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Duan L, Zhang C, Chen X, Wang E, Ye Z, Duan Y, Huang L. Myocardial Priority Promotes Cardiovascular Recovery for Acute Type A Aortic Dissection Combined with Coronary Artery Disease Undergoing Aortic Arch Surgery. J Pers Med 2023; 13:1296. [PMID: 37763065 PMCID: PMC10532919 DOI: 10.3390/jpm13091296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 08/16/2023] [Accepted: 08/22/2023] [Indexed: 09/29/2023] Open
Abstract
The optimal surgical strategy for acute type A aortic dissection (ATAAD) with coronary artery disease (CAD) remains unclear. The goal of this study was to investigate the cardiovascular protective effects of the myocardial priority (MP) strategy or traditional selective cerebral perfusion (SCP) in ATAAD with CAD. A total of 214 adults were analyzed retrospectively, of which 80 underwent the MP strategy intraoperatively. Seventy-nine pairs were propensity-score-matched and divided into SCP and MP groups. The follow-up period ranged from 6 to 36 months. The MP group had a significantly shorter myocardial ischemic time, higher perfusion flow, higher radial artery pressure, and lower incidence of NIRS decrease >20% of the base value, but a longer lower limb circulatory arrest and bypass time than the SCP group. Although similar adverse cardiac and cerebrovascular events were observed in both groups, a shorter posthospital stay, less blood loss and transfusion, higher postoperative hemoglobin, lower creatinine, and higher PaO2/FiO2 were observed in the MP group. Subgroup analysis showed that when the TIMI Risk Score was <4, the MP group had a lower incidence of low cardiac output and lower postoperative cTnI level. The follow-up patients had similar morbidities between the two groups. The novel MP strategy is associated with a shortened myocardial ischemic time, better maintained perfusion of vital organs, and postoperative recovery after surgery for ATAAD combined with non-severe CAD.
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Affiliation(s)
- Lian Duan
- Department of Cardiovascular Surgery, National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha 410008, China
| | - Chengliang Zhang
- Department of Cardiovascular Surgery, National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha 410008, China
| | - Xuliang Chen
- Department of Cardiovascular Surgery, National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha 410008, China
| | - E Wang
- Department of Anesthesiology, National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha 410008, China; (E.W.)
| | - Zhi Ye
- Department of Anesthesiology, National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha 410008, China; (E.W.)
| | - Yanying Duan
- Department of Occupational and Environmental Health, Public Health School, Central South University, Changsha 410008, China
| | - Lingjin Huang
- Department of Cardiovascular Surgery, National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha 410008, China
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Di Chiara L, Galletti L. Selective versus standard cerebro-myocardial perfusion in neonates undergoing aortic arch repair: towards a further improvement for arch repair in neonates and infants. J Thorac Dis 2020; 12:5039-5041. [PMID: 33145075 PMCID: PMC7578492 DOI: 10.21037/jtd-20-13] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Luca Di Chiara
- Department of Cardiac Anaesthesia and Intensive Care, Bambino Gesù Hospital, Rome, Italy
| | - Lorenzo Galletti
- Department of Cardiac Surgery, Bambino Gesù Hospital, Rome, Italy
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Ergün S, Onan İS, Yildiz O, Çelik EC, Güneş M, Öztürk E, Güzeltaş A, Haydin S. Short- and midterm outcomes of aortic arch reconstruction: Beating heart versus cardiac arrest. J Card Surg 2020; 35:3317-3325. [PMID: 32996199 DOI: 10.1111/jocs.15048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 09/07/2020] [Accepted: 09/09/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVES We aimed to compare the short- and midterm results of perfusion strategies used for arch reconstruction surgery. MATERIAL AND METHODS One hundred and seventy-three consecutive patients who underwent aortic arch reconstruction surgery for transverse arcus hypoplasia between January 2011 and February 2020 were retrospectively analyzed. The patients were divided into two groups, as beating heart (BH) group and cardiac arrest (CA) group. RESULTS The CA group comprised 60 (35%) patients and the remaining 113 (65%) patients were in the BH group. The median age of the patients was 30 (interquartile range: 18-95) days. The incidences of acute renal failure (ARF) and delayed sternal closure were higher in the CA group (p = .05, <.001, respectively). Balloon angioplasty was performed in 5 (2%) patients and reoperation was performed in 11 (6%) patients due to restenosis. There were no statistically significant differences between the two groups in terms of reoperation or reintervention rates (p = .44 and .34, respectively). CONCLUSIONS Both strategies were associated with satisfactory midterm prevention of reintervention and reoperation. Given the lower incidence of ARF and delayed sternal closure in the postoperative period and similar midterm outcomes, we believe that the BH strategy is preferable.
