome, Italy


Sapienza, Università di Roma

Ospedale Sant’Andrea

Dipartimento 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


Sapienza, Università di Roma

Ospedale Sant’Andrea

Dipartimento di Cardiochirurgia

Objective

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)


Sapienza, Università di Roma

Ospedale Sant’Andrea

Dipartimento di Cardiochirurgia

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]


Sapienza, Università di Roma

Ospedale Sant’Andrea

Dipartimento di Cardiochirurgia

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


Sapienza, Università di Roma

Ospedale Sant’Andrea

Dipartimento di Cardiochirurgia

Results

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

136 papers

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)

35 papers


Sapienza, Università di Roma

Ospedale Sant’Andrea

Dipartimento di Cardiochirurgia

Results

Studypopulation

* Total of 1355 pts ** Total of 2895 pts


Sapienza, Università di Roma

Ospedale Sant’Andrea

Dipartimento di Cardiochirurgia

Results

Meta-analysisofoutcomes

8.0% (95CI 6.3-10.1)

Mortality p=0.92

7.8% (95CI 5.4-11.2)

7.1% (95CI 4.2-11.8)

PND p=0.37

4.5% (95CI 1.9-10.6)

12.1% (95CI 7.7-18.5)

TND p=0.03

4.5% (95CI 1.9-10.1)


Sapienza, Università di Roma

Ospedale Sant’Andrea

Dipartimento di Cardiochirurgia

Results

  • Meta-regression analysis showed that age, emergency, CPB time, CA time, and CA temperature did not influence effect size estimates

Regression of CA time for Mortality

Regression of CA time for TND

Q-model0.06

p=0.74

Q-model0.16

p=0.43

Regression of CA temp for Mortality

Regression of CA temp for TND

Q-model 0.07

p=0.79

Q-model0.08

p=0.66


Sapienza, Università di Roma

Ospedale Sant’Andrea

Dipartimento di Cardiochirurgia

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

Regression of CA time for PND

Regression of CA temp for PND

Q-model42.0

p<0.0001

Q-model16.5

P<0.0001

  • Egger’s test excluded publication bias for mortality (p=0.36), PND (p=0.31), and TND (p=0.48)


Sapienza, Università di Roma

Ospedale Sant’Andrea

Dipartimento di Cardiochirurgia

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


Sapienza, Università di Roma

Ospedale Sant’Andrea

Dipartimento di Cardiochirurgia

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


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