Unforeseen Rupture of Pseudoaneurysm of Common Carotid Artery: An Arduous Anesthetic Challenge

Pseudoaneurysm of the common carotid artery (CCA) is exceptionally unstable and unpredictable; it mandates quick medical attention in order to circumvent neurologic sequelae or hemorrhage. Unanticipated rupture is extremely lethal and a potential provocation for the anesthesia caregiver. It is an arduous challenge for an anesthetist to establish emergency airway when a huge bleeding pseudoaneurysm is compressing and deviating the trachea, securing invasive lines in collapsing vessels, volume and vasopressor resuscitation in deteriorating hemodynamics in order to maintain cerebral perfusion without compromising other vital organs, arranging huge amount of blood and blood products in a short span of time, and transferring an exsanguinating patient for the rapid institution of cardiopulmonary bypass. Not only preoperatively it also necessitates appropriate neuromonitoring and neuroprotection during and after surgery. The association of unforeseen rupture of common carotid artery pseudoaneurysm secondary to the tubercular spine and lifesaving management by the rapid institution of cardiopulmonary bypass (CPB) is a rare occasion. To the best of the authors’ knowledge, there is not any similar case in the peer?reviewed literature. Therefore, the authors enumerate the clinical experience of an unexpected rupture of CCA pseudoaneurysm requiring lifesaving CPB and emphasize the “Timely Teamed Effort Approach” that can sustain a life in such an inevitable situation.

Risk factors for continuous renal replacement therapy after total arch replacement of Stanford type A aortic dissection under moderate hypothermia circulatory arrest / 中华胸心血管外科杂志

Objective:To investigate the risk factors of acute kidney injury(AKI) combined with continuous renal replacement therapy(CRRT) after Stanford type A dissection under moderate hypothermia circulatory arrest(MHCA).Methods:From October 2017 to March 2020, all patients with Stanford type A dissection and total arch replacement surgery under MHCA were enrolled. According to whether receiving CRRT treatment, the patients were divided into CRRT group(49 cases) and control group(72 cases). Both tow groups chose the brain protection strategy of moderate hypothermia, the left common carotid artery and the innominate artery were perfused anteriorly. Relevant medical data was collected.Results:There was no statistical difference in age, sex, smoking history, and drinking history between the two groups of patients( P>0.10). There were statistical differences between the two groups in the diameter of the aortic sinus and whether Bentall surgery was performed at the same time( P≤0.05). On the 1st postoperative day, the serum creatinine(sCr) of the CRRT group was significantly higher than that of the control group[(214.04±79.51) μmol/L vs.(127.32±58.08) μmol/L]. The change trend of sCr was not obvious within 2 to 4 days after operation. The sCr of the control group was significantly lower than that of the CRRT group within 4 days after surgery[(264.20±111.76) μmol/L vs.(104.24±76.00) μmol/L]. The diameter of aortic sinus, combined with Bentall surgery, intraoperative red blood cell transfusion, intraoperative platelet transfusion, intraoperative autologous blood transfusion, intraoperative bleeding were positively correlated with whether CRRT was performed after surgery( P<0.10), while intraoperative plasma The amount of blood transfusion was negatively correlated with postoperative CRRT( P<0.05). Conclusion:The diameter of the aortic sinus before surgery, combined Bentall surgery, intraoperative blood transfusion products and intraoperative bleeding are risk factors for postoperative CRRT.

