1. Background  There are many reports about cerebral infarction after arch replacement, but few about neurocognitive function.  This study is aimed to evaluate neurocognitive outcomes after arch replacement. Purpose

2.  Patients : 62 cases (elective) TAA 55, Dissection 7  Gender : Male 40, Female 22  Age : 71±8.8 y.o. (34-84)  Concomitant procedures CABG14(23%) AVR 5(8.1%) Bentall 2(3.2%) History of CVD8(13%) Carotid Artery Disease(75% ≦ )6(9.7%) Neurological Dysfunction3(4.8%) Cerebral infarction (MRI)25(40%) Patients Characteristics

3. Deep-hypothermic circulatory arrest ＆ Selective cerebral perfusion Pump 1 Pump 2 Perfusion pressure 30 ～ 40mmHg 250ml/min 200ml/min Occlusion Balloon or Clamp CPB SCP Deep hypothermia 20 ℃ (Rectum) 14Fr. Catheter 12Fr. Catheter

4. Operative Results Operation time (min)462±112 CPB time (min)302±80.7 Aortic cross-clamping time (min)186±44.6 Circulatory arrest time (min)82.3±29.2 SCP time (min)133±35.5 Minimum rectal temperature ( ℃ ) 21±1.5 Brachiocepharic artery perfusion pressure (mmHg) 31.8±10 Left carotid artery perfusion pressure (mmHg)41.3±8.5

5. Methods  4 Tests Hasegawa Dementia Scale Kana-Pick Out Test Digit span Digit symbol test  Test timing Before operation ＆ 7days after operation  Definition of Neurocognitive dysfunction Positive is determined for more than 20% of impairment from pre-operation. Neurocognitive dysfunction is defined as 2 positives of the 4.

6. Hasegawa Dementia Scale (HDS) General function  Frequently performed dementia scale in Japan  2 tasks in 2 minutes Reading a short story Finding specific letters  Score Number of the letters Kana-Pick Out Test Executive function

7. Digit Span Attention and Recent memory  Score: Forward + Backward  Score: Number of the correct answers in 90 seconds Digit Symbol Test Attention and Psychomotor speed

8. Results of 4 Tests Pre-operation (n=53) POD 7th (n=53) P HDS26.7±2.5326.9±2.660.40 Kana-Pick Out Test19.6±10.118.6±11.60.27 Digit span12.2±3.3111.7±2.680.18 Digit symbol test32.4±14.128.4±14.1 ＜ 0.05 53 patients : Complete 6 : prolonged ventilation 9 patients : Incomplete 2 : cerebral infarction 1 : other

9. Neurocognitive Dysfunction HDS Kana Pick- Out Test Digit span Digit symbol test Positive 0 (0%) 21 (40%) 9 (17%) 19 (36%) Neurocognitive dysfunction 16(30%)

10. Predictors of Neurocognitive Dysfunction No Dysfunction (n=37) Dysfunction (n=16) P Age71±9.772±9.0 0.68 Gender (male)22 (59%) 10 (62.5%) 0.84 History of CVD6 (16%)2 (13%) 0.73 Neurological dysfunction 1 (2.7%)2 (13%) 0.16 Cerebral infarction (MRI) 17 (46%)6 (38%) 0.57 Carotid Artery Disease 3 (8.1%)2 (13%) 0.62No Dysfunction (n=37) Dysfunction(n=16)P Ope Time 443±92.4455±1210.057 CPB Time 289±79.6294±85.10.21 Clamp Time 178±38.3179±42.20.23 Arrest Time 76.3±24.577.8±26.60.29 SCP Time 124±28.0127±33.70.10 Minimum Temperature 21.2±1.5820.7±3.030.72

11.  On average, 22.5% of the CABG patients had a decline of at least 1 standard deviation in at least two of a total of nine or ten tests 2 months after their operation (P <.0001; 95% confidence interval, 18.7%-26.4%). Van Dijk D et al : J Thorac Cardiovasc Surg 2000;120:632-9  31%(22/71) of the patients after deep hypothermic circulatory arrest had a more than 50% negative change in memory or fine motor function and attention 1 week postoperatively. Ergin MA et al : Ann Thorac Surg 1999;67:1887-90 Comments

12. Conclusions  This study shows 30% of patients after arch replacement have neurocognitive dysfunction at the POD7th.  This acute result is acceptable, however follow up for long-term neurocognitive outcomes and its impacts on the QOL are required.