Levels of hypothermia and clinical outcomes in acute type a aortic dissection surgery with circulatory arrest and antegrade cerebral perfusion: A systematic review and meta-analysis

Abstract

Objectives

In acute type A aortic dissection (ATAAD) surgery requiring hypothermic circulatory arrest (HCA), substantial variation persists in cooling strategies, and the optimal target temperature before circulatory arrest remains debated. The objective of this study was to evaluate clinical outcomes associated with different hypothermia strategies in ATAAD surgery performed under HCA with antegrade cerebral perfusion (ACP).

Methods

This review followed PRISMA guidelines and a registered PROSPERO protocol. Comprehensive database searches identified comparative studies of hypothermia levels during ATAAD repair with ACP. After screening and quality assessment, data were extracted for meta-analysis using random-effects modeling, evaluating mortality, postoperative stroke, and the need of postoperative dialysis.

Results

The search yielded 11 eligible studies comprising 5996 patients. Most were observational and assessed mild–moderate temperature strategies. Meta-analysis showed reduced mortality and dialysis with warmer hypothermia, while the rates of postoperative stroke were similar. Heterogeneity was low except for postoperative dialysis, and publication bias was minimal to moderate across outcomes.

Conclusion

Across all evaluated outcomes, deeper hypothermia did not demonstrate superiority over warmer strategies regarding in-hospital mortality, postoperative stroke, or acute kidney failure requiring dialysis. A definitive optimal temperature threshold for ATAAD surgery requiring HCA and ACP remains to be established.

Keywords

acute type a aortic dissection hypothermic circulatory arrest antegrade cerebral perfusion

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References

Griepp

Di Luozzo

. Hypothermia for aortic surgery. J Thorac Cardiovasc Surg 2013; 145: S56–S58. https://doi.org/10.1016/j.jtcvs.2012.11.072

Tian

Wan

Bannon

, et al. A meta-analysis of deep hypothermic circulatory arrest alone versus with adjunctive selective antegrade cerebral perfusion. Ann Cardiothorac Surg 2013; 2: 261–270. https://doi.org/10.3978/j.issn.2225-319X.2013.05.11

Zhang

Zhou

Gao

, et al. The optimal degree of core temperature for hypothermic circulatory arrest in complex aortic arch surgery: results from 1310 patients. Eur J Cardio Thorac Surg 2024; 66: ezae311. https://doi.org/10.1093/ejcts/ezae311

Czerny

Grabenwoger

Berger

, et al. EACTS/STS guidelines for diagnosing and treating acute and chronic syndromes of the aortic organ. Ann Thorac Surg 2024; 118: 5–115. https://doi.org/10.1016/j.athoracsur.2024.01.021

Augoustides

Geirsson

Szeto

, et al. Observational study of mortality risk stratification by ischemic presentation in patients with acute type A aortic dissection: the penn classification. Nat Clin Pract Cardiovasc Med 2009; 6: 140–146. https://doi.org/10.1038/ncpcardio1417

Page

McKenzie

Bossuyt

, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021; 372: n71. https://doi.org/10.1136/bmj.n71

Clark

Sanders

Carter

, et al. Improving the translation of search strategies using the polyglot search translator: a randomized controlled trial. J Med Libr Assoc 2020; 108: 195–207. https://doi.org/10.5195/jmla.2020.834

Gudbjartsson

Ahlsson

Geirsson

, et al. Acute type A aortic dissection - a review. Scand Cardiovasc J 2020; 54: 1–13. https://doi.org/10.1080/14017431.2019.1660401

Stang

. Critical evaluation of the Newcastle-Ottawa scale for the assessment of the quality of nonrandomized studies in meta-analyses. Eur J Epidemiol 2010; 25: 603–605. https://doi.org/10.1007/s10654-010-9491-z

10.

Sterne

JAC

Savović

Page

, et al. RoB 2: a revised tool for assessing risk of bias in randomised trials. Bmj 2019; 366: l4898. https://doi.org/10.1136/bmj.l4898

11.

Viechtbauer

. Conducting meta-analyses in R with the metafor package. J Stat Software 2010; 36: 1–48. https://doi.org/10.18637/jss.v036.i03

12.