Efficacy of Aortic Valve Replacement with Ascending Aorta Grafting under Hypothermic Circulatory Arrest for the Patients with Shaggy/Calcified Aorta / 日本心臓血管外科学会雑誌

Purpose : The aim of this study is to evaluate the outcome of aortic valve replacement (AVR) with ascending aorta grafting under hypothermic circulatory arrest for patients with shaggy/calcified ascending aorta based on preoperative and intraoperative assessment of ascending aorta. Methods : From April 2010 to July 2019, 133 patients with aortic stenosis underwent AVR. Based on preoperative computed tomography and intraoperative epi aortic ultrasound, 121 patients were able to have their aorta clamped (C-AVR), while clamping was not possible for 12 patients due to shaggy/calcified in the ascending aorta (Asc-AVR). In Asc-AVR, ascending aorta was replaced to the vascular graft under hypothermic circulatory arrest with retrograde cerebral perfusion followed by AVR. Results : Although operative time and cardiopulmonary bypass time were prolonged and blood transfusion volume was significantly high in Asc-AVR, there were no significant differences in postoperative complications. Although postoperative MRI revealed two silent strokes, no symptomatic neurologic complications occurred in Asc-AVR. Five-year survival rates between groups were comparable (64.2% in Asc-AVR vs. 79.9% in C-AVR, p=0.420). Replacement of ascending aorta was not a risk factor of late death. Conclusion : AVR with ascending aorta grafting under hypothermic circulatory arrest based on preoperative and intraoperative assessment of ascending aorta is an acceptable method for patients with shaggy/calcified aorta.

Research progress on deep hypothermic circulatory arrest in rat model / 中国胸心血管外科临床杂志

@#Deep hypothermic circulatory arrest (DHCA) technology is the basic means of organ protection in complex aortic arch surgeries, congenital heart disease surgeries, pulmonary endarterectomy and other operations. The establishment of DHCA in rat model is helpful to explore the influence of DHCA and its pathophysiological pathways. However, there are some problems in this process, such as imperfect monitoring, inaccurate management and non-standard heparinization during the experimental period. It is necessary to review relevant literatures on DHCA rat model, in order to establish a DHCA rat model with standardized operation, clear standards and mature technology.

The application of deep hypothermic circulatory arrest in the surgical treatment of complex thoracoabdominal aortic aneurysm / 中华胸心血管外科杂志

Objective To discuss the application of deep hypothermic circulatory arrest in surgical treatment of complex thoracoabdominal aortic aneurysms and its near-midterm effect.Methods The clinical data of 34 cases of thoracoabdominal aortic aneurysm in the center from August 2009 to June 2018 were analyzed retrospectively.All the patients underwent surgery under deep hypothermic circulatory arrest.There were 23 males and 11 females; aged 23 -67 years, mean(42.26 ±10.96) years old; Crawford type Ⅰ in 12 cases and Crawford type Ⅱ in 22 cases; aneurysms with a maximum diameter of 50 -120 mm, mean(65.26 ±16.09) mm;Marfan syndrome 15 cases, atherosclerosis 14 cases, aortic coarctation in 5 cases;22 cases of hypertension;28 cases of first aortic surgery, 6 cases of re-aortic surgery.Surgical transthoracic and abdominal incision, ext-racapsular approach, femoral artery and inferior vena cava intubation, deep hypothermic circulatory arrest technique to complete proximal anastomosis, arterial tube reconstruction of intercostal artery, abdominal organ blood supply artery and four The bifur-cated vessels were anastomosed, and the bifurcated vessels were anastomosed with the "Y"type artificial blood vessel trunk. The bilateral radial arteries were end-to-end anastomosis in the 10 mm artificial blood vessels of the "Y"type artificial blood vessels.Results There were no complications of cranial nerve system in the whole group , deep hypothermic circulatory arrest (17.68 ±4.88) min, ventilator assist time(34.88 ±16.04) hours, postoperative renal failure in 5 cases, after CRRT treat-ment After recovery, 1 case of paraplegia after operation, muscle strength recovered after cerebrospinal fluid drainage and de-compression, and 1 case died in the whole group, and died of multiple organ failure.The patients were followed up for 3 months to 5 years, and the results were satisfactory.The survivors did not die.The survivors did not die.However, 5 patients underwent thoracic aortic replacement under deep hypothermic circulatory arrest for the first time , and 4 patients underwent reo-peration because of distal vasodilation.The reconstructed intercostal artery occlusion occurred in 4 patients, but no paraplegia occurred.Conclusion When cross clamping the aorta is not feasible,it is safe to perform proximal anastomosis with deep hy-pothermic circulatory arrest.