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Affiliation(s)
- Servet Ergün
- Department of Pediatric Cardiovascular Surgery, Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Education and Research Hospital, Istanbul, Turkey
| | - İsmihan Selen Onan
- Department of Pediatric Cardiovascular Surgery, Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Education and Research Hospital, Istanbul, Turkey
| | - Okan Yildiz
- Department of Pediatric Cardiovascular Surgery, Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Education and Research Hospital, Istanbul, Turkey
| | - Ekin Can Çelik
- Department Cardiovascular Surgery, Antalya Training and Research Hospital, Antalya, Turkey
| | - Mustafa Güneş
- Department of Pediatric Cardiovascular Surgery, Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Education and Research Hospital, Istanbul, Turkey
| | - Erkut Öztürk
- Department of Pediatric Cardiology, Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Education and Research Hospital, Istanbul, Turkey
| | - Alper Güzeltaş
- Department of Pediatric Cardiology, Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Education and Research Hospital, Istanbul, Turkey
| | - Sertaç Haydin
- Department of Pediatric Cardiovascular Surgery, Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Education and Research Hospital, Istanbul, Turkey
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Maminirina P, Pavy C, Bourgoin P, Baron O. Continuous cerebral and myocardial selective perfusion in neonatal aortic arch surgery. J Card Surg 2020; 35:2920-2926. [PMID: 32789922 DOI: 10.1111/jocs.14930] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND To assess the feasibility and early outcome of continuous cerebral and myocardial selective perfusion (CCMSP) during aortic arch surgery in neonates. METHODS We performed a single-center retrospective study between 2008 and 2019 on neonates who underwent aortic arch surgery with or without associated heart lesion repair. CCMSP with moderate hypothermia levels (28°C) was achieved using selective brachiocephalic artery and ascending aorta cannulation. Target rates of cerebral and myocardial perfusion were 25 to 35 mL/kg/min and 150 ml/m2/min. Cardiopulmonary bypass (CPB) variables and clinical outcomes were analyzed. RESULTS Overall, 69 neonates underwent either isolated aortic arch repair (n = 31) or aortic arch repair with ventricular septal defect (VSD) closure (n = 38). Age and weight medians were 8 [6 to 15] days and 3.4 [2.9-3.5] kg, respectively. Mean CPB and aortic clamping times were 134 ± 47 and 26 ± 5 minutes for isolated aortic arch repair, and 159 ± 47 and 75 ± 30 minutes for aortoplasty accompanied by VSD closure. Mean CCMSP time was 52 ± 21 minutes with cerebral rate of 32.6 ± 10 mL·kg-1 ·min-1 . Overall in hospital survival was 98.5% (68/69). Major complications were: postoperative cardiac failure requiring mechanical support followed by stroke (n = 1; 1.44%) and transient renal failure requiring dialysis (n = 2; 2.89%). Neither myocardial nor digestive complication occurred. CONCLUSION CCMSP is a safe and reproducible strategy for cerebral, myocardial and visceral protection in neonatal aortic arch repair, with or without VSD closure, resulting in low complication and mortality.
