Is Deep Hypothermic Cardiac Arrest Mandatory in Aortic Arch Surgeries?

ABSTRACT Cannulation strategies in aortic arch surgeries are a matter of immense discussion. Majority of time deep hypothermic circulatory arrest (DHCA) is the way out, but it does come with its set of demerits. Here we demonstrate a case with aortic arch dissection dealt with dual cannulation strategy in axillary and femoral artery without need for DHCA and ensuring complete neuroprotection of brain and spinal cord without hinderance of time factor. Inception of new ideas like this may decrease the need for DHCA and hence its drawbacks, thus decreasing the morbidity and mortality associated.

Efficacy of superficial temporal artery pressure-guided selective cerebral perfusion during deep hypothermic circulatory arrest in patients undergoing aortic arch surgery / 中华麻醉学杂志

Objective To evaluate the efficacy of superficial temporal artery(STA)pressure-guided selective cerebral perfusion(SCP)during deep hypothermic circulatory arrest(DHCA)in patients undergoing aortic arch surgery.Methods Ninety-six patients of both sexes,aged 35-64 yr,with body mass index of 19-23kg/m2,of American Society of Anesthesiologists physical status Ⅲ or Ⅳ,undergoing aortic arch surgery,were divided into STA pressure group(group A)and clinical experience group(group B)using a random number table,with 48 patients in each group.In group A,STA catheterization was performed after tracheal intubation,and arterial pressure was monitored.SCP flow was adjusted to maintain the target value of STA pressure between 30 and 40mmHg during DHCA in group A.SCP flow rate was set at 5-10ml·kg-1·min-1 according to clinical experience in group B.The volume of fluid perfused during SCP,emergence time,extubation time and duration of intensive care unit stay were recorded.Neurological function was evaluated during length of hospitalization after surgery,and the development of permanent and transient neurological dysfunction and mortality in hospital were recorded.Results Compared with group B,the volume of fluid perfused during SCP was significantly decreased,the emergence time,extubation time and duration of intensive care unit stay were shortened,the incidence of permanent and transient neurological dysfunction(2% and 4%,respectively)was decreased(P 0.05).Conclusion Maintaining STA pressure at 30-40mmHg is a reliable method for guiding SCP during DHCA in patients undergoing aortic arch surgery.

Comparison of the brain protection effect of unilateral or bilateral selective cerebral perfusion in total aortic arch replacement / 解放军医学杂志

Objective To compare the brain protection effect of unilateral and bilateral selective cerebral perfusion (SCP) techniques in patients undergoing total aortic arch replacement for DeBakey type I aortic dissecting aneurysm. Methods Twentyfour patients from Dec. 2013 to Dec. 2014 in General Hospital of PLA who underwent total aortic arch replacement were divided into two groups: unilateral SCP group (USCP group, n=16) and bilateral SCP group (BSCP group, n=8), according to different brain protective techniques applied during deep hypothermia and circulatory arrest. Preoperative and postoperative neurological examinations and brain CT scans were performed in two groups. During the operation, the cerebral oxygen saturation of patients was continuously monitored. The occurrence of postoperative temporary neurological dysfunction (TND) of all patients was observed and recorded. Results After the operation, all patients recovered smoothly. Three patients suffered from postoperative TND in the USCP group and 1 patient in the BSCP group. Preoperative and postoperative brain CT scans showed no significant difference between two groups. Also there was no intergroup difference in the cerebral oxygen saturation of patients (P>0.05). Conclusion In the surgery of total aortic arch replacement, the technique for unilateral selective cerebral perfusion is easy to perform, feasible, and effective on the protection of the brain in patients suffering from DeBakey type I aortic dissecting aneurysm.