The application of different temperature during hypothermic circulatory arrest on aortic arch surgery / 中国胸心血管外科临床杂志

@#We conducted a detailed analysis of different hypothermic circulatory arrest techniques, from its evolution, application on aortic arch surgery and research, focusing on the application and advantages and disadvantage, which provides some guide for the future discussion on the optimal temperature of hypothermic circulatory arrest.

Research progress of mast cells in the mechanism of intestinal injury caused by deep hypothermic circulatory arrest / 中国胸心血管外科临床杂志

@#Deep hypothermic circulatory arrest (DHCA) is an important assistant technique for complex cardiac surgery, which creates convenient operating conditions for surgery, and is also one of the measures to protect the brain during operation. However, the complications caused by this technique cannot be ignored, and it should be noticed that the occurrence of intestinal injury is relatively insidious, but brings great pain to patients and significantly reduces the quality of life after operation. Studies have shown that intestinal ischemia-reperfusion injury is induced by DHCA. It causes mast cells to activate and release many inflammatory mediators that destroy the intestinal mucosal epithelium barrier, and eventually lead to intestinal injury. This article reviewed the research progress of mast cells in the mechanism of DHCA-induced intestinal injury.

A long-term survival model of 40-min deep hypothermic circulatory arrest in rats / 中华急诊医学杂志

Objective To establish a long-term survival model of deep hypothermic circulatory arrest (DHCA) in rats,which could contribute to the research of organ damage mechanism and clinical treatments related to DHCA.Methods Twenty Sprague-Dawley rats were randomly (random number) divided into the sham group (n=10) and DHCA group (n=10).After anesthesia,a 20 G catheter was cannulated in the tail artery for arterial inflow,a multiorificed catheter in the right jugular vein for venous drainage,and a 24G catheter in the branch of left femoral artery for artery blood pressure monitoring.Rats in the DHCA group underwent DHCA procedure for 40 min after brain temperature cooled to 18℃,then rewarmed for 40 min,till the brain temperature were above 34℃.Rats in the sham group were cannulated but did not undergo cardiopulmonary bypass (CPB).Hemodynamic parameters and blood gas analysis were measured for 5 times (pre-CPB,15 min after CPB,10 min after rewarming,40 min after rewarming,and 30 min after CPB).Results One rat in the DHCA group died,and the rest rats survived.The lactate level in the DHCA group after rewarming during operation was significantly higher than that in the sham group (7.84 mmol/L vs 1.93 mmol/L,P＜0.05).Conclusions In this study,40-min DHCA model in rats is characterized by safe and long-term survival.

Clinical study of acute renal injury after deep hypothermic circulatory arrest / 中国胸心血管外科临床杂志

