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.

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 tech-niques 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 6692 patients were enrolled in 12 studies, of which 3902 patients received low-temperature circula-tory arrest plus ACP, and 2790 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 ac-cording to the actual situation of aortic arch surgery.

Early- and mid-term results of emergent aortic arch replacement using moderate hypothermic circulatory arrest and unilateral selective antegrade cerebral perfusion / 中国胸心血管外科临床杂志

@#Objective    To investigate the results of emergent aortic arch replacement using moderate hypothermic circulatory arrest and unilateral antegrade cerebral perfusion (MHCA+UACP). Methods    We retrospectively analyzed the clinical data of 146 patients who underwent emergent aortic arch replacement using MHCA+UACP in our institution from January 2008 to June 2018. There were 111 males and 35 females aged 60.3±7.2 years. According to different surgical approaches, patients were divided into two groups: a total arch replacement (TAR) group (n=104) and a semi arch replacement (SAR) group (n=42). Right axillary artery was cannulated for cardiopulmonary bypass (CPB) and cerebral perfusion. Core temperature at the onset of MHCA was 23.4±1.4 ℃. UACP was initiated at 18-22 ℃ with the flow of 5-10 ml/(kg·min). Flow was adjusted to maintain cerebral perfusion pressure of 50–60 mm Hg. Results    CPB time was 235.0±42.0 min. Aortic clamp time was 154.0±29.0 min. Circulatory arrest (CA) time was 48.1±13.0 min. The CPB time and CA time of the TAR group were longer than those of SAR group. Overall mortality rate was 9.6%. Complications included permanent neurological dysfunction (PND), temporary neurological dysfunction (TND), acute kidney injury (AKI) requiring dialysis and delayed extubation (mechanical ventilation time > 72 hours). Overall incidence of PND and TND was 2.7% and 6.8%, respectively. The incidence of AKI requiring dialysis was 4.1%. The incidence of delayed extubation was 21.9%. No difference of mortality rate or incidence of complications was found between the two groups. The average follow-up was 63.0±33.1 months. The 5-year survival rate was 72.6% in the TAR group and 85.5% in the SAR group. Conclusion    Emergent aortic arch replacement using MHCA+UACP can be accomplished with excellent results.

Optimized selective arterial perfusion approach in total aortic arch replacement of stanford type a aortic dissection / 第二军医大学学报

Objective To explore the curative effect of optimized selective arterial perfusion approach in the total aortic arch replacement of the Stanford type A aortic dissection. Methods From Sep. 2016 to Oct. 2017, 31 Stanford A aortic dissection patients received total aortic arch replacement with cardiopulmonary bypass of optimized selective arterial perfusion approach (O-CPB group, 25 males and 6 females, aged [50.87±9.08] years old) in our hospital. And 60 Stanford A aortic dissection patients, who underwent total aortic arch replacement with cardiopulmonary bypass of traditional approach in our hospital from Jan. 2015 to Oct. 2017, were included as control (T-CPB group, 52 males and 8 females, aged [48.38±12.46] years old). The perioperative blood biochemistry parameters and clinical data were compared between the two groups. Multivariate logistic regression was used to analyze the risk factors for postoperative 30-day mortality. Results Compared with the T-CPB group, the O-CPB group had significantly shorter extracorporeal circulation time, circulatory arrest time and operation time ([206.90±39.92] min vs [276.37±29.92] min, [5.03±1.54] min vs [21.73±6.67] min and [396.68±58.57] min vs [469.28±69.77] min, all P0.01). The blood consumption volume and ICU detention time were significantly less in the O-CPB group versus the T-CPB group ([1 401±738] mL vs [1 705±580] mL and [5.94±2.45] d vs [7.42±3.53] d, both P0.05). The postoperative blood lactate and C-reactive protein concentrations in the O-CPB group were significantly lower than those in the T-CPB group ([6.10±3.80] mmol/L vs [8.11±4.51] mmol/L and [72.13±22.86] mg/L vs [84.78±17.07] mg/L; P0.05, P0.01). The patients in the O-CPB group were awake earlier than those in the T-CPB group ([3.32±1.11] h vs [4.14±1.59] h, P0.05). The absolute value of postoperative Richmond agitation-sedation scale (RASS) score of the O-CPB and T-CPB groups were 1.23±1.06 and 2.15±1.30, respectively, and the difference was statistically significant (P0.01). In O-CPB group, the oxygenation index was significantly higher and mechanical ventilation time was significantly shorter versus the T-CPB group ([234.42±79.51] mmHg vs [183.10±77.26] mmHg and [50.19±37.63] h vs [70.12±40.84] h; P0.01, P0.05; 1 mmHg＝0.133 kPa). There was no significant difference in the postoperative 30-day mortality rate between the O-CPB and T-CPB groups (6.45% [2/31] vs 11.67% [7/60], P0.05). Multivariate logistic regression showed that circulatory arrest time≥31 min and blood consumption volume≥1 390 mL were independent risk factors of postoperative 30-day mortality of Stanford A aortic dissection patients undergoing total aortic arch replacement, with OR (95% CI) being 1.517 (1.153-1.995) and 1.006 (1.002-1.010), respectively. Conclusion With bilateral antegrade selective cerebral perfusion and moderate hypothermia perfusion in lower body, the optimized selective arterial perfusion approach needs shorter circulatory arrest time, and less blood consumption compared with cardiopulmonary bypass of traditional approach. Moreover, it has a good protective effect on the brain and lung during total aortic arch replacement of Stanford type A aortic dissection.