The management of extracorporeal circulation in modified total arch replacement combined with stented elephant trunk / 中国医师进修杂志

Objective To study the clinical experience of extracorporeal circulation management in modified total arch replacement combined with stented elephant trunk.Methods Fifty-eight patients with Stanford A aortic dissection underwent modified total arch replacement combined with stented elephant trunk.With the modified surgical technique,the technology of extracorporeal circulation was also modified with bilateral antegrade cerebral perfusion,the management of the temperature and blood protection.Results All patients were operated successfully.The operative time was 248-485 (396 ± 67) min,extracorporeal circulation time was 175-260 (181 ± 33) min,cross clamp time was 64-104 (85 ± 12) min,stop circulation time was 22-48 (32 ± 5) min,and selective cerebral perfusion time was 26-54 (39 ± 7) min.The ventilator assisted breathing time was 5.0-35.5 (23.0 ± 4.5) h,and ICU monitoring time was 24-140 (88 ± 12) h.Postoperative complications included transient neurologic deficit in 3 cases (5.2％,3/58),renal dysfunction in 5 case (8.6％,5/58),and pulmonary infection in 4 cases (6.9％,4/58).Conclusion To modified total arch replacement combined with stented elephant trunk,the modified management of extracorporeal circulation with bilateral antegrade cerebral perfusion,the management of temperature and blood protection,has a low prevalence of morbidity and mortality.

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.

S100 and S100β: biomarkers of cerebral damage in cardiac surgery with or without the use of cardiopulmonary bypass / S100 e S100β: biomarcadores de dano cerebral em cirurgia cardíaca com ou sem o uso de circulação extracorpórea

Objective: The present study is to describe the clinical impact of S100 and S100β for the evaluation of cerebral damage in cardiac surgery with or without the use of cardiopulmonary bypass (CPB). Methods: Quantitative results of S100 and S100β reported in the literature of the year range 1990-2014 were collected, screened and analyzed. Results: Cerebrospinal fluid and serum S100 levels showed a same trend reaching a peak at the end of CPB. The cerebrospinal fluid/serum S100 ratio decreased during CPB, reached a nadir at 6 h after CPB and then increased and kept high untill 24 h after CPB. Serum S100 at the end of CPB was much higher in infant than in adults, and in on-pump than in off-pump coronary artery bypass patients. ∆S100 increased with age and CPB time but lack of statistical significances. Patients receiving an aorta replacement had a much higher ∆S100 than those receiving a congenital heart defect repair. Serum S100β reached a peak at the end of CPB, whereas cerebrospinal fluid S100 continued to increase and reached a peak at 6 h after CPB. The cerebrospinal fluid/serum S100β ratio decreased during CPB, increased at the end of CPB, peaked 1 h after CPB, and then decreased abruptly. The increase of serum S100β at the end of CPB was associated with type of operation, younger age, lower core temperature and cerebral damages. ∆S100β displayed a decreasing trend with age, type of operation, shortening of CPB duration, increasing core temperature, lessening severity of cerebral damage and the application of intervenes. Linear correlation analysis revealed that serum S100β concentration at the end of CPB correlated closely with CPB duration. Conclusion: S100 and S100β in cerebrospinal fluid can be more accurate than in the serum for the evaluations of cerebral damage in cardiac surgery. However, cerebrospinal fluid biopsies are limited. But serum S100β and ∆S100β ...

Objetivo: O presente estudo descreve o impacto clínico de S100 e S100β para a avaliação do dano cerebral em cirurgia cardíaca com ou sem o uso de circulação extracorpórea (CEC). Métodos: Os resultados quantitativos de S100 e S100β relatados na literatura entre os anos 1990 e 2014 foram recolhidos, rastreados e analisados . Resultados: Os níveis do fluido cerebroespinal e níveis séricos S100 mostram uma mesma tendência, atingindo um pico no final da CEC. A relação de fluido cerebroespinal e soro S100 diminuiu durante a CEC, chegando a um nadir 6 h após a CEC, aumentando e mantendo alta até 24 h após a CEC. O soro S100 no final da CEC foi muito maior no infantil do que em adultos, e em pacientes de revascularização miocárdica com CEC do que em pacientes sem CEC. ∆S100 aumentou com a idade e tempo de CEC, mas sem significância estatística. Os pacientes que receberam substituição da aorta tinham um ∆S100 muito maior do que aqueles que fizeram reparo dos defeitos cardíacos congênitos. Soro S100β atingiu um pico no final da CEC, enquanto líquido cefalorraquidiano S100 continuou a aumentar e atingir um pico 6 h após a CEC. A proporção entre soro S100β e líquido cefalorraquidiano diminuiu durante a CEC, aumentando no final da CEC, com pico 1 h após a CEC, em seguida, diminuiu abruptamente. O aumento de soro S100β no final da CEC foi associado com o tipo de operação, menor idade, menor temperatura do coração e danos cerebrais. ∆S100β exibiu tendência decrescente com a idade, tipo de operação, encurtamento da duração da CEC, o aumento da temperatura do coração, diminuindo a gravidade do dano cerebral e da aplicação de intervenções. Análise de correlação linear revelou que a concentração sérica de S100β no final da CEC está intimamente relacionada com a duração do procedimento. Conclusão: Níveis de S100 e S100β no líquido cefalorraquidiano podem ser mais precisos do que no soro para as avaliações ...