@#Objective    To investigate the incidence of acute kidney injury (AKI) after deep hypothermic circulatory arrest (DHCA), to explore the risk factors and prognosis of postoperative AKI, and to establish a relatively accurate preoperative risk assessment strategy and prevention measures. Methods    The clinical data of 252 patients who underwent deep hypothermic circulatory surgery in our hospital from January 2014 to October 2018 were retrospectively analyzed. There were 179 males and 73 females with an average age of 53.6±11.6 years. The patients were divided into an AKI group and a non-AKI group according to the AKI diagnostic criteria developed by kidney disease improving global outcomes (KDIGO). The data of the two groups were compared, and the risk factors related to AKI after DHCA were analyzed by single factor and multivariate logistic regression. Results    Among the 252 patients enrolled, the incidence of AKI was 69.0%. The postoperative hospital mortality rate was 7.9% (20/252). The univariate analysis showed that the patient's age and body mass index (BMI)≥28 kg/m2, left ventricular ejection fraction<55%, preoperative serum creatinine (Scr)≥110 μmol/L, preoperative estimated glomerular filtration rate (eGFR), Cleveland score and intraoperative cardiopulmonary bypass time, intraoperative infusion of red blood cells, intraoperative infusion of plasma, postoperative  mechanical ventilation time≥40 h and other indicators were significantly different between the two groups (P<0.05); multivariate logistic regression analysis showed that there was significant difference between the two groups in age (OR=1.040, 95% CI 1.017–1.064, P=0.001), BMI≥28 kg/m2 (OR=2.335, 95%CI 1.093–4.990, P=0.029), eGFR<90 mL/(min·1.73 m2) (OR=2.044, 95%CI 1.082–3.863, P=0.028), preoperative Cleveland score (OR=1.300, 95%CI 1.054–1.604, P=0.014) and intraoperative cardiopulmonary bypass time (OR=1.009, 95%CI 1.002–1.017, P=0.014). Conclusion    The incidence of AKI is higher after DHCA. Patients with postoperative AKI have longer hospital stay and higher risk of hospitalization death. The age of patients, BMI≥28 kg/m2, eGFR<90 mL/(min·1.73) m2, Cleveland score, intraoperative extracorporeal circulation time are independent risk factors for AKI after DHCA.

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.

Right Subclavian Artery Bypass Grafting and Replacement of Two-Thirds of the Aortic Arch for a Rare Case Involving Aneurysm of the Right Subclavian Artery with Dissection / 日本心臓血管外科学会雑誌

A 69-year-old man was referred to our hospital because of a right upper mediastinal mass observed on chest roentgenogram. Computed tomography showed a dissecting aneurysm of the right subclavian artery and dissection of the ascending aorta. Furthermore, the ascending aorta was dilated. We subsequently reconstructed the right subclavian artery with a bypass graft and replaced the ascending aorta. Two-thirds of the aortic arch was placed in deep hypothermic circulatory arrest with retrograde cerebral perfusion. His postoperative course was uneventful with no neurological complications. While subclavian artery aneurysms are relatively rare in comparison to other peripheral artery aneurysms, subclavian artery aneurysms with aortic dissections are even rarer. The most important concerns during subclavian artery aneurysm repair are the method of surgical approach and the maintenance of sufficient cerebral flow. We suggested that deep hypothermic circulatory arrest with retrograde cerebral perfusion might prove useful in cases involving an intramural thrombus adherent to cerebral vessels. Therefore, patients with subclavian artery aneurysms must undergo extensive preoperative evaluation.

Analysis of risk factors for perioperative hyperbilirubinemia in Stanford type A aortic dissection / 中华胸心血管外科杂志

