Impact of Circulatory Arrest Duration on Perioperative Mortality: Insights From More Than 1200 Aortic Arch Reconstructions.

Abstract

Prolonged circulatory arrest during aortic arch reconstruction, including hemiarch replacement and total arch replacement (TAR), may increase perioperative risk, but the relationship between circulatory arrest duration and outcomes remains poorly defined. Patients undergoing aortic arch reconstruction from 2011 to 2025 were analyzed from an institutional database. Aortic arch reconstructions were performed under hypothermic circulatory arrest, with TAR using antegrade cerebral perfusion through an "arch-first" approach and hemiarch replacement using retrograde cerebral perfusion. The primary outcome was 30-day perioperative mortality. Circulatory arrest time, nadir temperature, and perioperative mortality and stroke were analyzed by generalized additive models with penalized splines. Multivariable models were adjusted for key clinical covariates. We analyzed 1202 patients (median age, 63 years; 35.6% female; 48.3% dissection) undergoing hemiarch replacement (n = 800) or TAR (n = 402). Median circulatory arrest times were 17.0 (12-24) minutes for hemiarch replacement and 26.0 (18-39) minutes for TAR. Perioperative mortality was 5.6% for hemiarch replacement and 14.9% for TAR. Circulatory arrest duration was independently associated with increased mortality (adjusted P = .036), with an inflection point at 25 minutes. In stratified analyses, circulatory arrest duration was significantly associated with mortality in hemiarch replacement (P = .006; inflection, 23.3 minutes) but not in TAR (P = .095). The combined effect of longer circulatory arrest and higher temperature increased postoperative stroke risk for both TAR (P = .035) and hemiarch replacement (P = .007). Prolonged circulatory arrest increases perioperative mortality in aortic arch surgery, with distinct risk probabilities for hemiarch replacement and TAR. Optimal outcomes may be achieved by tailoring temperature and perfusion strategies according to procedure and anticipated circulatory arrest duration.