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Affiliation(s)
- Pierre Maminirina
- Department of Pediatric Cardiac Surgery, University Hospital of Nantes, Nantes, France
| | - Carine Pavy
- Department of Pediatric Cardiac Surgery, University Hospital of Nantes, Nantes, France
| | - Pierre Bourgoin
- Department of Pediatric Cardiac Surgery, University Hospital of Nantes, Nantes, France
| | - Olivier Baron
- Department of Pediatric Cardiac Surgery, University Hospital of Nantes, Nantes, France
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Beating heart thoracic aortic surgery under selective myocardial perfusion for patients with congenital aortic anomalies. Gen Thorac Cardiovasc Surg 2020; 68:956-961. [PMID: 32034678 DOI: 10.1007/s11748-020-01304-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Accepted: 01/24/2020] [Indexed: 10/25/2022]
Abstract
OBJECTIVE We evaluated beating heart thoracic aortic surgery (BHTAS) using selective myocardial perfusion (SMP) in patients with aortic anomalies with complex surgical needs. METHODS Between 2012 and 2018, 27 infants with aortic anomalies underwent BHTAS using SMP. RESULTS Median body weight was 3.5 kg (range 2.6-5.2). In total, 15 cases of aortic coarctation, 7 cases of hypoplastic left heart syndrome, and 5 cases of interrupted aortic arch were included. An extended aortic arch anastomosis maneuver was used in 7 cases and aortic arch reconstruction compensated with an autologous pericardium patch was used in 6 cases. A Norwood-type procedure was used in 11 cases. The median Aristotle comprehensive score was 13.9 (7.0-20.0). BHTAS cases were not inferior in postoperative CK-MB/CK ratio (12.4 ± 2.8 in BHTAS vs 13.9 ± 3.6 in CTAS, p = 0.09), and there were no instances of myocardial ischemia. Two late deaths occurred due to shunt obstruction (n = 1) and valve malfunction (n = 1). Freedom from aortic reintervention was not inferior to conventional thoracic aortic surgery. BHTAS cases exhibited shorter cardiac arrest time than that of conventional thoracic aortic surgery in similar surgical procedures [CoA/VSD cases: 48.0 ± 8.0 min in the BHTAS cases and 65.7 ± 10.8 min in the CTAS cases (p = 0.0122), simple CoA/re-CoA cases: 0 min in the BHTAS cases and 20.1 ± 3.6 min in the CTAS cases]. CONCLUSIONS BHTAS reduced cardioplegic arrest time while maintaining postoperative CK-MB/CK ratio, mid-term death, and aortic reintervention rates.
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Luciani GB, Hoxha S, Angeli E, Petridis F, Careddu L, Rungatscher A, Caputo M, Gargiulo G. Selective versus standard cerebro-myocardial perfusion in neonates undergoing aortic arch repair: A multi-center study. Artif Organs 2019; 43:728-735. [PMID: 30698825 DOI: 10.1111/aor.13430] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 01/19/2019] [Accepted: 01/24/2019] [Indexed: 11/30/2022]
Abstract
The results of neonatal aortic arch surgery using cerebro-myocardial perfusion were analyzed. Selective cerebral and myocardial perfusion, using two separate pump rotors, was compared with standard perfusion, using a single pump rotor with an arterial line Y-connector. Between May 2008 and May 2016, 69 consecutive neonates underwent arch repair using either selective cerebro-myocardial perfusion (Group A, n = 34) or standard perfusion (Group B, n = 35). The groups were similar for age, weight, BSA, prevalence of one-stage or staged repair, and single ventricle palliation; male gender was more frequent in Group A. The duration of the cerebro-myocardial perfusion was comparable (27 ± 8 vs. 28 ± 7 min, P = 0.9), with higher flows in Group A (57 ± 27 vs. 39 ± 19 mL/kg/min, P = 0.01). Although cardioplegic arrest was more common in Group B (13/34 vs. 23/35, P = 0.03), the duration of myocardial ischemia was longer in Group A (64 ± 41 vs. 44 ± 14 min, P = 0.04). There was 1 hospital death in each group, with no permanent neurological injury in either group. Cardiac morbidity (1/34 vs. 7/35, P = 0.02) was more common in Group B, while extracardiac morbidity was similar in both the groups. During follow-up (3.2 ± 2.4 years), 5 late deaths occurred with a comparable 5-year survival rate (75 ± 17% vs. 88 ± 6%, P = 0.7) and freedom from arch reintervention (86 ± 6% vs. 84 ± 7%, P = 0.6). Risk of cardiac morbidity was greater with standard cerebro-myocardial perfusion (OR = 5.2, CI 3.3-6.8, P = 0.001) and with perfusion flows less than 50 mL/kg/min (OR 3.7, CI 1.87-5.95, P = 0.04). Cerebro-myocardial perfusion is a safe and effective strategy to protect the brain and heart in neonates undergoing arch repair. Selective techniques using higher perfusion flows may further attenuate cardiac morbidity.