Objective To analyze the independent risk factors and complications for perioperative hyperbilirubinemia in Stanford type A aortic dissection undergoing operation and investigate the management strategy of perioperative hyperbilirubi-nemia. Methods Between January 2013 and January 2018 from the department of great vessel surgery of heart centre of,290 cases of patients with Stanford type A aortic dissection undergoing operation were collected consecutively,male 210 cases,fe-male 80 cases. The related data and perioperative peak hyperbilirubinemia were recorded. According to the perioperative peak hyperbilirubinemia,patients were divided into 2 groups:≥51. 3 μmol/ L group and < 51. 3 μmol/ L group. Univariate and lo-gistic regression analysis were used to identify the independent risk factors. The perioperative complications were also recorded. Results Preoperative total bilirubin ≥ 17. 1 μmol/ L(OR = 2. 105,95％ CI: 1. 153 - 3. 125,P = 0. 016),cardiopulmonary bypass time > 3. 5 h(OR = 1. 103,95％ CI: 1. 316 - 6. 151,P = 0. 031),a large number of hemolysis(OR = 1. 503,95％CI: 1. 506 - 6. 651,P = 0. 029),the input amount of 24 h allogeneic red blood cell > 2000 ml(OR = 1. 381,95％ CI:0. 956 - 2. 552,P = 0. 036)were the independent risk factors for perioperative hyperbilirubinemia. The incidence rate of post-operative acute hepatic failure(2. 5％ vs. 0,P = 0. 021)and artificial liver therapy(2. 5％ vs. 0,P = 0. 021)in≥51. 3μmol/ L group were significantly increased. The incidence rate of postoperative acute lung injury(37. 5％ vs. 25. 2％,P =0. 039)and acute kidney injury(38. 7％ vs. 19. 5％,P = 0. 035)in 51. 3 μmol/ L group were also significantly increased. The duration of mechanical ventilation[(4. 1 ± 1. 6)days vs. (2. 8 ± 1. 3)days,P < 0. 05]and ICU stay time[(5. 1 ± 2. 3)days vs. (3. 9 ± 1. 8)days,P = 0. 035]and hospitalization time[( 19. 3 ± 3. 1)days vs. ( 17. 3 ± 2. 5)days,P = 0. 035]were sig-nificantly prolonged. Temporary nerve dysfunction(52. 5％ vs. 32. 6％,P = 0. 002)and in-hospital mortality( 17. 5％ vs. 8. 1％,P = 0. 037)were significantly increased. Conclusion Preoperative total bilirubin ≥ 17. 1 μmol/ L,cardiopulmonary bypass time > 3. 5 h,a large number of hemolysis,the input amount of 24 h allogeneic red blood cell > 2000 ml were the in-dependent risk factors for perioperative hyperbilirubinemia in Stanford type A aortic dissection. The perioperative complications in≥51. 3 μmol/ L group were significantly increased. Therefore,more attention should be paid to the independent risk factors for perioperative hyperbilirubinemia in Stanford type A aortic dissection,hyperbilirubinemia and its clearance should be moni-tored more actively and dynamically,the cause should be found more precisely,the treatment be more comprehensive to achieve to control the level of bilirubinemia and improve the prognosis.

Innovative improvement of circulatory arrest technique in acute stanford type A aortic dissection / 中华胸心血管外科杂志

Objective Total aortic arch replacement and stented elephant trunk surgery is an important surgical method for acute type A aortic dissection, and the short, middle, long term curative effect has been recognized by more and more experts at home and abroad.Circulatory arrest was an independent risk factor for postoperative complications and mortality in patients with type A aortic dissection.The aim of this article is to observed the effection of a new technology to block aortic arch, whicn can shorten the circulatory arrest time to 2 minutes and avoid harm of circulatory arrest on patients.Methods From May 2016 to February 2017, 68 patients with acute type A aortic dissection were divided into the conventional group and the modified group.All the patients underwent total arch replacement and stented elephant trunk surgery.The rectal temperature of the conventional group was 25℃ and circulatory arrest time was 20 min.While the rectal temperature of the modified group was 28℃ and and circulatory arrest time was 2 min.Results In the conventional operation group, 3 patients died after operation while all the patients in the modified group were cured and discharged.There are no differences between the two groups in the time of cardiopulmonary bypass(CPB) and heart arrest time(P>0.05).There are Significant differences in CPB time, circulatory arrest time, postoperative awake time, intubation time, amount of blood used, the amount of drainage during the first two days after operation, the time staying in ICU and the postoperative time in hospital.And the modified group was much better.(P<0.05)Conclusion The results of new technology blocking aortic arch in the patients with acute type A aortic dissection are better than the conventional surgical approach during the perioperative period.This technology is simple and effective.It is worth promoting.

