The Japan Cardiovascular Surgery Database Organization

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Presentation transcript:

The Japan Cardiovascular Surgery Database Organization Risk-adjusted and Case-matched Comparative Study Comparing Antegrade and Retrograde Cerebral Perfusion in Aortic Arch Surgery Based on the Japan Adult Cardiovascular Surgery Database The Japan Cardiovascular Surgery Database Organization Usui A, Miyata H, Ueda Y Motomura N, Takamoto S

Objective Antegrade cerebral perfusion (ACP) and retrograde cerebral perfusion (RCP) are two techniques for brain protection in aortic arch surgery. We conducted a large-scaled, comparative clinical study between ACP and RCP to evaluate up-to-date clinical outcomes based upon Japan Adult Cardiovascular Surgery Database (JACVSD).

Patients selection 2005-2007 116 institutes Risk adjusted analysis 8470 aortic surgery Use of ACP or RCP 3359 ACP 1232 RCP Ascending or arch AO Elective surgery No-dissection 10 pt./year < (65 institutes) Statistical analysis 1185 ACP 392 RCP Risk adjusted analysis 463 ACP 304 RCP Matched pair analysis

End points Mortality In-hospital complications: 30 days mortality Operative mortality In-hospital complications: CNS dysfunction (Stroke, TIA, Coma) Paraparesis / paraplegia Reoperation for any reason Prolonged ventilation 24< hours Renal failure required dialysis Deep sternal wound infection

Patients Characteristics for Risk Adjusted Analysis variables ACP RCP P value No. of patients 1185 392 Sex (male) 74.3% 69.1% 0.049 Smoking 52.4% 42.1% 0.000 Renal failure 7.7% 3.6% 0.003 Cerebrovascular accident 16.6% 11.5% 0.015 Congestive heart failure 3.5% Range of replacement (root) 6.1% 17.3% 　　　　　　　(Ascending) 50.7% 74.2% 　　　　　　　　　　 (Arch) 84.6% 37.5% Age 71 +/- 9 67 +/- 12 Annual volume 34 +/-19 39 +/- 23

Risk Adjusted Analysis ACP RCP Odds ratio (95%CI) P value No. of patients 1185 392 30-day mortality 3.21% 2.00% 0.63(0.25-1.58) 0.324 Operative mortality 5.15% 3.83% 0.74(0.37-1.49) 0.401 Morbidity Stroke 5.65% 2.81% 0.61(0.29-1.28) 0.189 Prolonged ventilation 15.02% 12.24% 1.00(0.67-1.50) 0.996 Reoperation 7.76% 7.40% 0.98(0.59-1.65) 0.948 Dialysis required 2.53% 3.06% 2.51(1.04-6.03) 0.04 Deep sternal infection 1.69% 1.79% 1.12(0.39-3.24) 0.837 Paraparesis 3.29% 2.04% 0.96(0.41-2.28) 0.934

Patient Characteristics by Propensity-matched Pairs variables ACP RCP P value No. of patients 463 304 Sex (male) 71.7% 68.1% 0.295 Smoking 45.8% 44.7% 0.824 Renal failure 3.4% 4.6% 0.325 Cerebrovascular accident 11.9% 12.5% 0.822 Congestive heart failure 5.0% 5.3% 0.868 Range of replacement (root) 11.2% 12.2% 0.730 　　　　　　　　　　　　　　(Ascending) 65.0% 70.1% 0.158 　　　　　　　　　　　　　　(Arch) 62.4% 48.4% 0.000 Age 69 +/-10 68 +/- 11 0.253 Annual volume 36 +/- 19 34 +/- 21 0.229

Propensity-matched Analysis ACP RCP Odds ratio (95%CI) P value No. of patients 463 304 30-day mortality 2.81% 2.30% 0.721(0.28-1.85) 0.497 Operative mortality 3.67% 3.95% 0.991(0.46-2.12) 0.981 Morbidity Stroke 4.54% 2.96% 0.610(0.27-1.36) 0.228 Transient 3.90% 5.90% 1.536(0.785-3.006) 0.21 Continuous Coma 1.30% 1.00% 0.683(0.168-2.774) 0.594 Prolonged ventilation 13.6% 13.5% 0.939(0.61-1.14) 0.774 Reoperation 7.56% 8.88% 1.129(0.66-1.92) 0.654 Dialysis required 3.29% 2.556(0.92-7.13) 0.073 Deep sternal infection 1.10% 1.64% 1.480(0.42-5.17) 0.539 Paraparesis 3.02% 0.752(0.30-1.89) 0.543

Effect of RCP in subgroups of patients Range of replacement Operative mortality Odds ratio (95%CI) p value Root 89 5.62% 0.418 (0.42-4.19) 0.458 Ascending 514 2.14% 1.203(0.36-4.03) 0.764 Arch 436 2.98% 0.395(0.10-1.50) 0.172 Distal 227 5.29% 1.113(0.32-3.88) 0.867 Range of replacement showed no significant effect of RCP for operative mortality.

Effect of RCP in subgroups of patients Cross clamp time (min) < 120 403 3.47% 1.036(0.348-3.083) 0.949 >-120 355 4.23% 1.071(0.363-3.158 0.9 Perfusion time (min) <200 421 5.46% 0.891(0.369-2.1519 0.798 >-200 337 1.78% 1.457(0.288-7.359) 0.649 Lowest core tempreture ℃ <22 392 3.83% 1.165(0.235-5.772) 0.851 >-22 368 3.80% 1.486(0.448-4.937) 0.518 Operation time (min) <400 381 6.30% 0.918(0.376-2.224) 0.851 >-400 385 1.30% 1.716(0.282-10.427) 0.558

Effect of RCP for Mortality and Neurologic dysfunction Risk adjusted analysis Propensity-matched analysis 30 day mortality Operative mortality Stroke Transient neurologic dysfunction Coma Paraparesis RCP showed no significant effect for operative mortality and neurologic dysfunction.

Conclusion This is the first clinical study based on a large scaled database. Both RCP and ACP provide excellent and comparable clinical outcomes including mortality, stroke and other morbidity. Brain protection has been applied for aortic arch surgery in reasonable selection criteria in Japan.