Expression of hypoxia-inducible factor 1 and neuroglobin in piglet cortex during deep hypothermic circulatory arrest / 中国病理生理杂志

AIM:To observe the expression of hypoxia-inducible factor 1 (HIF-1) and neuroglobin (NGB) in piglet cortex during deep hypothermic circulatory arrest.METHODS:Wuzhishan piglets were randomly assigned to car-diopulmonary bypass group ( CPB group) , 40 min of circulatory arrest ( CA) at 18 ℃ without cerebral perfusion ( DHCA group) or with selective antegrade cerebral perfusion ( SACP group) .After 180 min of reperfusion, cortical tissue was har-vested for determining HIF-1αand NGB expression by HE staining, Western blot and real-time PCR.RESULTS:Severer cerebral injury was observed in DHCA group than that in SACP group.After 180 min of reperfusion, HIF-1αprotein and mRNA levels were significantly higher in DHCA group than those in CPB group (P<0.05).Accordingly, SACP animal had higher levels of HIF-1αprotein and mRNA than those in DHCA group (P<0.05).Simultaneously, higher NGB pro-tein and mRNA levels were found in DHCA group than those in CPB group after 180 min of reperfusion ( P<0.05) .The SACP animal had higher levels of NGB protein and mRNA than those in DHCA group (P<0.05).CONCLUSION:Up-regulation of HIF-1 and NGB are involved in the mechanism against cerebral injury resulting from DHCA in the cortex and possibly a part of cerebral protective effect of SACP.

Neuroprotection of selective antegrade cerebral perfusion on pig model exposed to deep hypothermia circulatory arrest / 实用医学杂志

Objective To explore the expression of TLR4/NF-κB pathway in cerebral injury resulting from DHCA ( deep hypothermia circulatory arrest ) as well as the effect of SACP ( selective antegrade cerebral perfusion). Methods Twelve pigs were randomly assigned to DHCA group (n = 6) or SACP group (n = 6) at 18 ℃ for 80 min. IL-6 was assayed by ELISA. Apoptosis and NF-κB proteins were detected by fluorescence TUNEL and Western blot, respectively. The level of TLR4 was determined through qRT-PCR and Western blot. Results Serum IL-6 level of SACP group was significantly lower at the end of circulation arrest and experiment and apoptotic index and NF-κB protein were apparently lower in SACP group (P < 0.05). The level of TLR4 protein and mRNA from SACP group decreased significantly (P < 0.05). Conclusions TLR4/NF-κB pathway plays a critical role in pathogenesis of DHCA cerebral injury and attenuating TLR4/NF-κB cytokines probably contributes to neuroprotection of SACP. TLR4/NF-κB pathway may be a novel target for DHCA.