Effects of nitroglycerine on cooling and rewarming during cardiopulmonary bypass with deep hypothermic circulatory arrest / 临床麻醉学杂志

Objective To determine the effects of nitroglycerine on cooling and rewarming during cardiopulmonary bypass with deep hypothermic circulatory arrest (DHCAC).Methods Forty-six patients undergoing total aortic arch replacement with DHCAC, 38 males and 8 females, aged 26-74 years, falling into ASA physical status Ⅳ or Ⅴ, were randomly assigned to study group (n=24) and control group (n=22).The same cooling and rewarming methods were implemented in both groups.During cooling and rewarming, the study group received nitroglycerine infusion and the control group normal saline of same volume.The rectum rewarming time, the nasopharyngeal cooling and rewarming time were measured and compared.Results The time of rewarming rectum was significantly shorter in the study group compared to the control group [(104±30) min vs (127±31) min, P<0.05].There was no difference in cooling time , time of rewarming nasopharynx.Conclusion Nitroglycerine shortens the time of rewarming rectum during cardiopulmonary bypass with deep hypothermic circulatory arrest.

Anesthetic management of patent ductus arteriosus in adults.

Patent ductus arteriosus (PDA) is an extracardiac left to right shunt. It should be corrected at an early age, but some patients may survive into adult life even without repair. Anesthetic management for adult patients with PDA poses many challenges for the anesthesiologist due to alterations in the cardiopulmonary physiology. We report successful anesthesia management of a case of an adult patient of PDA with moderate pulmonary artery hypertension with infective endarteritis (two large mobile vegetations at the pulmonary end of the duct).

Sodium bicarbonate use and the risk of hypernatremia in thoracic aortic surgical patients with metabolic acidosis following deep hypothermic circulatory arrest.

Objective: Metabolic acidosis after deep hypothermic circulatory arrest (DHCA) for thoracic aortic operations is commonly managed with sodium bicarbonate (NaHCO3). The purpose of this study was to determine the relationships between total NaHCO3 dose and the severity of metabolic acidosis, duration of mechanical ventilation, duration of vasoactive infusions, and Intensive Care Unit (ICU) or hospital length of stay (LOS). Methods: In a single center, retrospective study, 87 consecutive elective thoracic aortic operations utilizing DHCA, were studied. Linear regression analysis was used to test for the relationships between the total NaHCO3 dose administered through postoperative day 2, clinical variables, arterial blood gas values, and short‑term clinical outcomes. Results: Seventy‑five patients (86%) received NaHCO3. Total NaHCO3 dose averaged 136 ± 112 mEq (range: 0.0–535 mEq) per patient. Total NaHCO3 dose correlated with minimum pH (r = 0.41, P < 0.0001), minimum serum bicarbonate (r = −0.40, P < 0.001), maximum serum lactate (r = 0.46, P = 0.007), duration of metabolic acidosis (r = 0.33, P = 0.002), and maximum serum sodium concentrations (r = 0.29, P = 0.007). Postoperative hypernatremia was present in 67% of patients and peaked at 12 h following DHCA. Eight percent of patients had a serum sodium ≥ 150 mEq/L. Total NaHCO3 dose did not correlate with anion gap, serum chloride, not the duration of mechanical ventilator support, vasoactive infusions, ICU or hospital LOS. Conclusion: Routine administration of NaHCO3 was common for the management of metabolic acidosis after DHCA. Total dose of NaHCO3 was a function of the severity and duration of metabolic acidosis. NaHCO3 administration contributed to postoperative hypernatremia that was often severe. The total NaHCO3 dose administered was unrelated to short‑term clinical outcomes.

RIFLE criteria for impact of acute kidney injury on early and long-term outcome after acute type A dissection surgery / 中华胸心血管外科杂志

