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Griepp RB, Ergin MA, Galla JD, Klein JJ, Spielvogel D, Griepp EB. Minimizing spinal cord injury during repair of descending thoracic and thoracoabdominal aneurysms: the Mount Sinai approach. Semin Thorac Cardiovasc Surg 1998; 10:25-8. [PMID: 9469774 DOI: 10.1016/s1043-0679(98)70013-9] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
In an effort to reduce the incidence of spinal cord injury following resection of descending thoracic and thoracoabdominal aneurysms, we have developed a multifaceted approach to maximize spinal cord perfusion which involves monitoring spinal cord function using somatosensory evoked potentials (SSEPs) intraoperatively and postoperatively. Intercostal and lumbar intersegmental vessels are sacrificed in a gradual stepwise fashion before the aneurysm is incised: none of these vessels is reattached unless SSEPs are abnormal following temporary occlusion, and this has not yet been observed. Postoperative spinal cord perfusion is maximized by keeping arterial pressure high and by draining cerebrospinal fluid if intrathecal pressure is elevated. Only two cases of permanent paraplegia have developed in 95 patients. Multivariate analysis showed extensive aneurysms (spanning 10 or more intersegmental arteries) and a history of smoking as the only significant risk factors for development of spinal cord injury.
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Griepp RB, Juvonen T, Griepp EB, McCollough JN, Ergin MA. Is retrograde cerebral perfusion an effective means of neural support during deep hypothermic circulatory arrest? Ann Thorac Surg 1997; 64:913-6. [PMID: 9307519 DOI: 10.1016/s0003-4975(97)00745-5] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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Juvonen T, Ergin MA, Galla JD, Lansman SL, Nguyen KH, McCullough JN, Levy D, de Asla RA, Bodian CA, Griepp RB. Prospective study of the natural history of thoracic aortic aneurysms. Ann Thorac Surg 1997; 63:1533-45. [PMID: 9205145 DOI: 10.1016/s0003-4975(97)00414-1] [Citation(s) in RCA: 229] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND The decision whether or not to recommend resection of moderately large descending thoracic and thoracoabdominal aneurysms requires weighing the relatively high mortality and significant risk of paraplegia associated with operation against the likelihood that the aneurysm will rupture spontaneously, with an almost invariably fatal outcome. To better define the risk of aneurysm rupture, we undertook a prospective study of patients who had not had operation on their moderately large descending thoracic and thoracoabdominal aneurysms. METHODS Patients were enrolled at the time of their second computed tomographic scans: three-dimensional computer-generated reconstructions allowed determination of several dimensional parameters for each study, including diameters and cross-sectional areas at the site of maximal dilatation in the descending aorta and in the abdomen as well as total thoracoabdominal surface area. Comparisons of serial studies permitted calculation of yearly rates of change in these dimensions. RESULTS Of 114 patients, 8 died of causes unrelated to the aneurysm, 26 died of rupture, 20 met previously determined criteria for operation, and 60 survived without operation or rupture. Multivariate regression analysis identified maximal diameter in the descending and in the abdominal aorta as independent risk factors for rupture, as well as older age, the presence of even uncharacteristic pain, and a history of chronic obstructive pulmonary disease. A piecewise exponential model enabled construction of an equation allowing calculation of rate of rupture in patients in whom the values of the risk factors are known, and also of the probability of rupture in a given individual over a specified time interval. CONCLUSIONS Because using this equation--based on easily determined risk factors (age, pain, chronic obstructive pulmonary disease, maximal thoracic and maximal abdominal aortic diameter)--allows the risk of aneurysm rupture within a given interval to be estimated fairly accurately for each individual patient, it is our current practice to recommend operation when the calculated risk of rupture within 1 year exceeds the anticipated mortality of elective operation, rather than relying on general operative guidelines based almost exclusively on aneurysm size.
