Reemplazo de aorta ascendente con paro circulatorio con hipotermia sistémica moderada y perfusión cerebral retrógrada / Total replacement of the ascending aorta with moderate systemic hypothermic circulatory arrest and retrograde cerebral perfusion

Resumen: Antecedentes: El daño neurológico es una complicación devastadora de la cirugía con paro circulatorio del cayado aórtico y aorta ascendente. La perfusión anterógrada del encéfalo permite disminuir la incidencia de esta complicación, pero es un procedimiento engorroso que interfiere el campo quirúrgico. Para procedimientos más simples que requieran de paro circulatorio de menor duración, la Perfusión Cerebral Retrógrada (PCR) es una alternativa válida. Objetivo: Evaluar nuestros resultados en la cirugía del reemplazo total de la aorta ascendente tubular con paro circulatorio con hipotermia sistémica moderada y PCR. Material y Método: Entre enero de 2015 y enero de 2020 se identificaron los pacientes en la Base de Datos del Servicio de Cirugía Cardiaca de nuestra institución, se revisaron los protocolos operatorios, registros de perfusión y epicrisis, para obtener datos demográficos, clínicos y quirúrgicos pertinentes. La supervivencia alejada se certificó a través del "Servicio Registro Civil e Identificación de Chile". Resultados: En el periodo en estudio, 27 pacientes (21 hombres) tuvieron un reemplazo total de la aorta ascendente tubular con paro circulatorio con hipotermia moderada y PCR. Ocho pacientes tenían una cirugía previa; 7 de estos un reemplazo valvular aórtico. El 75% de los otros 20 pacientes tenía una válvula aórtica bicúspide. El diámetro máximo de la aorta ascendente fue en promedio 53,7 mm (45 a 67), y fue reemplazada en el 52% de los casos con un tubo protésico de 34 mm (promedio:32,4 mm; margen:30 a 34 mm). En 20 pacientes se efectuó un reemplazo valvular aórtico (15 con prótesis biológica). El tiempo promedio de circulación extracorpórea fue 174,6 min (97 a 243) y la temperatura sistémica mínima promedio fue 21ºC (18 a 25). El tiempo promedio de paro circulatorio fue 22,3 min (12 a 40) y de PCR 13 min (6 a 27). No hubo mortalidad operatoria. La morbilidad más frecuente fue la fibrilación auricular (33%). Una paciente presentó un episodio convulsivo aislado y otro fue reoperado por hemorragia postoperatoria. Una paciente falleció a los 48 meses de su operación. Conclusión: El paro circulatorio con hipotermia sistémica moderada y PCR para la cirugía de reemplazo total de la aorta ascendente facilitó la operación, con baja mortalidad y morbilidad en este grupo de pacientes.

Abstract: Background. Neurological damage is a devastating complication of aortic arch and ascending aorta surgery with deep hypothermic circulatory arrest. Antegrade cerebral perfusion significantly decreases the incidence of this complication, but it is a cumbersome procedure that interfere the surgical field. For more simple procedures, requiring a shorter period of circulatory arrest, retrograde cerebral perfusion (RCP) would be a valid alternative. Objective. To evaluate the results of total surgical replacement of the tubular ascending aorta with moderate hypothermic circulatory arrest and retrograde cerebral perfusion (RCP). Methods. Patients operated between January 2015 and January 2020 were included.Demographic, clinical and surgical information was obtained from the operatives notes, perfusion registry and discharge reports. Long-term survival was certified by the "Chilean Civil and Identification Registry". Results. 27 patients (21 men) underwent a total replacement of the tubular ascending aorta with circulatory arrest with moderate hypothermia and RCP. Eight patients had been previously operated on;7 of them had a previous aortic valve replacement. Of the remaining 20 patients, 75% had a bicuspid aortic valve. Average maximum diameter of the ascending aorta was 53.7 mm (45 - 67). Average size of the ascending aorta replacement graft was 32.4 mm (30 -34). In 20 patients a concomitant aortic valve replacement was performed (15 with a biological valve). Mean extracorporeal circulation time was 174.6 min (97 - 243) and mean minimal systemic temperature was 21ºC (18 - 25). Mean circulatory arrest time was 22.3 min (12 - 40) and mean RCP time was 13 min (6 - 27), There was no operative mortality. Atrial fibrillation was the most frequent post-operative morbidity (33%). One patient presented an isolated convulsive episode and another was re-operated due to postoperative hemorrhage. One patient died, 48 months after her operation. Conclusion. Moderate hypothermic circulatory arrest with RCP simplifies total tubular ascending aorta replacement, with low mortality and morbidity.

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.

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.

Anesthetic Management of Patient with Renal Cell Carcinoma Extending into the Right Atrium Using Adjunctive Deep Hypothermic Circulatory Arrest: A case report / 대한마취과학회지

Renal cell carcinoma is associated with inferior vena cava tumor spread in 4~10% of cases and with extension of the tumor thrombus into the right atrium in less than 1% of cases. Because inferior vena caval involvement does not affect the ultimate survival in patients with nonmetastatic renal cell carcinoma, aggressive surgical resection is indicated. We experienced a case of complete tumor excision with radical nephrectomy and inferior vena caval and right atrial thrombectomy using adjunctive cardiopulmonary bypass(CPB) and deep hypothermic circulatory arrest(DHCA). During total circulatory arrest(TCA), we protected brain from ischemic insult using deep hypothermia, retrograde cerebral perfusion, thiopental, and high dose steroid. The patient recovered uneventfully except minor neuropsychiatric symptom for 3 weeks after operation.

Effect of lidocaine on cerebral protection provided by retrograde cerebral perfusion / 中华麻醉学杂志

Objective:To observe the effect of lidocaine on cerebral protection provided by retrograde cerebral perfusion. Method:Sixteen mongrel dogs underwent cardiopulmonary bypass and were cooled to 20 C. Circulation was then stopped and retrograde cerebral perfusion was carried out for 120 min,then CPB was resumed and animals were rewarmed to 36 C. Animals were divided into two groups:in lidocaine group(n=8),lidocaine was administrated continuously throughout the experiment (4mg/kg then 0.2mg?kg~(-1)?min~(-1) during cardiopulmonary bypass, 0.5mg/min during retrograde cerebral perfusion);in control group(n=8),normal saline was given at the same rate. Result:Cerebral tissue creatine phosphate and adenosine triphosphate concentrations and energy charge were significantly higher in the lidocaine group than those in the control group by the end of the experiment (creatine phosphate:2.44?0.53 versus 1.61?0.49?mol/g wet w,P