Objective To investigate the impact of acute kidney injury ( AKI ) on early and long-term outcome using RIFLEcriteria in patients after acute type A dissection surgery.Methods Between January 2006 and June 2011, 286 cases a-cute type A dissection patients underwent deep hypothermic circulatory arrest surgery were retrospectively analyzed .Using RIFLEcriteria to classfy AKI to risk, injury and failure stages and comparing 30-day mortality, dialysis, ventilation time, ICU stay, hospital stay and cost, and three-year mortality.Multivariate analyses were performed to identify predictors of failure stage.Results AKI was detected in 160 patients(55.9%), and risk 85 cases(29.7%), injury 39 cases(13.6%), failure 36 cases(12.6%).Dialysis rate, ventilation time, ICU stay, cost, and 30-day mortality increased with worsening severity of renal injury, and these was significant increased in failure stage than other groups .There was no association between severity of renal injury and 3-year mortality.Multiple logistic regression showed that malperfusion syndrome ( OR =3.499, 95%CI:1.019-12.013, P=0.047) and WBC(OR=1.121, 95%CI:1.017 -1.237, P=0.022) were independent predictors of renal failure.Conclusion Postoperative mild and morderate acute kidney injury were common in acute type A dissection pa-tients.The severe acute kidney injury had association with poor early outcome .

Unilateral Selective Cerebral Perfusion during Aortic Valve Replacement in Patients with a Compromised Aorta / 日本心臓血管外科学会雑誌

<b>Background</b> : Aortic valve stenosis may be complicated by atherosclerotic lesions in the ascending aorta, which may cause cerebral infarction due to intraoperative dispersion of atheromas. We describe herein a safe aortic cross-clamping technique after removal of the sclerotic lesion in the ascending aorta during short-term unilateral selective cerebral perfusion and mild hypothermic circulatory arrest. <b>Methods</b> : From January 2006 to March 2014, a total of 144 patients underwent aortic valve replacement (AVR) for treatment of aortic valve stenosis. Patients who required ascending aorta replacement surgery, had infective endocarditis, or required emergency surgery were excluded. Five patients underwent AVR using unilateral selective cerebral perfusion and mild hypothermic circulatory arrest due to the presence of atherosclerotic plaques or severe calcification of the ascending aorta (Compromised Aorta group), and 139 patients underwent AVR using ascending aortic perfusion and clamping (Control group). Cardiopulmonary bypass using the right axillary and femoral arteries was started and cooled to a pharyngeal temperature of 34°C in the Compromised Aorta group. During hypothermic circulatory arrest, the brachiocephalic artery was clamped and unilateral selective cerebral perfusion was administered from the right axillary artery. The perfusion volume was adjusted to 500 to 800 ml while using the cerebral oxygen saturation monitor. After transection of the ascending aorta, the atheroma and suture line calcification were removed. A suitable site for cross-clamping was identified under direct vision, and the aorta was carefully cross-clamped. <b>Results</b> : The patients in the Compromised Aorta group required a mean circulatory arrest period of 3.8 min (range, 3.0-5.5 min). The mean minimum value of the left-side cerebral oxygen saturation was 52.0% (range, 45-58%). No patients in the Compromised Aorta group died or developed cerebral complications (95% confidence interval (CI) 0.000-0.522). Complications in the Control group included in-hospital mortality (3/140, 2.2% ; 95%CI : 0.003-0.046 ; <i>p</i>=0.899), stroke (2/139, 1.4% ; <i>p</i>=0.932), transient neurologic deficits (4/139, 2.9% ; <i>p</i>=0.867), and total cerebral complications (6/139, 4.3% ; 95%CI : 0.009-0.077 ; <i>p</i>=0.806). Additionally, there were no significant differences between the Compromised Aorta and Control groups in the operative time (345.8±71.8 vs. 333.6±85.4 min, respectively ; <i>p</i>=0.754), cardiopulmonary bypass time (196.4±63.6 vs. 199.2±50.0 min, respectively ; <i>p</i>=0.902), and aortic cross-clamp time (132.0±44.1 vs. 124.8±36.3 min, respectively ; <i>p</i>=0.666). <b>Conclusion</b> : Short-term unilateral selective cerebral perfusion and mild hypothermic circulatory arrest is a safe strategy in patients undergoing AVR with a severely atherosclerotic aorta. The outcomes of this strategy were equivalent to those in the Control group, which had fewer atherosclerotic lesions in the ascending aorta.

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.

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.