Cerebral protection in hemi-aortic arch surgery (original) (raw)
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The Journal of Thoracic and Cardiovascular Surgery, 2014
Objective: To evaluate our extensive clinical experience using deep hypothermic circulatory arrest (DHCA) as a sole method of cerebral protection during aortic arch surgery, with an emphasis on determining the safe duration of DHCA. Methods: A total of 490 consecutive patients (303 males [61.8%], mean age, 62.7 AE 13.5 years) underwent surgical interventions on the aortic arch with straight DHCA for cerebral protection. Of the procedures, 65 (13.3%) were either urgent or emergency. Aortic aneurysms (n ¼ 417, 85.1%) and dissections (n ¼ 71, 14.5%) were the main indications for surgery. Results: The mean DHCA duration was 29.2 AE 7.9 minutes at a mean bladder temperature of 18.7 C. The overall mortality was 2.4% (12 of 490), and elective mortality was 1.4% (6 of 425). The seizure rate was 1.4% (7 of 490). Six patients (1.2%) developed renal failure that required dialysis. The postoperative stroke rate was 1.6% (8 of 490) and was 1.2% (5 of 425) for the elective cases. The overall stroke rate for patients requiring <50 minutes of DHCA was 1.3% (6 of 478), significantly different from the 16.7% (2 of 12) stroke rate for patients requiring >50 minutes of DHCA (P ¼ .014). Multivariate analysis revealed a DHCA time >50 minutes (odds ratio, 5.11 AE 4.01, P ¼ .038) and aortic dissection (odds ratio, 3.59 AE 1.72, P ¼ .008) to be strong predictors of composite adverse outcomes. Conclusions: Straight DHCA is a safe and effective technique of cerebral protection for the absolute majority of interventions involving the aortic arch. At experienced centers, up to 50 minutes of DHCA can be considered safe, without significant postoperative mortality or neurologic sequelae.
Expert Review of Cardiovascular Therapy, 2007
Introduction Deep hypothermic circulatory arrest (DHCA) is a surgical technique that aims to protect the brain during cardiac and aortic surgeries. It was established in the 1950s and promoted in the 1970s [1]. The main principle of this technique is to reduce brain metabolism by cooling the body below 18C, allowing for more extended periods of interrupted blood flow [2]. The metabolism rates decrease by about 7% for every 1°C drop below 37°C [3,4]. Moreover, when the body temperature reaches 20°C, oxygen consumption is reduced to 20% of normothermic values [5].
The Annals of Thoracic Surgery, 2010
Methods. A retrospective review was performed for all aortic arch cases involving uSACP between January 2004 and December 2009. Of these 412 patients, 97 (24%) were treated emergently. Adverse outcomes included operative mortality, permanent neurologic dysfunction, temporary neurologic dysfunction, and renal failure requiring dialysis. Potential selection bias was controlled by the inclusion of 11 covariates. Multivariable logistic regression analysis was used to model adverse outcome as a function of MHCA and the covariates. Adjusted odds ratios were formulated along with 95% confidence intervals.
Annals of thoracic and cardiovascular surgery: official journal of the Association of Thoracic and Cardiovascular Surgeons of Asia
Objective: Despite theoretical advantages of antegrade (ACP) and retrograde cerebral perfusion (RCP) in addition to deep hypothermic arrest (DHA) in aortic arch surgery, there is still controversy about the best method of cerebral protection. We reviewed our experience with neurological outcome after aortic arch repair over the last five years. Methods: Sixty-two patients undergoing aortic arch repair were reviewed. Five patients (8.1%) had Marfan's syndrome, 11 (17.7%) had previous cardiac operations, and 13 (21.0%) also received coronary bypass grafting (CABG). The extent of arch replacement was proximal level in 40 (64.5%), distal level in 18 (29.0%), and total in 13 (21.0%). The method of cerebral protection was DHA alone in 14 patients, DHA with RCP in 23, and DHA with ACP in 25. Pre-, intra-, and postoperative variables in the three categories of cerebral protection were compared. Specifically, the independent predictors of mortality, stroke, and temporary neurological dysfunction (TND) were examined. Results: Overall hospital mortality was 5 (8.0%). Stroke occurred in 4 patients (6.4%), and TND in 5 (8.0%). There were no significant differences among the groups in mortality or neurological dysfunction. Total brain exclusion time (TBET) was significantly longer in ACP (DHA, 25.2±12.0 min; ACP, 61.8±44.1 min; RCP, 36.4±20.5 min; p=0.023). Multivariate analysis showed a trend for TBET of longer than 90 minutes as a predictor of stroke (p=0.06; odds ratio, 7.9). The actuarial survival rate was 88.7% at five years (DHA, 85.7%; ACP, 80.0%; RCP, 100%; no significant difference). Conclusions: Despite more complicated arch repairs requiring a significantly longer cerebral exclusion time which were performed in the group receiving ACP, there was no significant increase in stroke or death rates. Increasing confidence in the ability of ACP has led us to perform the most appropriate arch repair without compromising the extent of replacement for fear of exceeding the "safe" period of circulatory arrest. (Ann Thorac Cardiovasc Surg 2003; 9: 174-9)
Annals of thoracic and cardiovascular surgery : official journal of the Association of Thoracic and Cardiovascular Surgeons of Asia, 2008
In spite of recent advances in thoracic aortic surgery, postoperative neurological injury still remains the main cause of mortality and morbidity after aortic arch operation. The use of cardiopulmonary bypass (CPB) and hypothermic circulatory arrest, temporary interruption of brain circulation, transient cerebral hypoperfusion, and manipulations on the frequently atheromatic aorta all produce neurological damages. The basic established techniques and perfusion strategies during aortic arch replacement number three: hypothermic circulatory arrest (HCA), antegrade cerebral perfusion (ACP), and retrograde cerebral perfusion (RCP). During the past decade and after several experimental studies, RCP lost its previous place in the armamentarium of brain protection, giving it up to ACP as a major method of brain perfusion during HCA. HCA should be applied at a temperature of asymptotically equal to 20 degrees C with long-lasting cooling and rewarming and should not exceed by itself the time...