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Nguyen KH, Ergin MA, Galla JD, Lansman SL, McCullough JN, Griepp RB. The Bentall procedure in patients with Marfan's syndrome. J Card Surg 1997; 12:142-6. [PMID: 9271738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
From 1985 to 1996, 18 patients with Marfan's syndrome underwent the Bentall procedure at Mount Sinai Hospital. They are compared with 38 patients aged < 40 without Marfan's syndrome who also underwent composite valve-graft replacement of the ascending aorta. The mean age of the non-Marfan group was 33 while that of the Marfan group was 29. Nearly three-quarters of each group were male. Aortic dissection was present in 33% of the Marfan group but only in 18% of the other group. Seventy-eight percent of the Marfan patients and 89% of the non-Marfan patients had aortic regurgitation. Twenty-one percent of the patients in the control group nevertheless had gross aortic pathology suggestive of Marfan's syndrome and may have had variants of the syndrome; 26% of the non-Marfan group had a bicuspid aortic valve. A modification of the Bentall procedure with implantation of coronary artery buttons was performed in the majority of the patients in both groups. Three patients, all in the group with Marfan's syndrome, required a concomitant mitral valve procedure. There was one death in each group. Two non-Marfan patients required reoperation; neither had dissection. Four patients with Marfan's syndrome underwent reoperation for distal disease in the aorta; they comprised one third of the Marfan patients who had aortic dissection. Three late complications occurred in the group with Marfan's syndrome: progressive cardiomyopathy; myocardial infarction; and late tamponade. There were also two late sudden deaths in the group with Marfan's syndrome, which may have been the consequence of aortic rupture. No difference in immediate operative mortality following the Bentall procedure was noted between patients with and without Marfan's syndrome, but young patients without Marfan's syndrome seem to have better event-free and long-term survival. In patients with Marfan's syndrome, the presence of acute dissection makes reoperation more likely, and sudden death from rupture still occurs despite careful postoperative surveillance. A higher incidence of severe mitral valve disease was found among young patients with Marfan syndrome than in controls.
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Griepp RB, Ergin MA, McCullough JN, Nguyen KH, Juvonen T, Chang N, Griepp EB. Use of hypothermic circulatory arrest for cerebral protection during aortic surgery. J Card Surg 1997; 12:312-21. [PMID: 9271761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Optimal use of hypothermic circulatory arrest during aortic surgery requires understanding of its physiology. Research in laboratory animals and clinical observations have now documented that considerable residual cerebral metabolism remains with cooling to levels of 15-18 degrees C, especially if cooling intervals are short, reflected by persistent jugular venous desaturation. Cooling should be continued to below 15 degrees C if the duration of HCA is expected to exceed 20 minutes, and continued until jugular venous saturations exceed 95%. There is considerable laboratory evidence that even short durations of HCA are followed by a prolonged interval of increased cerebral vascular resistance during which cerebral metabolism is maintained at normal levels by markedly increased oxygen extraction. Clinical observations have now confirmed that considerable jugular venous desaturation is present in patients following HCA: it is more pronounced with prolonged HCA, and is still present as late as six hours after the start of rewarming. This reinforces the concept of a prolonged postoperative vulnerable interval following HCA, during which any compromise in oxygen delivery has the potential for producing cerebral injury. Several adjunctive measures have been shown to improve outcome following HCA. The simplest and most important is topical hypothermia: packing the head in ice during the interval of HCA. Retrograde cerebral perfusion (RCP) has also been shown to improve EEG recovery as well as histological and behavioral outcome in laboratory animals following prolonged HCA, but some of its effect may be secondary to its efficacy in keeping the brain cold, since RCP provides very low rates of flow and supports metabolism at a much lower level than antegrade perfusion at the same temperature. But despite the clear superiority of antegrade perfusion, and the documentation of some benefits of RCP in laboratory measures of cerebral protection, clinical results using RCP and ACP have not yet demonstrated the superiority of these methods over use of HCA alone, perhaps because these modalities are usually employed in patients with unusually high risk of neurological injury: those with dissection or with clot or atheroma in the aorta. Nevertheless, recent years have seen considerable reduction in mortality following aortic surgery, especially in older patients, and a trend toward a lower incidence of permanent neurologic dysfunction. The presence of preoperative rupture or hemodynamic compromise, and of clot or atheroma in the aorta, remain the most significant risk factors both for death and occurrence of stroke.