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Affiliation(s)
| | - Stiljan Hoxha
- Pediatric Cardiac Surgery Unit, University of Verona, Verona, Italy
| | - Emanuela Angeli
- Pediatric Cardiac Surgery Unit, University of Bologna, Bologna, Italy
| | | | - Lucio Careddu
- Pediatric Cardiac Surgery Unit, University of Bologna, Bologna, Italy
| | | | - Massimo Caputo
- Bristol Heart Center, University of Bristol, Bristol, United Kingdom
| | - Gaetano Gargiulo
- Pediatric Cardiac Surgery Unit, University of Bologna, Bologna, Italy
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Hoxha S, Abbasciano RG, Sandrini C, Rossetti L, Menon T, Barozzi L, Linardi D, Rungatscher A, Faggian G, Luciani GB. Selective Cerebro-Myocardial Perfusion in Complex Neonatal Aortic Arch Pathology: Midterm Results. Artif Organs 2018; 42:457-463. [PMID: 29508410 DOI: 10.1111/aor.13128] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2017] [Revised: 01/06/2018] [Accepted: 01/09/2018] [Indexed: 01/13/2023]
Abstract
Aortic arch repair in newborns and infants has traditionally been accomplished using a period of deep hypothermic circulatory arrest. To reduce neurologic and cardiac dysfunction related to circulatory arrest and myocardial ischemia during complex aortic arch surgery, an alternative and novel strategy for cerebro-myocardial protection was recently developed, where regional low-flow perfusion is combined with controlled and independent coronary perfusion. The aim of the present retrospective study was to assess short-term and mid-term results of selective and independent cerebro-myocardial perfusion in neonatal aortic arch surgery. From April 2008 to August 2015, 28 consecutive neonates underwent aortic arch surgery under cerebro-myocardial perfusion. There were 17 male and 11 female, with median age of 15 days (3-30 days) and median body weight of 3 kg (1.6-4.2 kg), 9 (32%) of whom with low body weight (<2.5 kg). The spectrum of pathologies treated was heterogeneous and included 13 neonates having single-stage biventricular repair (46%), 7 staged biventricular repair (25%), and 8 single-ventricle repair (29%). All operations were performed under moderate hypothermia and with a "beating heart and brain." Average cardiopulmonary bypass time was 131 ± 64 min (42-310 min). A period of cardiac arrest to complete intra-cardiac repair was required in nine patients (32%), and circulatory arrest in 1 to repair total anomalous pulmonary venous connection. Average time of splanchnic ischemia during cerebro-myocardial perfusion was 30 ± 11 min (15-69 min). Renal dysfunction, requiring a period of peritoneal dialysis was observed in 10 (36%) patients, while liver dysfunction was noted only in 3 (11%). There were three (11%) early and two late deaths during a median follow-up of 2.9 years (range 6 months-7.7 years), with an actuarial survival of 82% at 7 years. At latest follow-up, no patient showed signs of cardiac or neurologic dysfunction. The present experience shows that a strategy of selective and independent cerebro-myocardial perfusion is safe, versatile, and feasible in high-risk neonates with complex congenital arch pathology. Encouraging outcomes were noted in terms of cardiac and neurological function, with limited end-organ morbidity.