Analysis of in-hospital death of aortic arch replacement under deep hypothermic circulatory arrest and antegrade cerebral perfusion / 中华胸心血管外科杂志

Objective To analyze risk factors for in-hospital death of aortic arch replacement under deep hypothermic circulatory arrest and antegrade cerebral perfusion.Methods Between January 2005 and December 2011,626 cases aortic arch replacement under deep hypothermic circulatory arrest and antegrade cerebral perfusion were retrospectively analyzed.The cause of death were recorded and univariate and multivariate analysis (multiple logistic regression) were used to identify the risk factors.Results In-hospital death occurred in 29 cases (4.6％) and in them 2 cases because of aortic dissection rupture,5 cases severe neurological injury,11 cases low cardiac output syndrome and 11 cases multiple organ failure.Multiple logistic regression showed that stroke history(OR =6.703,95％ CI:1.664-27.000,P ＝ 0.007),preoperative hemodynamic instability(OR =6.441,95％ CI:1.213-34.212,P =0.029),eardiopulmonary bypass time(OR =1.008,95％ CI:1.002-1.014,P =0.007) and CABG(OP =4.525,95％ CI:1.542-13.279,P =0.006) were independent risk factors for in-hospital death.Conclusion Stroke history,preoperative hemodvnamic instability and coronary involvement indicate high risk in operation,and mortality maybe can be reduced by controlling CPB time.

The effect of flow management of cerebral perfusion during aortic arch surgery on the neurological complication / 中华胸心血管外科杂志

Objective To investigate the effect of flow management of cerebral perfusion during aortic arch surgery on the neurological complication.Methods From March 2007 to November 2011,189 patients underwent aortic arch surgery with hypothermic circulatory arrest plus antegrade cerebral perfusion in our department.The clinical data were analyzed retrospectively.According to the different methods of cerebral perfusion flow nanagement,patients were divided into two groups.Single pump with double limb (to the lower body and brain) perfusion was used in group A (96 patients),based on natural distribution of petfusion flow without control.Modified flow management was used in group B (93 patients).A magnetic flow sensor probes was installed on the brain perfusion limb to monitor and control the cerebral perfusion flow precisely (10 ml · kg-1 · min-1).Postoperative neurological complications were compared between two groups.Results There was no significant difference between the two groups in CPB time,aortic clamping time and circulatory arreating time.However,the morbidity of postoperative neurological complications in group B was much lower than that in group A (1.1％ vs 5.2％,P ＜0.05).Conclusion When performing antegrade cerebral perfusion during aortic arch surgery,precisely control of cerebral perfusion flow can reduce the morbidity of postoperative neurological complications effectively.

Nervous system protection in the treatment of DeBakey type Ⅰ aortic dissection with hybrid procedure / 中华胸心血管外科杂志