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Galla JD, Ergin MA, Lansman SL, DeAsla RA, Nguyen KH, McCullough JN, Griepp RB. Identification of risk factors in patients undergoing thoracoabdominal aneurysm repair. J Card Surg 1997; 12:292-9. [PMID: 9271759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Developments and advances in surgical and anesthetic techniques have lead to increased survival in patients undergoing complex thoracic aortic aneurysm repairs. The decision to operate, however, continues to be based in a large degree on the clinical impression of the patient's ability to withstand the rigors of the procedure. As part of the ongoing effort of our department to further elucidate those parameters that impart added risk to patients, the diameters and volumes of CT-imaged aortas were determined for 67 surgical and nonoperatively managed patients. Significant differences were found between those patients not requiring surgery, and both those undergoing operation and those that died of rupture. Similarly, the average yearly increase in volume in surgical and rupture patients was higher than that of nonoperatively managed patients. Those patients who smoked also were found to have a significant yearly increase in size of their aortas relative to those patents that did not. An algorithm for managing patients presenting with thoracoabdominal aneurysms based upon size at initial presentation, change in annual diameter and volume, and estimated risk for paraplegia is presented.
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Griepp RB, Ergin MA, Galla JD, Lansman S, Khan N, Quintana C, McCollough J, Bodian C. Looking for the artery of Adamkiewicz: a quest to minimize paraplegia after operations for aneurysms of the descending thoracic and thoracoabdominal aorta. J Thorac Cardiovasc Surg 1996; 112:1202-13; discussion 1213-5. [PMID: 8911316 DOI: 10.1016/s0022-5223(96)70133-2] [Citation(s) in RCA: 247] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
All patients undergoing resection of thoracic or thoracoabdominal aneurysms at Mount Sinai Hospital since November 1993 had spinal cord function monitored with somatosensory-evoked potentials as part of a multimodality approach to reducing spinal cord injury. In the segment to be resected, each pair of intersegmental vessels was sequentially clamped, and they were subsequently sacrificed only if no change in somatosensory evoked potentials occurred within 8 to 10 minutes after occlusion. Adjunctive protective measures included mild hypothermia (31 degrees to 33 degrees C), distal perfusion, corticosteroids, maintenance of high normal blood pressures, avoidance of nitroprusside, and cerebrospinal fluid drainage. Ninety-five consecutive patients operated on since 1993 (group II) were compared with 138 earlier patients (group I). Preoperative characteristics such as age, sex, etiology of aneurysm, emergency operation, and reoperation did not differ between groups, nor did operative variables such as incidence of rupture and extent of resection. Group I had slightly more smokers and slightly fewer hypertensive individuals. Group II patients had a significantly better outcome with respect to in-hospital mortality (10.5% vs 18%, p = 0.045) and paraplegia (2% vs 8%, p = 0.008). By multivariate analysis, rupture and diabetes were associated with significantly higher in-hospital mortality, and smoking greatly increased the incidence of paraplegia. The extent of the aneurysm was a major determinant of mortality and paraplegia. The low paraplegia rate in group II was achieved without reattachment of a single intercostal or lumbar artery. No patient with fewer than 10 intersegmental arteries severed had paraplegia, and spinal cord ischemia was reversible in three patients after adjunctive maneuvers were performed to improve perfusion, suggesting that spinal cord blood supply is unlikely to depend on a single "artery of Adamkiewicz."