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Affiliation(s)
- Stiljan Hoxha
- Division of Cardiac Surgery, University of Verona, Verona, Italy.,Department of Surgery, Dentistry, Pediatrics and Gynecology, University of Verona, Verona, Italy.,Department of Medicine, University of Verona, Verona, Italy
| | - Riccardo Giuseppe Abbasciano
- Division of Cardiac Surgery, University of Verona, Verona, Italy.,Department of Surgery, Dentistry, Pediatrics and Gynecology, University of Verona, Verona, Italy.,Department of Medicine, University of Verona, Verona, Italy
| | | | - Lucia Rossetti
- Division of Cardiology, University of Verona, Verona, Italy
| | - Tiziano Menon
- Division of Cardiac Surgery, University of Verona, Verona, Italy.,Department of Surgery, Dentistry, Pediatrics and Gynecology, University of Verona, Verona, Italy.,Department of Medicine, University of Verona, Verona, Italy
| | - Luca Barozzi
- Division of Cardiac Surgery, University of Verona, Verona, Italy.,Department of Surgery, Dentistry, Pediatrics and Gynecology, University of Verona, Verona, Italy.,Department of Medicine, University of Verona, Verona, Italy
| | - Daniele Linardi
- Division of Cardiac Surgery, University of Verona, Verona, Italy.,Department of Surgery, Dentistry, Pediatrics and Gynecology, University of Verona, Verona, Italy.,Department of Medicine, University of Verona, Verona, Italy
| | - Alessio Rungatscher
- Division of Cardiac Surgery, University of Verona, Verona, Italy.,Department of Surgery, Dentistry, Pediatrics and Gynecology, University of Verona, Verona, Italy.,Department of Medicine, University of Verona, Verona, Italy
| | - Giuseppe Faggian
- Division of Cardiac Surgery, University of Verona, Verona, Italy.,Department of Surgery, Dentistry, Pediatrics and Gynecology, University of Verona, Verona, Italy.,Department of Medicine, University of Verona, Verona, Italy
| | - Giovanni Battista Luciani
- Division of Cardiac Surgery, University of Verona, Verona, Italy.,Department of Surgery, Dentistry, Pediatrics and Gynecology, University of Verona, Verona, Italy.,Department of Medicine, University of Verona, Verona, Italy
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Murtuza B, Alsoufi B. Current Readings on Surgery for the Neonate With Hypoplastic Aortic Arch. Semin Thorac Cardiovasc Surg 2017; 29:S1043-0679(17)30294-0. [PMID: 29180283 DOI: 10.1053/j.semtcvs.2017.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/09/2017] [Indexed: 11/11/2022]
Abstract
Aortic arch hypoplasia is commonly present in neonates born with ductal-dependent coarctation of the aorta. The ideal surgical repair of neonates with proximal arch hypoplasia continues to be debated. Controversy exists about the fate of the hypoplastic proximal aortic arch following surgical repair and whether that will eventually grow to normal size upon relief of the distal obstruction or will persist as a residual lesion that can affect the long-term outlook of those patients. There is new evidence that residual proximal arch hypoplasia and the shape of the reconstructed arch both have an important impact on vascular remodeling and on the subsequent development of hypertension. Those concerns about late outcomes despite what was originally deemed a successful repair in infancy, coupled with improved cardiopulmonary bypass and cerebral perfusion techniques that allow surgeons to address proximal arch hypoplasia with low morbidity, have rekindled the debate on how to address proximal arch hypoplasia, with the aim to offer a neonatal surgery that would last for a lifetime and provide both optimal early recovery and late freedom from hypertension and related complications.
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Affiliation(s)
- Bari Murtuza
- Division of Cardiothoracic Surgery, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia
| | - Bahaaldin Alsoufi
- Division of Cardiothoracic Surgery, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia.