Objective The present study aims to summarize the clinical experience and methods of nervous system protection in the treatment of DeBakey type Ⅰ aortic dissection with hybrid procedure.Methods From Jan 2009 to Jun 2011,56 patients suffering from DeBakey Ⅰ aortic dissection underwent hybrid procedure.The ascending aorta part were replaced under conventional cardiopulmonary bypass,and the0 aortic arch branch vessels were reconstructed,and then a stent graft was implanted to cover the aortic arch and part of the descending aorta.The unilateral antegrade cerebral perfusion(UACP) and/or bilateral antegrade cerebral perfusion (BACP) combined with femoral artery perfusion was used,and the left subclavian arteries were selectively reconstructed according to cerebral arteries and aorta computed tomography angiography scan.Results All the patients went through the procedure successfully.BACP combined with femoral artery perfusion was applied in 16 patients,UACP combined with femoral artery perfusion in 33 patients,and 7 were perfused with only femoral artery cannulation.Of all the patients,19 underwent the innominate artery and left common carotid artery reconstruction and the other 37 patients underwent the innominate artery,the left common carotid artery and the left subclavian artery reconstruction.The cardiopulmonary time was 44 -95 min,mean (65 ±24) min; aortic clamping time was 32 -71 min,mean (48 ±29)min; the cerebral perfusion time was 24 -44 min,mean (32 ± 13) min.One ( 1.8％ ) patient,who was perfused with only femoral artery cannulation,suffered from permanent neurological dysfunction,and 5 (8.9％) had transient neurological dysfunction.One patient died from severe infection,1 patient was given up because of permanent neurological dysfunction,and the rest 54 patients recovered and discharged.The patients were followed up 1 to 25 months,and there was no newly occurred neurological dysfunc tion.The CTA examination 3 months post-operative revealed that the branch bypass vessels were unobstructed.There was no subclavain steal symptom occurred in the 19 patients whose left subclavian arteries were not reconstructed.The left upper limb strength was slightly lessened in 3 patients and recovered 6 - 12 months later.Conclusion In the treatment of DeBakey type Ⅰ aortic dissection with hybrid procedure,the selective use UACP and/or BACP combined with femoral artery perfusion can avoid deep hypothermic and circulatory arrest and provide the continuous cerebral and spinal perfusion.This perfusion strategy in hybrid procedure can decrease the morbidity of post-operative nervous system disorders with satisfactory nervous system protection effect.

Unilateral versus bilateral cerebral perfusion in deep hypothermia circulatory arrest surgery / 中华胸心血管外科杂志

Objective To study the applicability of unilateral and bilateral antegrade cerebral perfusion during deep hy-potbermia circulatory arrest (DHCT) surgery and to determine a better method of brain protection. Methods 60 patients un-derwent aortic arch surgery were random divided into either unilateral cerebral perfusion group with a cannula in the innominate artery (n = 30 ) , or bilateral cerebral peffusion gToup with an additional cannula in the left carotid artery ( n = 30 ). S-100β,neuron specific enolase (NSE) were assayed at the following time points: the beginning of cardiopulmonary bypass (T_1), the beginning of circulatory arrcst( T_2 ), antegradc cerebral perfusion (ACP) 25 min( T_3 ), the end of ACP( T_4 ), the end of car-diopulmonary bypass ( T_5 ) , 1h( T_6 ) , 6h ( T_7 ) and 24h( T_8 ) after operation. Neurological deficit incidence and mortality were also obtained. Results There is no statistical significance for S-100β and NSE plasma concentration among time points of T_1、T_2 and T_3. But every time point among T_4、T_5、T_6、T_7 ,Ts do have statistical significances. The incidence of central nervous system dysfunction in group unilateral ACP was higher than that in group bilateral ACP ( 33.33% vs. 10.00%, P = 0.028 ).But there is no significant difference between the two groups in mortality( 3.33% vs. 6.66% ,P = 1. 000 ). Conclusion There is no significant difference between unilateral ACP and bilateral ACP in 25 min during DHCA. But as the DHCA time extends, the effect of bilateral ACP will be better.

Anesthetic Management during Aortic Arch Surgery Using Anterograde Selective Cerebral Perfusion / 대한마취과학회지

Cerebral protection during aortic arch surgery is an anesthetic challenge, since the surgical procedures for aortic arch aneurysm involve an interruption of cerebral blood flow. We report a successfully managed case of aortic arch aneurysm repair with antegrade selective cerebral perfusion (SCP) during TCA (total circulatory arrest) using a transcranial oximeter, cerebral oxygenation was monitored during surgery. Although at the beginning of TCA a decrease in the regional cerebral oxygen saturation was observed, this was soon recovered by SCP. Except for the short period of TCA without SCP, regional cerebral oxygen saturation (rSO2) value were well maintained during surgery.