Sun

Yang

, et al. Randomized controlled trial of moderate hypothermia versus deep hypothermia anesthesia on brain injury during stanford A aortic dissection surgery. Heart Vessel 2018; 33: 66. https://doi.org/10.1007/s00380-017-1037-9

13.

Dong

Xiong

Zhang

, et al. Different hypothermic and cerebral perfusion strategies in extended arch replacement for acute type a aortic dissection: a retrospective comparative study. J Cardiothorac Surg 2020; 15: 236. https://doi.org/10.1186/s13019-020-01284-y

14.

Dong

, et al. A modified hypothermic circulatory arrest technique improves early and near-midterm results in patients with acute type A aortic dissection. Heart Surg Forum 2021; 24: E675–E679. https://doi.org/10.1532/hsf.3879

15.

Tang

Deng

, et al. Impact of mild hypothermic circulatory arrest on surgical outcomes in acute type a aortic dissection patients: a single-centre study. BMC Cardiovasc Disord 2025; 25: 32. https://doi.org/10.1186/s12872-024-04443-4

16.

Wang

Wei

, et al. Impact of high-moderate hypothermic circulatory arrest on postoperative major adverse events in acute type A aortic dissection. Int J Cardiol 2025; 438: 133561. https://doi.org/10.1016/j.ijcard.2025.133561

17.

Wang

, et al.

Does higher temperature during moderate hypothermic circulatory arrest increase the risk of paraplegia in acute DeBakey I aortic dissection patients?

Can J Cardiol 2025; 41: 749–74920240760. https://doi.org/10.1016/j.cjca.2024.06.027

18.

Qiu

Fang

, et al. Optimal degree of hypothermia in total arch replacement for type A aortic dissection. Front Cardiovasc Med 2021; 8: 668333. https://doi.org/10.3389/fcvm.2021.668333

19.

Numata

Tsutsumi

Monta

, et al. Acute type A aortic dissection repair with mild-to-moderate hypothermic circulatory arrest and selective cerebral perfusion. J Cardiovasc Surg 2015; 56: 525.

20.

Macrina

Acconcia

Tritapepe

, et al. Hypothermia during surgical treatment of type A aortic dissection: a 16 years' experience. Int J Vasc Med 2020; 2020: 3893261. https://doi.org/10.1155/2020/3893261

21.

Leshnower

Thourani

Halkos

, et al. Moderate versus deep hypothermia with unilateral selective antegrade cerebral perfusion for acute type A dissection. Ann Thorac Surg 2015; 100: 1563–1568. https://doi.org/10.1016/j.athoracsur.2015.05.032

22.

McCullough

Zhang

Reich

, et al. Cerebral metabolic suppression during hypothermic circulatory arrest in humans. Ann Thorac Surg 1999; 67: 1895–1899. https://doi.org/10.1016/S0003-4975(99)00441-5

23.

Bjurbom

Franco-Cereceda

Olsson

. Management of acute type A aortic dissection in the nordic countries. Scand Cardiovasc J 2026; 60: 2613535. https://doi.org/10.1080/14017431.2026.2613535

24.

Uimonen

Olsson

Jeppsson

, et al. Cardiopulmonary bypass time during surgery for acute type A aortic dissection and mid-term survival. J Cardiovasc Dev Dis 2025; 12: 20250407. https://doi.org/10.3390/jcdd12040139

25.

Kumar

Suneja

Bayman

, et al. Association between postoperative acute kidney injury and duration of cardiopulmonary bypass: a meta-analysis. J Cardiothorac Vasc Anesth 2012; 26: 64. https://doi.org/10.1053/j.jvca.2011.07.007

26.

Urcun

Altun

Pala

. Early and late predictors of postoperative neurocognitive dysfunction in cardiac surgery. Ideggyogyaszati Szle 2022; 75: 231–240. https://doi.org/10.18071/isz.75.0231

27.

Greilich

Brouse

Beckham

, et al. Reductions in platelet contractile force correlate with duration of cardiopulmonary bypass and blood loss in patients undergoing cardiac surgery. Thromb Res 2002; 105: 523–529. https://doi.org/10.1016/s0049-3848(02)00061-0

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