Meta-analysis of the effects of anterograde and retrograde cerebral perfusion in aortic arch surgery / 中华胸心血管外科杂志

Objective@#To explore the differences in brain protection between anterograde cerebral perfusion(ACP) and retrograde cerebral perfusion(RCP) in aortic arch surgery.@*Methods@#Aortic arch circulatory surgery, ACP and RCP techniques were searched at the Cochrane Library, PubMed, EMBASE, Wanfang Database and the Chinese Biomedical Database from January 2013 to December 2018. Cohort studies were then performed with early postoperative death, transient neurological dysfunction(TND), stroke, and transient ischemic attack(TIA). For each study, data on endpoints in the ACP and RCP groups were used to generate risk ratios(RR) and 95% confidence intervals(CI). The funnel chart was used to test publication bias.@*Results@#A total of 6 692 patients were enrolled in 12 studies, of which 3 902 patients received low-temperature circulatory arrest plus ACP, and 2 790 patients received low-temperature circulatory arrest plus RCP. Summary analysis showed that the early postoperative death(RR=0.83, 95%CI=0.51-1.35, P=0.46), stroke(RR=1.09, 95%CI=0.91-1.31, P=0.33), transient neurological dysfunction(RR=0.81, 95%CI=0.17-3.91, P=0.80) and transient ischemic attack(RR=1.00, 95%CI=0.74-1.34, P=1.00) in both groups were no significant differences(all P>0.05).@*Conclusion@#There are no significant differences in postoperative mortality and neurological dysfunction between antegrade cerebral perfusion and retrograde cerebral perfusion in the aortic arch surgery. Combined with hypothermic circulatory arrest, it can be selected according to the actual situation of aortic arch surgery.

Retrograde Autologous Priming: Is It Really Effective in Reducing Red Blood Cell Transfusions during Extracorporeal Circulation? / 대한흉부외과학회지

BACKGROUND: Retrograde autologous priming (RAP) is known to be useful in decreasing the need of transfusions in cardiac surgery because it prevents excessive hemodilution due to the crystalloid priming of cardiopulmonary bypass circuit. However, there are also negative side effects in terms of blood conservation. We analyzed the intraoperative blood-conserving effect of RAP and also investigated the efficacy of autotransfusion and ultrafiltration as a supplemental method for RAP. MATERIAL AND METHOD: From January 2005 to December 2007, 117 patients who underwent isolated coronary artery bypass operations using cardiopulmonary bypass (CPB) were enrolled. Mean age was 63.9+/-9.1 years (range 36~83 years) and 34 patients were female. There were 62 patients in the RAP group and 55 patients in he control group. Intraoperative autotransfusion was performed via the arterial line. RAP was done just before initiating CPB using retrograde drainage of the crystalloid priming solution. Both conventional (CUF) and modified (MUF) ultrafiltrations were done during and after CPB, respectively. The transfusion threshold was less than 20% in hematocrit. RESULT: Autotransfusions were done in 79 patients (67.5%) and the average amount was 142.5+/-65.4 mL (range 30~320 mL). Homologous red blood cell (RBC) transfusion was done in 47 patients (40.2%) and mean amount of transfused RBC was 404.3+/-222.6 mL. Risk factors for transfusions were body surface area (OR 0.01, 95% CI 0.00~0.63, p=0.030) and cardiopulmonary bypass time (OR 1.04, 95% CI 1.01~1.08, p=0.019). RAP was not effective in terms of the rate of transfusion (34.5% vs 45.2%, p=0.24). However, the amount of transfused RBC was significantly decreased (526.3+/-242.3ml vs 321.4.+/-166.3 mL, p=0.001). Autotransfusion and ultrafiltration revealed additive and cumulative effects in decreasing transfusion amount (one; 600.0+/-231.0 mL, two; 533.3+/-264.6 mL, three; 346.7+/-176.7 mL, four; 300.0+/-146.1 mL, p=0.002). CONCLUSION: Even though RAP did not appear to be effective in terms of the number of patients receiving intraoperative RBC transfusions, it could conserve blood in terms of the amount transfused and with the additive effects of autotransfusion and ultrafiltration. If we want to maximize the blood conserving effect of RAP, more aggressive control will be necessary - such as high threshold of transfusion trigger or strict regulation of crystalloid infusion, and so forth.

