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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, - PowerPoint PPT Presentation
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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
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
Sapienza, Università di RomaOspedale Sant’AndreaDipartimento 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 RomaOspedale Sant’AndreaDipartimento 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 RomaOspedale Sant’AndreaDipartimento di Cardiochirurgia
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
Sapienza, Università di RomaOspedale Sant’AndreaDipartimento di Cardiochirurgia
Results
Sapienza, Università di RomaOspedale Sant’AndreaDipartimento di Cardiochirurgia
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
Sapienza, Università di RomaOspedale Sant’AndreaDipartimento di Cardiochirurgia
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
Sapienza, Università di RomaOspedale Sant’AndreaDipartimento di Cardiochirurgia
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
Sapienza, Università di RomaOspedale Sant’AndreaDipartimento di Cardiochirurgia
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
Sapienza, Università di RomaOspedale Sant’AndreaDipartimento 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
Sapienza, Università di RomaOspedale Sant’AndreaDipartimento di Cardiochirurgia