Risk factors and treatments for neurological complications after deep hypothermic ciculatory arrest operation / 中国医师杂志

Objective To investigate the risk factors for neurological complications after deep hypothermic ciculatory arrest (DHCA) operation.Methods From January 2009 to October 2013, 70 patients who were diagnosed as aortic dissection or aortic an-eurysm underwent aortic operations under DHCA .According to the occurrence of neurological complications after surgery , patients were divided into neurological complication group (26 patients) and normal group (44 patients).Risk factors of neurological complications after surgery were evaluated by univariate analysis and multivariate logistic regression analysis .Results Central neurological compli-cations occurred in 26 patients (37.14%) , including 18 patients with temporary neurological dysfunction and 7 patients with perma-nent neurological dysfunction , 1 patient with paraplegia , 1 patient died of cerebral infarction .Univariate analysis showed that hyperten-sion disease( P =0.001), emergency surgery within 72 hours( P =0.009),cardiopulmonary bypass time ( P =0.015),antegrade se-lective cerebral perfusion ( ASCP) ( P =0.005 ) , hemodilution degree ( P =0.001 ) , erythrocyte ( P =0.033 ) and plasma ( P =0.034 ) transfusion volume in the perioperative period , oxygen index <200 mmHg in 4 hours postoperatively ( P =0.043 ) , arterial blood pressure instability ( P =0.037 ) and hypernatremia in 24 hours postoperatively ( P =0.001 ) , and the Acute Physiology And Chronic Health Evaluation II (APACHE II) score are the risk factors for central neurological complication .Hypertension disease( P =0.017 ) , emergency surgery within 72 hours ( P =0.048 ) , ASCP ( P =0.015 ) , hypernatremia in 24 hours postoperatively ( P =0.008 ) were independent determinats for central neurological complication .Conclusions A series of procedure including evaluating patients condition correctly before operation , controlling hypertension effectively in the perioperative period , applying the ASCP and the suitable hemodilution degree in operation , maintaining electrolyte balance , and correcting hypernatremia timely in the postoperative pe-riod maybe reduce the incidence of neurological complications after DHCA operation .

Síndrome do coração esquerdo hipoplásico: estratégia cirúrgica e comparação de resultados com técnicas de Norwood x Sano / Hypoplastic left heart syndrome: the report of a surgical strategy and comparative results of Norwood x Norwood-Sano approach

OBJETIVOS: Relatar estratégia cirúrgica na síndrome do coração esquerdo hipoplásico (SCEH), que possibilita tempo curto de parada circulatória hipotérmica e reconstrução do arco aórtico com pericárdio autólogo. Comparar os resultados das técnicas de restabelecimento da circulação pulmonar: anastomose Blalock-Taussig modificado e tubo ventrículo direito para artéria pulmonar. MÉTODOS: Estudo retrospectivo de 78 neonatos com SCEH, consecutivamente operados entre março de 1999 e junho de 2006. Foi usada a mesma técnica de reconstrução da neoaorta e duas técnicas diferentes de restabelecimento da circulação pulmonar: anastomose BTm, nos primeiros 37 neonatos, e tubo VD-AP, nos últimos 41. A canulação do canal arterial para a perfusão sistêmica foi a parte principal da estratégia cirúrgica para diminuir o tempo de parada circulatória hipotérmica. RESULTADOS: A sobrevida imediata foi de 74,35 por cento, sendo de 67,57 por cento no grupo BTm e de 80,49 por cento no grupo Tubo VD-AP (p=0,21). O tempo de parada circulatória hipotérmica foi de 45,79 por cento±1,99 min e 36,8±1,52 min (p=0,0012) e a mortalidade entre o primeiro e segundo estágios foi de 40 por cento e 6,9 por cento, respectivamente, nos grupos BTm e Tubo VD-AP (p=0,007). Coarctação da aorta ocorreu em cinco pacientes. A comparação das curvas de sobrevida (Kaplan-Meier) mostrou melhor resultado com o Tubo VD-AP (p=0,003). CONCLUSÕES: Essa estratégia cirúrgica resultou em tempo curto de parada circulatória, baixa mortalidade e baixa incidência de coarctação aórtica. Embora o melhor resultado imediato com o Tubo VD-AP não tenha sido significante, a menor mortalidade interestágios e a maior sobrevida em médio prazo no grupo VD-AP foram vantagens que atingiram significância estatística.