The Changes of Brain Injury Markers (S100-beta, Neuron-Specific enolase) After Retrograde Cerebral Perfusion Under Total Circulatory Arrest in Pigs / 대한흉부외과학회지

BACKGROUND: We previously published the data that proved the safety of retrograde cerebral perfusion for 120 minutes. At this time, we planned to check the neuron-specific enolase and S100-beta in serum and urine to assess the possibility of early detection of cerebral injury. MATERIAL AND METHOD: We used pigs(Landrace species) weighing 35 kg and performed RCP for 120 minutes. After the weaning of cardiopulmonary bypass, we observed the pigs for another 120 minutes. Systemic arterial pressure, central venous pressure, and serum and urine levels of neuron-specific enolose (NSE) and S100beta protein were checked. Central venous pressure during RCP was maintained in the range of 20 to 25 mmHg. RESULT: Serum levels of NSE(ng/ml) were 0.67+/-0.18(induction of anesthesia), 0.53+/-0.47(soon after CPB), 0.44+/-0.27(20min after CPB), 0.24+/-0.09(RCP 20min), 0.37+/-0.35(RCP 40min), 0.33+/-0.21(RCP 60min), 0.37+/-0.22(RCP 80min), 0.41+/-0.23(RCP 100 min), 0.48+/-0.26(RCP 120min), 0.42+/-0.29(30min after rewarming), 0.35+/-0.32(60min after rewarming, 0.42+/-0.37(CPBoff 30min), 0.47+/-0.34(CPBoff 60min), 0.47+/-0.28(CPBoff 90min), and 0.57+/-0.29(CPBoff 120min). There was no statistically significant difference in levels between before and after RCP(ANOVA, p>0.05). Urine levels of NSE also showed no statistically significant difference in levels between before and after RCP. There was no correlation between urine and serum levels of NSE(Pearson correlation, p>0.05). Serum levels of S100beta protein(ng/ml) during the same time frames were 0.14+/-0.08, 0.15+/-0.07, 0.22+/-0.15, 0.23+/-0.07, 0.28+/-0.10, 0.40+/-0.05, 0.47+/-0.03, 0.49+/-0.12, 0.43+/-0.11, 0.46+/-0.15, 0.62+/-0.17, 0.77+/-0.21, 0.78+/-0.23, 0.77+/-0.23, and 0.82+/-0.33. There was statistically significant difference in levels between before and after RCP(ANOVA, p<0.05). Urine levels of NSE also showed statistically significant difference in levels between before and after RCP(ANOVA, p<0.05). There was significant correlation between urine and serum levels of NSE(Pearson correlation, p<0.05). CONCLUSION: The author observed the increase in serum and urine levels of S100beta after 120 minutes of RCP. Significant correlation between serum and urine levels was observed. The results were considered to be the fundamental data that could correlate this study with human-based study.

The Changes of Cerebral Metabolic Parameters, Serum Levels of Neuron-Specific Enolase and S-100beta Protein During Retrograde Cerebral Perfusion Under Profound Hypothermic Total Circulatory Arrest / 대한흉부외과학회지

BACKGROUND: Retrograde cerebral perfusion(RCP) is one of the methods used for brain protection during aortic arch surgery. The author previously published the data, however, for the safety of it, there still remains many controversies. The author performed RCP and checked various parameters to clarify the possibility of early detection of cerebral injury. MATERIAL AND METHOD: The author used pigs(Landrace species) weighing 25 to 30 kg and performed RCP for 120 minutes. After weaning of cardiopulmonary bypass, we observed pigs for another 120 minutes. Rectal temperature, jugular venous oxygen saturation, central venous pressure were continuously monitored, and the hemodynamic values, histological changes, and serum levels of neuron-specific enolose(NSE) and S100beta protein were checked. Central venous pressure during RCP was maintained in the range of 20 to 25 mmHg. RESULT: Flow rates(ml/min) during RCP were 224.3+/-87.5(20min), 227.1+/-111.0(40min), 221.4+/-119.5 (60min), 230.0+/-136.5(80min), 234.3+/-146.1(100min), and 184.3+/-50.0(120min). Serum levels of NSE did not increase after retrograde cerebral perfusion. Serum levels of S100beta protein(ng/ml) were 0.12+/-0.07(induction of anesthesia), 0.12+/-0.07(soon after CPB), 0.19+/-0.12(20min after CPB), 0.25+/-0.06(RCP 20min), 0.29+/-0.08(RCP 40min), 0.41+/-0.05(RCP 60min), 0.49+/-0.03(RCP 80min), 0.51+/-0.10(RCP 100 min), 0.46+/-0.11(RCP 120min), 0.52+/-0.15(30min after rewarming), 0.62+/-0.15(60min after rewarming, 0.76+/-0.17(CPBoff 30min), 0.81+/-0.20(CPBoff 60min), 0.84+/-0.23(CPBoff 90min) and 0.94+/-0.33(CPBoff 120min). The levels of S100beta after RCP were significantly higher than thosebefore RCP(p<0.05). The author could observe the mitochondrial swellings using transmission electron microscopy in neocortex, basal ganglia and hippocampus(CA1 region). CONCLUSION: The author observed the increase of serum S100beta after 120 minutes of RCP. The correlation between its level and brain injury is still unclear. The results should be reevaluated with longterm survival model also considering the confounding factors like cardiopulmonary bypass.