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• W2898570769 abstract "We thank Abjigitova and colleagues [1Abjigitova D. Bogers A.J.J.C. Bekkers J.A. Mokhles M.M. When cold matters, consider your options (letter).Ann Thorac Surg. 2019; 107: 1290Abstract Full Text Full Text PDF Scopus (1) Google Scholar] for their comments regarding our manuscript [2Sultan I. Bianco V. Yazji I. et al.Hemiarch reconstruction versus clamped aortic anastomosis for concomitant ascending aortic aneurysm.Ann Thorac Surg. 2018; 106: 750-756Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar]. Retrograde cerebral perfusion (RCP) is used routinely at our institution for hemiarch replacement in both elective and emergent settings depending on the predicted time of circulatory arrest (when <30 minutes). With this strategy, our stroke rates are well below the national averages in the context of either aneurysm or type A aortic dissection [2Sultan I. Bianco V. Yazji I. et al.Hemiarch reconstruction versus clamped aortic anastomosis for concomitant ascending aortic aneurysm.Ann Thorac Surg. 2018; 106: 750-756Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar, 3Trivedi D. Navid F. Balzer J.R. et al.Aggressive aortic arch and carotid replacement strategy for type A aortic dissection improves neurologic outcomes.Ann Thorac Surg. 2016; 101: 896-903Abstract Full Text Full Text PDF PubMed Scopus (67) Google Scholar]. RCP has several distinct advantages over antegrade cerebral perfusion (ACP), provided the arrest period is not extended beyond 45 minutes. These advantages include (1) the allowance for a truly no-touch technique of the brachiocephalic arteries, (2) clearance of any embolic air or debris from the cerebral arterial circulation, and (3) uniformly distributed and efficient cooling of the entire brain. Our data confirm that using RCP alone for cerebral protection in the context of hemiarch replacement is very safe and effective. Notably, other centers continue to advocate its use for even more complex (ie, longer) arch reconstructions [4Lau C. Gaudino M. Iannacone E.M. et al.Retrograde cerebral perfusion is effective for prolonged circulatory arrest in arch aneurysm repair.Ann Thorac Surg. 2018; 105: 491-497Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar]. Alternatively, we routinely use ACP for total arch reconstruction, as these require longer arrest periods. We prefer using a brachiocephalic-first technique with sequentially administered bilateral ACP whereby the innominate or right common carotid is reconstructed first and the left common carotid second, or vice versa, followed by the left subclavian and then distal arch anastomoses [3Trivedi D. Navid F. Balzer J.R. et al.Aggressive aortic arch and carotid replacement strategy for type A aortic dissection improves neurologic outcomes.Ann Thorac Surg. 2016; 101: 896-903Abstract Full Text Full Text PDF PubMed Scopus (67) Google Scholar]. Despite the repeated rhetoric that ACP is “superior” to by many groups, there are inadequate data to for such a claim in the context of hemiarch reconstruction or hypothermic circulatory arrest times that average less than 40 minutes [5Arnaoutakis G.J. Vallabhajosyula P. Bavaria J.E. et al.The impact of deep versus moderate hypothermia on postoperative kidney function after elective aortic hemiarch repair.Ann Thorac Surg. 2016; 102: 1313-1321Abstract Full Text Full Text PDF PubMed Scopus (44) Google Scholar]. To date there have been 5 relatively small randomized, controlled trials (RCTs) comparing RCP with ACP, and none of them have demonstrated superiority of ACP over RCP with respect to clinical outcomes. Strikingly, the most recent RCT by Leshnower and colleagues [6Leshnower BG, Rangaraju S, Allen JW, et al. A pilot study of deep hypothermia + retrograde cerebral perfusion vs. moderate hypothermia + antegrade cerebral perfusion. Paper presented at: The Society of Thoracic Surgery 54th Annual Meeting; January 30, 2018; Fort Lauderdale, FL.Google Scholar] demonstrated a 100% rate of magnetic resonance diffusion weighted imaging–identified cerebral emboli among patients undergoing elective hemiarch reconstruction using ACP at moderate hypothermia compared with a 45% embolic rate among an equivalent cohort using hypothermic RCP. This latest study has prompted a larger more rigorous multiinstitutional RCT led by the Emory University and University of Pittsburgh programs. With respect to the reviewers’ final points, the propensity matching was performed in our study using standard methodology and the final multivariable logistic regression model was used to generate the propensity scores which included all preoperative variables. In addition, some relevant operative variables were included to make the comparison more stringent, although we recognize that this strategy can introduce the potential for some confounding variability. Finally, we advocate using a restrictive transfusion protocol and consequently have a low threshold for reexploring patients with postoperative bleeding to further minimize transfusions. There was clearly a significant difference in mediastinal reexploration rate between the 2 cohorts, although most reoperations did not reveal any distinct surgical bleeding site and rather were a consequence of consumptive coagulopathy that corrected with mediastinal washout. When Cold Matters, Consider Your OptionsThe Annals of Thoracic SurgeryVol. 107Issue 4PreviewWith interest we have read the article entitled “Hemiarch Reconstruction Versus Clamped Aortic Anastomosis for Concomitant Ascending Aortic Aneurysm” by Sultan and colleagues [1]. Full-Text PDF" @default.
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