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Shore-Lesserson L, Reich DL, Vela-Cantos F, Ammar T, Ergin MA. Tranexamic acid reduces transfusions and mediastinal drainage in repeat cardiac surgery. Anesth Analg 1996; 83:18-26. [PMID: 8659732 DOI: 10.1097/00000539-199607000-00005] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
The administration of tranexamic acid (TA) prior to cardiopulmonary bypass (CPB) has been associated with reduced bleeding during and after cardiac surgery. In a prospective, randomized, controlled, double-blind clinical trial, adult patients undergoing repeat open heart surgery received TA (n = 17) or an equal volume of saline placebo (n = 13). In the TA group, a 20-mg/kg intravenous (IV) initial dose of TA at akin incision was followed by an infusion of 2 mg.kg-1.h-1, which continued for the duration of the surgical procedure. Identical transfusion guidelines were followed in both groups. Routine coagulation tests, D-dimer levels, mediastinal tube drainage, and transfusion requirements were compared. Cumulative postoperative mediastinal tube drainage measured at 24 h was 649 +/- 391 mliter (mean +/- SD) in the TA group compared with 923 +/- 496 mliter in the placebo group (P < 0.01). Forty-eight-and 72-h mediastinal tube drainage were also significantly less in the TA group (P < 0.01). Seven of 17 TA patients received to transfusion of allogeneic blood products compared with 1 of 13 placebo patients (P = 0.047). The incidence and volumes of platelet and fresh frozen plasma transfusion in the TA group were not significantly different in comparison with the placebo group. The perioperative increase in D-dimer levels (post-CPB minus pre-CPB) in the placebo group (median difference = 675 ng/mliter, range 125-1648) was significantly more than in the TA group (median difference = 182 ng/mliter, range -426-1950; P = 0.003). Sternal closure occurred in 41 +/- 21 min in the TA group and 61 +/- 49 min in the placebo group (P = 0.14), and the subjective bleeding score was less in the TA group than in the placebo group (2.38 +/- 0.78 vs 3.08 +/- 1.04; P = 0.045). The data from the current study support the prophylactic use of TA in patients undergoing repeat cardiac surgery. TA administered prior to CPB reduced the incidence of allogeneic transfusions and postoperative mediastinal tube drainage, and improved the subjective assessment of post-CPB hemostasis in a group of patients at moderately high risk for perioperative bleeding.
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Schor JS, Yerlioglu ME, Galla JD, Lansman SL, Ergin MA, Griepp RB. Selective management of acute type B aortic dissection: long-term follow-up. Ann Thorac Surg 1996; 61:1339-41. [PMID: 8633937 DOI: 10.1016/0003-4975(96)00105-1] [Citation(s) in RCA: 95] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Since 1985, we have selectively treated acute type B aortic dissections. Initial treatment lowered blood pressure and heart rate. Transesophageal echocardiography and computed tomographic scans were used to diagnose and follow up the patients. Patients were operated on for organ ischemia, pain, hypertension, or increasing subpleural fluid on computed tomographic scan. METHODS We retrospectively reviewed consecutive patients admitted over a 10-year period to the Mt. Sinai Hospital. RESULTS From August 1985 to May 1995, 68 patients were seen. Three died soon after admission during initial diagnostic evaluation. Seventeen patients underwent operation without mortality or paraplegia (group 1). Forty-seven of 48 patients treated nonoperatively were discharged; 1 patient died of rupture on day 7 (group 2). Actuarial survival for all 68 patients at 1 and 5 years was 92% +/- 4% and 82% +/- 8%. Group 1 survival was 93% +/- 4% and 68% +/- 5%, and group 2 survival was 90% +/- 6% and 87% +/-14%. There were no differences between groups. Late intervention was required in 2 group 1 patients (12%) and in 12 of 48 group 2 patients (25%), again without mortality or paraplegia. CONCLUSIONS This experience suggests that selective management of acute type B aortic dissection results in acceptable short-term and long-term survival. Avoiding early operation did not compromise late results.
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Ergin MA, McCullough J, Galla JD, Lansman SL, Griepp RB. Radical replacement of the aortic root in acute type A dissection: indications and outcome. Eur J Cardiothorac Surg 1996; 10:840-4; discussion 845. [PMID: 8911836 DOI: 10.1016/s1010-7940(96)80308-3] [Citation(s) in RCA: 53] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
OBJECTIVE Failure of the repair at the proximal aorta is an important cause of morbidity and mortality following surgical treatment of acute type A dissection. This review was undertaken to determine the influence of total composite replacement of the ascending aorta and the root on the operative risk and long-term survival. METHODS In a consecutive series of 73 patients with acute type A dissections between 1985 and 1994, 19 (26%) patients with radical root replacement (group I) were compared with 54 patients who had conventional valve-preserving root reconstruction (group II). RESULTS Group I represented a higher operative risk with the presence of significant aortic regurgitation (13/19 68.4% vs 23/54 42.5% P < 0.05), aortic dilatation (19/19 100% vs 32/54 59.2% P < 0.00), and coronary dissection (13/19 68.4% vs 3/54 5.5% P < 0.000). In spite of this there was no difference in operative mortality (3/19 15.7% vs 7/54 12.9%, NS) or the occurrence of major postoperative complications: bleeding (3/19 15.7% vs 7/54 12.9%, NS), respiratory (5/19 26.3% vs 11/54 20.3%, NS), stroke (2/19 10.5% vs 3/54 5.5%, NS). Patients with radical root replacement had substantially better event-free survival at 5 years (87.5% +/- 11.7% vs 67.1% +/- 8.9%) and 9 years (87.5% +/- 21.9% vs 63.0% +/- 19.2%). CONCLUSIONS This experience confirms that, in the treatment of acute type A dissection, an aggressive approach to aortic root pathology is indicated for specific indications, and can be carried out with good early and excellent long-term results.