European Journal of Cardio-Thoracic Surgery, 2010
Objectives: Antegrade cerebral perfusion (ACP) during hypothermic circulatory arrest (HCA) for ascending/transverse arch repair is used for cerebral protection. This study evaluates ACP in combination with retrograde cerebral perfusion (RCP) during extended HCA and compares it to RCP-only. Methods: Between January 2005 and April 2007, we performed 64 consecutive arch repairs requiring extended HCA (>40 min). RCPonly was used with 34 patients and ACP with brief RCP ('integrated') was used with 30 patients. Mean HCA time was 51 AE 13 min. Mean RCP-only time was 47 AE 9.6 min; in the integrated group, mean ACP time was 42 AE 14.4 min with an added RCP time of 10.8 AE 7.6 min. For the entire cohort, 95% (61/64) underwent total arch repair, and 67% (43/64) had elephant trunk reconstruction. Variables predictive of mortality and neurological outcomes were analysed prospectively, but technique selection was non-randomised. Results: Preoperative and operative variables did not differ between the RCP-only and the integrated groups except for aortic valve replacement, which was more frequently performed in the integrated group (33% (10/30) vs 12% (4/34), P = 0.05), and preoperative renal dysfunction, which was more frequent in the RCP group (26% (9/34) vs 7% (2/30), P = 0.04). No significant difference was observed in outcomes between the groups; however, the integrated group had higher mortality, stroke and temporary neurological deficit than RCP-only. Conclusions: The observed trends in actual outcomes were a cause for concern. ACP combined with a short period of RCP did not provide better outcomes than RCP-only. The use of RCP remains warranted in our experience.
The Annals of Thoracic Surgery, 2001
Background. To determine the optimal method of brain protection during deep hypothermic circulatory arrest (DHCA) for arch repair. Methods. Of 139 potential aortic arch repairs (denominator), we randomized 30 patients to either DHCA alone (n ؍ 10), DHCA plus retrograde brain perfusion (RBP) (n ؍ 10), or antegrade perfusion (ANTE) (n ؍ 10); a further 5 coronary bypass (CAB) patients were controls. Fifty-one neurocognitive subscores were obtained for each patient at each of four intervals: preoperatively, 3 to 6 days postoperatively, 2 to 3 weeks postoperatively, and 6 months postoperatively. Intraoperative and postoperative S-100 blood levels and electroencephalograms were also obtained. Results. For the denominator, the 30-day and hospital survival rate was 97.8% (136 of 139) and the stroke rate 2.8% (4 of 139). For the randomized patients, the survival rate was 100% and no patient suffered a stroke or seizure. Circulatory arrest (CA) times were not different (DHCA: RBP:ANTE) for 11 total arch repairs (including 6 elephant trunk; mean, 41.4 minutes; standard deviation, 15). Hemiarch repairs (n ؍ 17) were quickest with DHCA (mean 10.0 minutes; standard deviation, 3.6; p ؍ 0.011) and longest with ANTE (mean 23.8 minutes; standard deviation, 10.28; p ؍ 0.004). Of the patients, 96% had clinical neurocognitive impairment at 3 to 6 days, but by 2 to 3 weeks only 9% had a residual new deficit (1 DHCA, 1 RBP, 1 ANTE), and by 6 months these 3 patients had recovered. Comparison of postoperative mean scores showed the DHCA group did better than RBP patients in 5 of 7 significantly different (p < 0.05) scores and versus 9 of 9 ANTE patients. There were no S-100 level differences between CA groups, but levels were significantly higher versus the CAB controls, particularly at the end of bypass (p < 0.0001); however, these may have been influenced by other variables such as greater pump time, cardiotomy use, and postoperative autotransfusion. Circulatory arrest (p ؍ 0.01) and pump time (p ؍ 0.057) correlated with peak S-100 levels. Conclusions. The results of hypothermic arrest have improved; however, there is no neurocognitive advantage with RBP or ANTE. Nevertheless, retrograde brain perfusion may, in a larger study, potentially reduce the risk of strokes related to embolic material. S-100 levels may be artificial. In patients with severe atheroma or high risk for embolic strokes, we use a combination of retrograde and antegrade perfusion on a selective basis.