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Kim ER, Kim WH, Nam J, Choi K, Jang WS, Kwak JG. Mid-Term Outcomes of Repair of Coarctation of Aorta With Hypoplastic Arch: Extended End-to-side Anastomosis Technique. Semin Thorac Cardiovasc Surg 2017; 29:S1043-0679(17)30289-7. [PMID: 29111297 DOI: 10.1053/j.semtcvs.2017.10.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/20/2017] [Indexed: 11/11/2022]
Abstract
The optimal surgical repair technique for coarctation associated with aortic arch hypoplasia (CoA-AAH) in neonates and infants is controversial. This study evaluates our current strategy using extended end-to-side anastomosis under selective cerebral and myocardial perfusion in treating this group of patients. Through a retrospective review, we analyzed the outcome of 87 infants who underwent surgical repair of CoA-AAH from January 2004 to December 2015. Patients with functional single ventricle were excluded. There were no early mortalities, and 4 patients (4.6%) experienced early complications. Eighty-five patients (97.7%) were followed up during a mean duration of 6.1 ± 3.53 years. There were 2 late mortalities (2.3%) and 3 reintervention (3.5%) of the aortic arch. Ten-year overall survival and freedom from reintervention for the entire cohort was 97.7% and 96.3%, respectively. At last follow-up, 4 patients (4.5%) showed a peak velocity greater than 2.5 m/s across the repair site. Seven patients (8.2%) were hypertensive. Our strategy with extended end-to-side anastomosis under selective cerebral and myocardial perfusion is safe and effective for repairing CoA-AAH in neonates and infants. Concomitant repair of associated cardiac anomalies can be done without added risk. Mid-term results are excellent with low rates of mortality, reintervention, and late hypertension.
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Affiliation(s)
- Eung Re Kim
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Children's Hospital, Seoul, Republic of Korea
| | - Woong-Han Kim
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Children's Hospital, Seoul, Republic of Korea.
| | - Jinhae Nam
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Children's Hospital, Seoul, Republic of Korea
| | - Kwangho Choi
- Department of Thoracic and Cardiovascular Surgery, Pusan National University Yangsan Hospital, Pusan, Republic of Korea
| | - Woo Sung Jang
- Department of Thoracic and Cardiovascular Surgery, Keimyung University Dongsan Medical Center, Daegu, Republic of Korea
| | - Jae Gun Kwak
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Children's Hospital, Seoul, Republic of Korea
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Gupta B, Dodge-Khatami A, Tucker J, Taylor MB, Maposa D, Urencio M, Salazar JD. Antegrade cerebral perfusion at 25 °C for arch reconstruction in newborns and children preserves perioperative cerebral oxygenation and serum creatinine. Transl Pediatr 2016; 5:114-124. [PMID: 27709092 PMCID: PMC5035759 DOI: 10.21037/tp.2016.06.03] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Antegrade cerebral perfusion (ACP) typically is used with deep hypothermia for cerebral protection during aortic arch reconstructions. The impact of ACP on cerebral oxygenation and serum creatinine at a more tepid 25 °C was studied in newborns and children. METHODS Between 2010 and 2014, 61 newborns and children (<5 years old) underwent aortic arch reconstruction using moderate hypothermia (25.0±0.9 °C) with ACP and a pH-stat blood gas management strategy. These included 44% Norwood-type operations, 30% isolated arch reconstructions, and 26% arch reconstructions with other major procedures. Median patient age at surgery was 9 days (range, 3 days-4.7 years). Cerebral oxygenation (NIRS) was monitored continuously perioperatively for 120 hours. Serum creatinine was monitored daily. RESULTS Median cardiopulmonary bypass (CPB) and cross clamp times were 181 minutes (range, 82-652 minutes) and 72 minutes (range, 10-364 minutes), respectively. ACP was performed at a mean flow rate of 46±6 mL/min/kg for a median of 48 minutes (range, 10-123 minutes). Cerebral and somatic NIRS were preserved intraoperatively and remained at baseline postoperatively during the first 120 hours. Peak postoperative serum creatinine levels averaged 0.7±0.3 mg/dL for all patients. There were 4 (6.6%) discharge mortalities. Six patients (9.8%) required ECMO support. Median postoperative length of hospital and intensive care unit (ICU) stay were 16 days(range, 4-104 days) and 9 days (range, 1-104 days), respectively. Two patients (3.3%) received short-term peritoneal dialysis for fluid removal, and none required hemodialysis. Three patients (4.9%) had an isolated seizure which resolved with medical therapy, and none had a neurologic deficit or stroke. CONCLUSIONS ACP at 25 °C preserved perioperative cerebral oxygenation and serum creatinine for newborns and children undergoing arch reconstruction. Early outcomes are encouraging, and additional study is warranted to assess the impact on late outcomes.