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Silvay G, Ergin MA, Griepp RB, Reich DL. DEEP HYPOTHERMIC CIRCULATORY ARREST IN ADULT AORTIC SURGERY. Anesth Analg 1995. [DOI: 10.1213/00000539-199504001-00053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Ergin MA. Surgical techniques in prosthetic valve endocarditis. Semin Thorac Cardiovasc Surg 1995; 7:54-60. [PMID: 7893838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Annular extension of the infectious process is common in prosthetic valve endocarditis and carries a substantial prognostic significance in determining the immediate and late results of the surgical treatment of prosthetic valve endocarditis. Advanced destruction of the annular tissues requires complex reparative techniques for treatment. The cardiac surgeon faces the challenge of removing all infected tissues while preserving and restoring the functional integrity of the ventricular inlet and outlet. Familiarity with a growing number of specialized techniques is necessary for effective surgical treatment of these destructive lesions. This article is a synopsis of surgical techniques that we have found useful in the treatment of extensive annular destruction in bacterial endocarditis.
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Galla JD, Ergin MA, Sadeghi AM, Lansman SL, Danto J, Griepp RB. A new technique using somatosensory evoked potential guidance during descending and thoracoabdominal aortic repairs. J Card Surg 1994; 9:662-72. [PMID: 7841646 DOI: 10.1111/j.1540-8191.1994.tb00900.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Recent work in our laboratory has demonstrated the effectiveness of somatosensory evoked potentials (SEPs) in identifying the critical intercostal arteries (CICAs) for preserving spinal cord integrity during simulated aortic aneurysm repairs in the pig. Further studies have also demonstrated increased preservation of neurological function during prolonged aortic clamping if CICAs are perfused until ligation or clipping, as opposed to transaortic identification of back-bleeding intercostals and their subsequent ligation. We have developed a technique of repair of descending thoracic and thoracoabdominal aortic aneurysms and dissections that uses these principles. Since January 1993, 26 patients have undergone repair of their aortas using this new technique and SEP directed intercostal artery ablation. There were 22 (85%) long-term survivors among 10 thoracoabdominal and 16 descending aortic repairs. All patients with uncorrected abnormal SEP recordings developed paralysis; one patient who required reimplantation of an intercostal artery island into the aortic graft had normal neurological function postoperatively. Paraplegia was seen in only one of the surviving patients, but this patient had normal intra- and postoperative SEPs (4% false negative). Our experience suggests that SEP-guided obliteration of intercostal arteries while maintaining perfusion may be a useful approach to the surgical repair of descending and thoracoabdominal aortic disease.
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Abstract
The technique of open distal anastomosis using deep hypothermic circulatory arrest was used in 69 cases of acute type A aortic dissection. These cases were subcategorized by site of intimal tear, which was found in the ascending aorta in 41 patients (60%), in the arch in 22 patients (32%), and in the descending aorta in 5 patients (7%). Clinical characteristics and complications are described for these subtypes. Hospital mortality, which was 14.5% overall for acute type A dissections, was 14.6% for ascending tears, 18.2% for arch tears, and 0% for descending aortic tears. Six-year survival was 69% +/- 15% for ascending tears, 69% +/- 22% for arch tears, and 80% +/- 25% for descending tears (mean +/- SEM, p = NS). A classification system for aortic dissection is proposed, based on both site of origin and propagation.