OBJECTIVES: To report a surgical strategy for the Norwood procedure in the hypoplastic left heart syndrome (HLHS) that enables short hypothermic circulatory arrest time and aortic arch reconstruction with autologous pericardium patch. To compare the results of the modified Blalock-Taussig (mBT) shunt and the right ventricle-to-pulmonary artery (RV-PA) conduit procedures as the source of pulmonary blood flow. Method: Retrospective study of 78 newborns consecutively operated between March, 1999 and June 2006. One technique for reconstruction of the neoaorta and two different techniques for reestablishment of the pulmonary blood flow: the mBT shunt in the first 37 newborns and RV-PA conduit in the last 41. Cannulation of the ductus arteriosus for systemic perfusion was the main part of the surgical strategy to reduce the hypothermic circulatory arrest time. Results: In-hospital survival for the entire cohort was 74,35 percent, or 67.57 percent for the mBT shunt and 80,49 percent for RV-PA conduit groups (p=0,21). Hypothermic circulatory arrest times were 45.79±1.99 min and 36,8±1,52 min (p=0,0012), respectively. Mortality rates between first and second stages were 40 percent for the mBT shunt and 6,9 percent for RV-PA conduit groups (p=0,007). Late coarctation of the aorta occurred in five patients Actuarial survival curves(Kaplan-Meier) comparison showed better results with VD-AP conduit (p=0,003). Conclusions: This surgical strategy resulted in short circulatory arrest time, low mortality and low incidence of aortic coarctation. Although the higher rate of survival to first palliation stage with the RV-PA conduit was not significant, the lower interstage mortality and superior medium-term survival in RV-AP group were statistically advantageous.

The Impact of Cardiac Surgery with Deep Hypothermic Circulatory Arrest on Systemic Inflammatory Response and Postoperative Morbidity in Adults

BACKGROUND: The inflammatory response to cardiopulmonary bypass (CPB) surgery is believed to play an important role in the end organ dysfunction after open heart surgery. The effect of temperature on the post-bypass inflammatory response has been studied in normothermic and hypothermic patients. This study compared the influence on the systemic inflammatory response and postoperative morbidity in hypothermic cardiopulmonary bypass patients with those in patients in deep hypothermic circulatory arrest. METHODS: Fifty patients undergoing elective redo-valvular replacement or double valve replacement using a hypothermic cardiopulmonary bypass (26-28oC, H Group) and 9 patients undergoing an elective ascending aortic aneurysm replacement using deep hypothermic circulatory arrest (16oC, D Group) were prospectively investigated. The serum samples were collected to estimate the interleukin (IL)-6 and tumor necrosis factor (TNF)-alpha levels immediately after induction, 30 min after the initiation of the CPB, 30 min after weaning from the CPB, 2 hours after the CPB, 24 hours after the CPB. RESULTS: Patients preoperative and intraoperative characteristics (age, gender, aortic cross clamping time, cardiopulmonary bypass time) were not similar in the two groups. The serum level of IL-6 and TNF-alpha were also similar in the two groups. There were no statistical differences in the intubation time, ICU stay and oxygenation index (arterial PO2/inspired fraction of oxygen). There were also no statistical differences in the incidence of systemic inflammatory response syndrome and the APACHE II scores. CONCLUSIONS: Deep hypothermic circulatory arrest was not shown to produce a more profound inflammatory response or influence the postoperative morbidity than a hypothermic cardiopulmonary bypass.