Neurocognitive Dysfunction After Short (<20 Minutes) Duration Hypothermic Circulatory Arrest

G Chad Hughes; Edward P Chen; Jeffrey N Browndyke; Wilson Y Szeto; J Michael DiMaio; William T Brinkman; Jeffrey G Gaca; James A Blumenthal; Jorn A Karhausen; Michael L James; David Yanez; Yi-Ju Li; Joseph P Mathew

doi:10.1016/j.athoracsur.2024.09.015

Neurocognitive Dysfunction After Short (<20 Minutes) Duration Hypothermic Circulatory Arrest

Ann Thorac Surg. 2024 Sep 23:S0003-4975(24)00781-1. doi: 10.1016/j.athoracsur.2024.09.015. Online ahead of print.

Authors

Affiliations

¹ Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina. Electronic address: gchad.hughes@duke.edu.
² Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina.
³ Division of Behavioral Medicine and Neurosciences, Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina.
⁴ Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania.
⁵ The Heart Hospital, Baylor Scott and White, Plano, Texas.
⁶ Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina.
⁷ Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina; Department of Neurology, Duke University Medical Center, Durham, North Carolina.
⁸ Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, North Carolina.

PMID: 39322053
DOI: 10.1016/j.athoracsur.2024.09.015

Abstract

Background: It has long been held that the safe duration of hypothermic circulatory arrest (HCA) is at least 25 to 30 minutes. However, this belief is based primarily on clinical outcomes research and has not been systematically investigated using more sensitive brain imaging and neurocognitive assessments.

Methods: This exploratory substudy of the randomized Cognitive Effects of Body Temperature During Hypothermic Circulatory Arrest (GOT ICE) trial, which compared outcomes for deep vs moderate hypothermia during aortic arch surgery, investigated the frequency of neurocognitive and structural and functional magnetic resonance imaging (MRI) deficits with HCA of short (<20 minutes) duration. Neurocognitive deficit was defined as ≥1 SD decline in ≥1 of 5 cognitive domains on neurocognitive testing.

Results: Of 228 GOT ICE participants with complete 4-week cognitive data, 74.6% (n = 170 of 228) had HCA durations <20 minutes, including 59 patients randomized to deep hypothermia (<20.0 °C), 55 patients randomized to low-moderate (20.1-24.0 °C) hypothermia, and 56 randomized to high-moderate (24.1-28.0 °C) hypothermia. Of these participants, cognitive deficit was detected 4 weeks postoperatively in ∼40% of patients in all 3 groups (deep hypothermia, 22 of 59 [37.3%]; low-moderate hypothermia, 23 of 55 [41.8%]; and high-moderate hypothermia, 24 of 56 [42.9%]). Furthermore, in a subset of patients with complete MRI data (n = 43), baseline to 4-week postoperative right frontal lobe functional connectivity change was inversely associated with HCA duration (range, 8-17 minutes; P for familywise error rate < .01).

Conclusions: Even short durations of HCA result in cognitive deficits in ∼40% of patients, independent of systemic hypothermia temperature. HCA duration was inversely associated with frontal lobe functional MRI connectivity, a finding suggesting that this brain region may be preferentially sensitive to HCA. Surgeons should be aware that even short durations of HCA may not provide complete neuroprotection after aortic arch surgery.