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Midulla PS, Gandsas A, Sadeghi AM, Mezrow CK, Yerlioglu ME, Wang W, Wolfe D, Ergin MA, Griepp RB. Comparison of retrograde cerebral perfusion to antegrade cerebral perfusion and hypothermic circulatory arrest in a chronic porcine model. J Card Surg 1994; 9:560-74; discussion 575. [PMID: 7994098 DOI: 10.1111/j.1540-8191.1994.tb00889.x] [Citation(s) in RCA: 69] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Retrograde cerebral perfusion (RCP) is a new method of cerebral protection that has been touted as an improvement over hypothermic circulatory arrest (HCA). However, RCP has been used clinically for durations and at temperatures that are "safe" for HCA alone. This study was designed to compare RCP to HCA and antegrade cerebral perfusion (ACP) deliberately exceeding "safe" limits, in order to determine unequivocally whether RCP provides better cerebral protection than HCA. Four groups of six Yorkshire pigs (20 to 30 kg) were randomly assigned to undergo 90 minutes of RCP, ACP, HCA, or HCA with heads packed in ice (HCA-HP) at an esophageal temperature of 20 degrees C. Arterial, mixed venous and cerebral venous oxygen, glucose and lactate contents; quantitative EEG; were monitored at baseline (37 degrees C); at the end of cooling cardiopulmonary bypass (20 degrees C); during rewarming (30 degrees C); and at two and four hours post intervention. Animals were recovered and were evaluated daily using a quantitative behavioral score (0 to 9). Mean behavioral score was lower in the HCA group than in the other three groups at seven days (HCA 5.8 +/- 1.1; RCP 8.5 +/- 0.2; ACP 9.0 +/- 0.0; HCA-HP 8.5 +/- 0.2, p < 0.05). Recovery of QEEG was better in the ACP group than in all others, but the RCP group had faster EEG recovery than HCA alone, although not better than HCA-HP (HCA 15 +/- 4; RCP 27 +/- 3; ACP 78 +/- 5; HCA-HP 19 +/- 3, p < 0.001). However, histopathological evidence of ischemic injury was present in 5 of 6 HCA animals and also in 4 of 6 of the HCP-HP group, but only in 1 of 6 RCP animals and in none of the ACP group. This study demonstrates that ACP affords the best cerebral protection by all outcome measures, but RCP provides clear improvement compared to HCA.
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Ergin MA, Griepp EB, Lansman SL, Galla JD, Levy M, Griepp RB. Hypothermic circulatory arrest and other methods of cerebral protection during operations on the thoracic aorta. J Card Surg 1994; 9:525-37. [PMID: 7994095 DOI: 10.1111/j.1540-8191.1994.tb00886.x] [Citation(s) in RCA: 117] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Current surgical techniques in operations on the thoracic aorta frequently require exclusion of the cerebral circulation for varying periods. During these periods, hypothermic circulatory arrest (HCA), selective cerebral perfusion (SCP), and retrograde cerebral perfusion (RCP) can be used for cerebral protection. Hypothermia is the principle component of these methods of protection. The main protective effect of hypothermia is based on reduction of cerebral energy expenditures and largely depends on adequate suppression of cerebral function. It is most effective at deep hypothermic levels (13 degrees C to 15 degrees C). Measures that preserve autoregulation of cerebral blood flow help increase the margin of safety with all methods of protection. There is solid experimental and clinical data indicating the safe limits and outcome following HCA. Current applications of SCP and RCP are fairly recent developments and do not have comparable supporting data. SCP can be used without deep hypothermia and allows prolonged periods of cerebral protection, but is complex in application. RCP is simpler, but always requires deep hypothermia. Present clinical data do not allow separation of its protective effect from that of HCA alone. Recent modifications in the application of HCA include monitoring of cerebral O2 extraction, and selective use of supplemental SCP to limit arrest times to less than 50 minutes, or RCP to prevent embolic strokes, as indicated. These changes appear to have reduced the overall mortality, the severity of embolic strokes, and stroke-related mortality.
