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Hughes GC, Chen EP, Browndyke JN, Szeto WY, DiMaio JM, Brinkman WT, Gaca JG, Blumenthal JA, Karhausen JA, Bisanar T, James ML, Yanez D, Li YJ, Mathew JP. Cognitive Effects of Body Temperature During Hypothermic Circulatory Arrest Trial (GOT ICE): A Randomized Clinical Trial Comparing Outcomes After Aortic Arch Surgery. Circulation 2024; 149:658-668. [PMID: 38084590 PMCID: PMC10922813 DOI: 10.1161/circulationaha.123.067022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Accepted: 11/10/2023] [Indexed: 02/28/2024]
Abstract
BACKGROUND Deep hypothermia has been the standard for hypothermic circulatory arrest (HCA) during aortic arch surgery. However, centers worldwide have shifted toward lesser hypothermia with antegrade cerebral perfusion. This has been supported by retrospective data, but there has yet to be a multicenter, prospective randomized study comparing deep versus moderate hypothermia during HCA. METHODS This was a randomized single-blind trial (GOT ICE [Cognitive Effects of Body Temperature During Hypothermic Circulatory Arrest]) of patients undergoing arch surgery with HCA plus antegrade cerebral perfusion at 4 US referral aortic centers (August 2016-December 2021). Patients were randomized to 1 of 3 hypothermia groups: DP, deep (≤20.0 °C); LM, low-moderate (20.1-24.0 °C); and HM, high-moderate (24.1-28.0 °C). The primary outcome was composite global cognitive change score between baseline and 4 weeks postoperatively. Analysis followed the intention-to-treat principle to evaluate if: (1) LM noninferior to DP on global cognitive change score; (2) DP superior to HM. The secondary outcomes were domain-specific cognitive change scores, neuroimaging findings, quality of life, and adverse events. RESULTS A total of 308 patients consented; 282 met inclusion and were randomized. A total of 273 completed surgery, and 251 completed the 4-week follow-up (DP, 85 [34%]; LM, 80 [34%]; HM, 86 [34%]). Mean global cognitive change score from baseline to 4 weeks in the LM group was noninferior to the DP group; likewise, no significant difference was observed between DP and HM. Noninferiority of LM versus DP, and lack of difference between DP and HM, remained for domain-specific cognitive change scores, except structured verbal memory, with noninferiority of LM versus DP not established and structured verbal memory better preserved in DP versus HM (P = 0.036). There were no significant differences in structural or functional magnetic resonance imaging brain imaging between groups postoperatively. Regardless of temperature, patients who underwent HCA demonstrated significant reductions in cerebral gray matter volume, cortical thickness, and regional brain functional connectivity. Thirty-day in-hospital mortality, major morbidity, and quality of life were not different between groups. CONCLUSIONS This randomized multicenter study evaluating arch surgery HCA temperature strategies found low-moderate hypothermia noninferior to traditional deep hypothermia on global cognitive change 4 weeks after surgery, although in secondary analysis, structured verbal memory was better preserved in the deep group. The verbal memory differences in the low- and high-moderate groups and structural and functional connectivity reductions from baseline merit further investigation and suggest opportunities to further optimize brain perfusion during HCA. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT02834065.
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Affiliation(s)
- G Chad Hughes
- Department of Surgery, Division of Thoracic and Cardiovascular Surgery (G.C.H., E.P.C., J.G.G.), Duke University Medical Center, Durham, NC
| | - Edward P Chen
- Department of Surgery, Division of Thoracic and Cardiovascular Surgery (G.C.H., E.P.C., J.G.G.), Duke University Medical Center, Durham, NC
| | - Jeffrey N Browndyke
- Department of Psychiatry & Behavioral Sciences, Division of Behavioral Medicine & Neurosciences (J.N.B., J.A.B.), Duke University Medical Center, Durham, NC
| | - Wilson Y Szeto
- Department of Surgery, Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia (W.Y.S.)
| | - J Michael DiMaio
- The Heart Hospital, Baylor Scott and White, Plano, TX (J.M.D., W.T.B.)