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Affiliation(s)
- Bhawna Gupta
- Division of Cardiothoracic Surgery, The Children's Heart Center, The University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Ali Dodge-Khatami
- Division of Cardiothoracic Surgery, The Children's Heart Center, The University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Juan Tucker
- Division of Cardiothoracic Surgery, The Children's Heart Center, The University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Mary B Taylor
- Divisions of Pediatric Critical Care and Pediatric Cardiology, The Children's Heart Center, The University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Douglas Maposa
- Division of Pediatric Anesthesiology, The Children's Heart Center, The University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Miguel Urencio
- Division of Cardiothoracic Surgery, The Children's Heart Center, The University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Jorge D Salazar
- Division of Cardiothoracic Surgery, The Children's Heart Center, The University of Mississippi Medical Center, Jackson, Mississippi, USA
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Janssen C, Kellermann S, Münch F, Purbojo A, Cesnjevar RA, Rüffer A. Myocardial Protection During Aortic Arch Repair in a Piglet Model: Beating Heart Technique Compared With Crystalloid Cardioplegia. Ann Thorac Surg 2015; 100:1758-66. [DOI: 10.1016/j.athoracsur.2015.06.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Revised: 05/19/2015] [Accepted: 06/01/2015] [Indexed: 11/26/2022]
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Continuous cerebral and myocardial perfusion during one-stage repair for aortic coarctation with ventricular septal defect. Pediatr Cardiol 2013; 34:872-9. [PMID: 23132178 DOI: 10.1007/s00246-012-0561-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2012] [Accepted: 10/11/2012] [Indexed: 10/27/2022]
Abstract
Controversy still exists concerning the use of deep hypothermic circulatory arrest (DHCA) and selective antegrade cerebral perfusion (SACP) for repair of aortic coarctation (CoA) with ventricular septal defect (VSD). This report therefore describes outcomes of patients undergoing continuous cerebral and myocardial perfusion (CCMP) under mild hypothermia compared with DHCA and SACP. Retrospective analysis was performed for 110 consecutive patients undergoing anatomic reconstruction of CoA with VSD closure between 1999 and 2011. Patients repaired under CCMP with mild hypothermia (32 °C) (group A, n = 60) were compared with those repaired under DHCA (18 °C) and SACP (group B, n = 50). In group A, the single arterial cannula perfusion technique was used for 15 patients (25 %), and the dual arterial cannula perfusion technique was used for 45 patients (75 %). The preoperative data were similar in the two groups. Group A had no hospital mortalities, compared with two mortalities (4 %) in group B. Group A had shorter myocardial ischemic and cardiopulmonary times, fewer delayed sternal closures, a shorter time to extubation, lower postoperative lactate levels, and fewer patients with low cardiac output requiring extracorporeal membrane oxygenation or with multiorgan failure than group B. During the postoperative course, no clinical or electrical neurologic events occurred in either group. The mean follow-up period was 5.2 ± 3.2 years for group A and 7.5 ± 3.1 years for group B (P = 0.048). One late death occurred in group B and no late deaths in group A. The actuarial survival for the two groups was similar (100 % for group A vs 96 % for group B; P = 0.264). The freedom from all types of cardiac reintervention was 96.7 % in group A and 89.6 % in group B (P = 0.688). All the patients were free of neurologic symptoms. The authors' perfusion strategy using CCMP with mild hypothermia for repair of CoA with VSD is feasible, safe, and associated with improved postoperative recovery and should be the method of choice.