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Dapunt OE, Midulla PS, Sadeghi AM, Mezrow CK, Wolfe D, Gandsas A, Zappulla RA, Bodian CA, Ergin MA, Griepp RB. Pathogenesis of spinal cord injury during simulated aneurysm repair in a chronic animal model. Ann Thorac Surg 1994; 58:689-96; discussion 696-7. [PMID: 7944690 DOI: 10.1016/0003-4975(94)90729-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
The pathogenesis of paraplegia after repair of thoracic aortic aneurysms is controversial. Using direct spinal cord evoked potential monitoring, critical intercostal arteries (CICA) were identified to evaluate the impact of backbleeding and ligation versus that of preservation during simulated aneurysm repair. Thirty pigs (40 kg) were randomly assigned to one of five groups. In groups 1 through 4, a thoracic segment containing CICA was cross-clamped for 60 minutes and distal aortic perfusion was provided by a centrifugal pump. In groups 1 and 2, the thoracic segment was vented, maintaining segment pressure at 0 mm Hg; CICA were ligated in group 1 and preserved in group 2. Thoracic segment was perfused at 70 mm Hg in groups 3 and 4; CICA were ligated in group 3 and preserved in group 4. Critical intercostal artery ligations were performed at the end of the cross-clamp period. In group 5 simple cross-clamping at the left subclavian artery was performed as a control. The combination of venting and ligation of CICA correlated with impaired neurologic outcome according to Tarlov's score (median, 1.5 in group 1 versus 3 in group 2; p = 0.015), indicated by a significant difference in median values of direct spinal cord evoked potential amplitude (expressed as a fraction of baseline values) at 120 minutes after cross-clamping (0.76 in group 1 versus 0.98 in group 2; p = 0.0082).(ABSTRACT TRUNCATED AT 250 WORDS)
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Israel DH, Sharma SK, Ambrose JA, Ergin MA, Griepp RR. Cardiac catheterization and selective coronary angiography in ascending aortic aneurysm or dissection. CATHETERIZATION AND CARDIOVASCULAR DIAGNOSIS 1994; 32:232-7. [PMID: 7954770 DOI: 10.1002/ccd.1810320307] [Citation(s) in RCA: 25] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Cardiac catheterization and coronary angiography can be technically demanding and is potentially risky in patients with ascending aortic aneurysm or dissection. We describe our approach to and results in catheterizing 63 patients with ascending aortic pathology.
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Ergin MA, Phillips RA, Galla JD, Lansman SL, Mendelson DS, Quintana CS, Griepp RB. Significance of distal false lumen after type A dissection repair. Ann Thorac Surg 1994; 57:820-4; discussion 825. [PMID: 8166525 DOI: 10.1016/0003-4975(94)90182-1] [Citation(s) in RCA: 126] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Fifty-eight patients underwent repair of acute type A dissection between 1986 and 1992. Follow-up aortogram, computed tomographic scan with contrast, magnetic resonance imaging scan, or a combination of these tests was available in 38 patients with preoperatively patent distal false lumens. All distal anastomoses were constructed with the open technique during a period of circulatory arrest. There were 25 suture and 13 intraluminal graft anastomoses. Patency of the distal false lumen was found in 47.3%. Use of the intraluminal graft for the distal anastomosis decreased patency, although not significantly (4/13, 30% versus 14/25, 56%; p = 0.14). The direction of flow into the false lumen was antegrade in 11 of 24 (45.8%) of sutured anastomoses and 0 of 9 intraluminal graft anastomoses (p < 0.01). Actuarial survival at 5 years for patients with closed distal false lumen was 95% +/- 4.8% versus 76% +/- 15% for patients with patency of the distal false lumen (p = not significant). Event-free survival at 5 years for both groups was 84% +/- 8.3% (closed false lumen) and 63% +/- 13.5% (patency of distal false lumen; p = not significant). This experience indicates that in the treatment of acute type A dissections, operative strategy and anastomotic technique play a role in reducing the incidence of patency and related complications of the distal false lumen.
