1. 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

2. 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).

3. 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

4. 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

5. 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

6. 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( )
0.324
Operative mortality
5.15%
3.83%
0.74( )
0.401
Morbidity
Stroke
5.65%
2.81%
0.61( )
0.189
Prolonged ventilation
15.02%
12.24%
1.00( )
0.996
Reoperation
7.76%
7.40%
0.98( )
0.948
Dialysis required
2.53%
3.06%
2.51( )
0.04
Deep sternal infection
1.69%
1.79%
1.12( )
0.837
Paraparesis
3.29%
2.04%
0.96( )
0.934

7. 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

8. 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( )
0.497
Operative mortality
3.67%
3.95%
0.991( )
0.981
Morbidity
Stroke
4.54%
2.96%
0.610( )
0.228
Transient
3.90%
5.90%
1.536( )
0.21
Continuous Coma
1.30%
1.00%
0.683( )
0.594
Prolonged ventilation
13.6%
13.5%
0.939( )
0.774
Reoperation
7.56%
8.88%
1.129( )
0.654
Dialysis required
3.29%
2.556( )
0.073
Deep sternal infection
1.10%
1.64%
1.480( )
0.539
Paraparesis
3.02%
0.752( )
0.543

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

10. Effect of RCP in subgroups of patients
Cross clamp time (min)
< 120
403
3.47%
1.036( )
0.949
>-120
355
4.23%
1.071(
0.9
Perfusion time (min)
<200
421
5.46%
0.891(
0.798
>-200
337
1.78%
1.457( )
0.649
Lowest core tempreture ℃
<22
392
3.83%
1.165( )
0.851
>-22
368
3.80%
1.486( )
0.518
Operation time (min)
<400
381
6.30%
0.918( )
0.851
>-400
385
1.30%
1.716( )
0.558

11. 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.

12. 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.