| | | | - Jeffrey G Gaca
- Department of Surgery, Division of Thoracic and Cardiovascular Surgery (G.C.H., E.P.C., J.G.G.), Duke University Medical Center, Durham, NC
| | - James A Blumenthal
- Department of Psychiatry & Behavioral Sciences, Division of Behavioral Medicine & Neurosciences (J.N.B., J.A.B.), Duke University Medical Center, Durham, NC
| | - Jorn A Karhausen
- Department of Anesthesiology (J.A.K., T.B., M.L.J., J.P.M.), Duke University School of Medicine, Durham, NC
| | - Tiffany Bisanar
- Department of Anesthesiology (J.A.K., T.B., M.L.J., J.P.M.), Duke University School of Medicine, Durham, NC
| | - Michael L James
- Department of Anesthesiology (J.A.K., T.B., M.L.J., J.P.M.), Duke University School of Medicine, Durham, NC
- Department of Neurology (M.L.J.), Duke University School of Medicine, Durham, NC
| | - David Yanez
- Department of Biostatistics and Bioinformatics (D.Y., Y.-J.L.), Duke University School of Medicine, Durham, NC
| | - Yi-Ju Li
- Department of Biostatistics and Bioinformatics (D.Y., Y.-J.L.), Duke University School of Medicine, Durham, NC
| | - Joseph P Mathew
- Department of Anesthesiology (J.A.K., T.B., M.L.J., J.P.M.), Duke University School of Medicine, Durham, NC
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Elhelali A, Hynes N, Devane D, Sultan S, Kavanagh EP, Morris L, Veerasingam D, Jordan F. Hybrid repair versus conventional open repair for thoracic aortic arch aneurysms. Cochrane Database Syst Rev 2021; 6:CD012923. [PMID: 34085713 PMCID: PMC8407084 DOI: 10.1002/14651858.cd012923.pub2] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Thoracic aortic arch aneurysms (TAAs) can be a life-threatening condition due to the potential risk of rupture. Treatment is recommended when the risk of rupture is greater than the risk of surgical complications. Depending on the cause, size and growth rate of the TAA, treatment may vary from close observation to emergency surgery. Aneurysms of the thoracic aorta can be managed by a number of surgical techniques. Open surgical repair (OSR) of aneurysms involves either partial or total replacement of the aorta, which is dependent on the extent of the diseased segment of the aorta. During OSR, the aneurysm is replaced with a synthetic graft. Hybrid repair (HR) involves a combination of open surgery with endovascular aortic stent graft placement. Hybrid repair requires varying degrees of invasiveness, depending on the number of supra-aortic branches that require debranching. The hybrid technique that combines supra-aortic vascular debranching with stent grafting of the aortic arch has been introduced as a therapeutic alternative. However, the short- and long-term outcomes of HR remain unclear, due to technical difficulties and complications as a result of the angulation of the aortic arch as well as handling of the arch during surgery. OBJECTIVES To assess the effectiveness and safety of HR versus conventional OSR for the treatment of TAAs. SEARCH METHODS The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL and AMED databases and World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 22 March 2021. We also searched references of relevant articles retrieved from the electronic search for additional citations. SELECTION CRITERIA We considered for inclusion in the review all published and unpublished randomised controlled trials (RCTs) and controlled clinical trials (CCTs) comparing HR to OSR for TAAs. DATA COLLECTION AND ANALYSIS Two review authors independently screened all titles and abstracts obtained from the literature search to identify those that met the inclusion criteria. We retrieved the full text of studies deemed as potentially relevant by at least one review author. The same review authors screened the full-text articles independently for inclusion or exclusion. MAIN RESULTS No RCTs or CCTs met the inclusion criteria for this review. AUTHORS' CONCLUSIONS Due to the lack of RCTs or CCTs, we were unable to determine the safety and effectiveness of HR compared to OSR in people with TAAs, and we are unable to provide high-certainty evidence on the optimal surgical intervention for this cohort of patients. High-quality RCTs or CCTs are necessary, addressing the objective of this review.