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Ergin MA, Galla JD, Lansman SL, Quintana C, Bodian C, Griepp RB. Hypothermic circulatory arrest in operations on the thoracic aorta. Determinants of operative mortality and neurologic outcome. J Thorac Cardiovasc Surg 1994; 107:788-97; discussion 797-9. [PMID: 8127108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
This study was undertaken to determine the factors that influence the final outcome after hypothermic circulatory arrest. Between 1985 and 1992 a uniform method of hypothermic circulatory arrest was used in 200 patients as the primary method of cerebral protection during operations on aneurysms of the thoracic aorta. There were 30 hospital deaths (15%). Age greater than 60 years (relative risk 3.7, p < 0.02), emergency operation and hemodynamic compromise (relative risk 22.2, p < 0.000), concomitant procedures (relative risk 2.7, p < 0.04), presentation with new neurologic symptoms (relative risk 5.2, p < 0.04), and postoperative permanent neurologic deficits (relative risk 9.4, p < 0.000) were found to be significant predictors of operative mortality. A total of 183 patients were available for evaluation of neurologic function and outcome. Multivariate analysis of this cohort of patients by multiple logistic regression showed that temporary neurologic dysfunction occurred in 36 cases (19%). Temporary neurologic dysfunction correlated with the duration of hypothermic circulatory arrest (47 +/- 16 minutes; odds ratio 1.06/minute; p < 0.001) and age (66 +/- 14 years; odds ratio 1.07/year; p < 0.001). Embolic strokes occurred in 22 patients (11%) and were associated with permanent deficits in 13 (7%). Strokes correlated significantly with age (older than 60, 21% versus younger than 60, 1%; p < 0.001) and operations on the arch and descending aortic aneurysms containing clot or atheroma (p < 0.001). This experience shows that the operative mortality is not affected by any parameters related to the use of hypothermic circulatory arrest. The incidence of temporary neurologic dysfunction rises linearly in relation to the age of the patient and the duration of hypothermic circulatory arrest. However, permanent neurologic injury is a result of thromboembolic events and is not related to the method of cerebral protection used. Additional methods to prevent perioperative embolic strokes are needed. Hypothermic circulatory arrest affords adequate cerebral protection if the arrest period is kept less than 60 minutes. We will continue to use this modality until the safety and utility of the alternate methods of cerebral protection are shown to be superior.
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Lansman SL, Cohen M, Galla JD, Machac J, Quintana CS, Ergin MA, Griepp RB. Coronary bypass with ejection fraction of 0.20 or less using centigrade cardioplegia: long-term follow-up. Ann Thorac Surg 1993; 56:480-5; discussion 485-6. [PMID: 8379719 DOI: 10.1016/0003-4975(93)90883-j] [Citation(s) in RCA: 54] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Forty-two patients with an ejection fraction of 0.20 or less underwent coronary artery bypass grafting from 1986 to 1990 using a method of myocardial protection we term "centigrade cardioplegia," combining single-dose, cold, crystalloid cardioplegia, systemic hypothermia, and local hypothermia. Thirty-day mortality was 4.8% (2/42). Perioperative morbidity included two myocardial infarctions (4.8%) and one stroke (2.4%), which fully resolved. Postoperative left ventricular function improved (left ventricular ejection fraction, 0.157 +/- 0.028 to 0.226 +/- 0.085; p < 0.0002), as did New York Heart Association class (3.4 +/- 0.73 to 1.8 +/- 0.63; p < 0.0001) and Canadian class (3.3 +/- 0.81 to 0.61 +/- 0.92). Survival, 88% at 1 year, declined to 68% at 3 years and 34% at 6 years. This high-risk group had very acceptable short-term results, indicating adequate intraoperative myocardial protection. Four clinical variables were associated with long-term survival: (1) chief complaint of pain only (p = 0.05), (2) history of unstable angina (p = 0.04), (3) Canadian class less than IV (p = 0.05), and (4) New York Heart Association class less than IV (p = 0.05). Reduced survival, although not statistically significant (p = 0.07), was noted for right ventricular ejection fraction of 0.30 or less. These factors may help predict which patients with severe left ventricular dysfunction will benefit from revascularization.
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Denber HC, Fuster V, Ergin MA, Schmuziger M. [Psychological effects of heart surgery. Preliminary study]. ANNALES MEDICO-PSYCHOLOGIQUES 1993; 151:502-5. [PMID: 8279735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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Ergin MA, Griepp RB. When, why, and how should the native aortic valve be preserved in patients with annuloaortic ectasia or Marfan syndrome? Semin Thorac Cardiovasc Surg 1993; 5:91-2. [PMID: 8425010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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Ergin MA, Griepp RB. Composite aortic valve replacement and graft replacement of the ascending aorta plus coronary ostial reimplantation: how I do it. Semin Thorac Cardiovasc Surg 1993; 5:88-90. [PMID: 8425009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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