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Affiliation(s)
- Ala Elhelali
- School of Nursing and Midwifery, National University of Ireland Galway, Galway, Ireland
| | - Niamh Hynes
- Department of Vascular and Endovascular Surgery, The Galway Clinic, Galway, Ireland
| | - Declan Devane
- School of Nursing and Midwifery, National University of Ireland Galway, Galway, Ireland
| | - Sherif Sultan
- Vascular Surgery, Galway University Hospital, Galway, Ireland
| | - Edel P Kavanagh
- Department of Vascular and Endovascular Surgery, The Galway Clinic, Galway, Ireland
| | - Liam Morris
- Mechanical and Industrial Engineering, Galway-Mayo Institute of Technology, Galway, Ireland
| | - Dave Veerasingam
- Cardiothoracic Surgery, Galway University Hospital, Galway, Ireland
| | - Fionnuala Jordan
- School of Nursing and Midwifery, National University of Ireland Galway, Galway, Ireland
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Falasa MP, Arnaoutakis GJ, Janelle GM, Beaver TM. Neuromonitoring and neuroprotection advances for aortic arch surgery. JTCVS Tech 2021; 7:11-19. [PMID: 34318192 PMCID: PMC8312079 DOI: 10.1016/j.xjtc.2020.12.045] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 12/30/2020] [Indexed: 11/15/2022] Open
Affiliation(s)
- Matt P. Falasa
- Department of Surgery, University of Florida, Gainesville, Fla
| | - George J. Arnaoutakis
- Department of Surgery, University of Florida, Gainesville, Fla
- Division of Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, Fla
| | - Greg M. Janelle
- Department of Anesthesiology, University of Florida, Gainesville, Fla
| | - Thomas M. Beaver
- Department of Surgery, University of Florida, Gainesville, Fla
- Division of Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, Fla
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Elhelali A, Hynes N, Devane D, Sultan S, Kavanagh EP, Morris L, Veerasingam D, Jordan F. Hybrid repair versus conventional open repair for thoracic aortic arch aneurysms. Cochrane Database Syst Rev 2018. [DOI: 10.1002/14651858.cd012923] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Affiliation(s)
- Ala Elhelali
- Galway-Mayo Institute of Technology; Mechanical and Industrial Engineering; Dublin Road Galway Ireland
| | - Niamh Hynes
- The Galway Clinic; Department of Vascular and Endovascular Surgery; Doughiska Galway Ireland
| | - Declan Devane
- National University of Ireland Galway; School of Nursing and Midwifery; University Road Galway Ireland
| | - Sherif Sultan
- Galway University Hospital; Vascular Surgery; Newcastle Galway Ireland
| | - Edel P Kavanagh
- The Galway Clinic; Department of Vascular and Endovascular Surgery; Doughiska Galway Ireland
| | - Liam Morris
- Galway-Mayo Institute of Technology; Mechanical and Industrial Engineering; Dublin Road Galway Ireland
| | - Dave Veerasingam
- Galway University Hospital; Cardiothoracic Surgery; Newcastle Road Galway Ireland
| | - Fionnuala Jordan
- National University of Ireland Galway; School of Nursing and Midwifery; University Road Galway Ireland
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Tian DH, Wan B, Bannon PG, Misfeld M, LeMaire SA, Kazui T, Kouchoukos NT, Elefteriades JA, Bavaria JE, Coselli JS, Griepp RB, Mohr FW, Oo A, Svensson LG, Hughes GC, Underwood MJ, Chen EP, Sundt TM, Yan TD. A meta-analysis of deep hypothermic circulatory arrest alone versus with adjunctive selective antegrade cerebral perfusion. Ann Cardiothorac Surg 2013; 2:261-70. [PMID: 23977593 DOI: 10.3978/j.issn.2225-319x.2013.05.11] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2013] [Accepted: 05/20/2013] [Indexed: 11/14/2022]
Abstract
INTRODUCTION Recognizing the importance of neuroprotection in aortic arch surgery, deep hypothermic circulatory arrest (DHCA) now underpins operative practice as it minimizes cerebral metabolic activity. When prolonged periods of circulatory arrest are required, selective antegrade cerebral perfusion (SACP) is supplemented as an adjunct. However, concerns exist over the risks of SACP in introducing embolism and hypo- and hyper-perfusing the brain. The present meta-analysis aims to compare postoperative outcomes in arch surgery using DHCA alone or DHCA + SACP as neuroprotection strategies. METHODS Electronic searches were performed using six databases from their inception to January 2013. Two reviewers independently identified all relevant studies comparing DHCA alone with DHCA + SACP. Data were extracted and meta-analyzed according to pre-defined clinical endpoints. RESULTS Nine comparative studies were identified in the present meta-analysis, with 648 patients employing DHCA alone and 370 utilizing DHCA + SACP. No significant differences in temporary or permanent neurological outcomes were identified. DHCA + SACP was associated with significantly better survival outcomes (P=0.008, I(2)=0%), despite longer cardiopulmonary bypass time. Infrequent and inconsistent reporting of other clinical results precluded analysis of systemic outcomes. CONCLUSIONS The present meta-analysis indicate the superiority of DHCA + SACP in terms of mortality outcomes.
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Affiliation(s)
- David H Tian
- Collaborative Research (CORE) Group, Sydney, Australia
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