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Chen H, Zhang H, Hong H, Zhu Z, Liu J. Outcome of continuous cerebral and myocardial perfusion under mild hypothermia for aortic coarctation with ventricular septal defect repair. J Card Surg 2013; 28:64-9. [PMID: 23330580 DOI: 10.1111/jocs.12046] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2012] [Revised: 10/17/2012] [Accepted: 10/22/2012] [Indexed: 11/27/2022]
Abstract
BACKGROUND Controversy still exists on the use of the optimal cardiopulmonary bypass (CPB) management in aortic coarctation (CoA) with ventricular septal defect (VSD) repair. We report the outcome of patients undergoing continuous cerebral and myocardial perfusion (CCMP) under mild hypothermia. METHOD This is a retrospective analysis of 60 consecutive patients undergoing anatomic reconstruction of CoA with VSD closure between 1999 and 2011. Single arterial cannula perfusion technique was used in 15 (25%) patients, and a dual arterial cannula perfusion technique was used in 45 (75%) patients. RESULTS There were no hospital or late mortalities. Average CPB time was 105 ± 28 minutes, aortic clamp 27 ± 7 minutes, and descending aortic cross-clamp time 24 ± 5 minutes. Average continuous cerebral perfusion flow was 64 ± 8 mL/kg per minute. No patient needed delayed sternal closure. Average duration of ventilation was 38 ± 20 hours, ICU stay 7 ± 3 days, and hospital stay 14 ± 6 days. No patient required revision for bleeding and/or extracorporeal membrane oxygenation support. No neurologic complications were noted. CONCLUSION A perfusion strategy using CCMP with mild hypothermia for CoA and VSD repair is feasible and safe.
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Affiliation(s)
- Huiwen Chen
- Department of Cardiothoracic Surgery, Heart Center, Shanghai Children’s Medical Center, School of Medicine, Shanghai Jiaotong University, Shanghai, China
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Langley SM, Sunstrom RE, Reed RD, Rekito AJ, Gerrah R. The neonatal hypoplastic aortic arch: decisions and more decisions. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2013; 16:43-51. [PMID: 23561817 DOI: 10.1053/j.pcsu.2013.01.008] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Neonatal patients with hypoplasia of the aortic arch constitute a heterogeneous group with a wide spectrum of severity. The milder end of the spectrum comprises patients with aortic coarctation and isthmus hypoplasia. At the other end of the spectrum are patients with severe transverse arch hypoplasia or hypoplastic left heart syndrome. The aim of this paper is to discuss the various strategies and surgical approaches available for this group of patients, focusing on the surgical decisions that influence individual patient management. Many of the things discussed are applicable to any neonatal arch problem. We also describe and discuss in detail our surgical technique for patients who undergo neonatal repair of a hypoplastic aortic arch via median sternotomy.
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Affiliation(s)
- Stephen M Langley
- Section of Pediatric and Congenital Cardiac Surgery, Doernbecher Children’s Hospital, Oregon Health & Science University, Portland, OR 97239, USA.
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Retraction: Selective cerebro-myocardial perfusion under mild hypothermia during primary repair for aortic coarctation with ventricular septal defect. Artif Organs 2012; 37:418. [PMID: 23121259 DOI: 10.1111/j.1525-1594.2012.01545.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The following article from Artificial Organs, "Selective Cerebro-Myocardial Perfusion Under Mild Hypothermia During Primary Repair for Aortic Coarctation With Ventricular Septal Defect" by Huiwen Chen, Haifa Hong, Zhongqun Zhu and Jinfen Liu, published online on 2 November 2012 in Wiley Online Library (wileyonlinelibrary.com), has been retracted by agreement between the authors, the journal Editor-in-Chief, Paul S. Malchesky, the International Center for Artificial Organs and Transplantation and Wiley Periodicals, Inc. The retraction has been agreed due to simultaneous publication of a substantially similar article, "Continuous Cerebral and Myocardial Perfusion During One-Stage Repair for Aortic Coarctation With Ventricular Septal Defect", by Huiwen Chen, Haifa Hong, Zhongqun Zhu and Jinfen Liu, in Pediatric Cardiology 7 November 2012 [Epub ahead of print].
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Ji B, Liu J, Wang X, Long C. Combined cerebral and myocardial perfusion in aortic arch reconstruction for pediatric patients. Artif Organs 2012; 36:324-5; author reply 325. [PMID: 22375798 DOI: 10.1111/j.1525-1594.2011.01432.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Luciani GB, De Rita F, Menon T. Reply to Ji and Associates. Artif Organs 2012. [DOI: 10.1111/j.1525-1594.2012.01439.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Luciani GB, De Rita F, Faggian G, Mazzucco A. An alternative method for neonatal cerebro-myocardial perfusion. Interact Cardiovasc Thorac Surg 2012; 14:645-7. [PMID: 22307393 DOI: 10.1093/icvts/ivr152] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Several techniques have already been described for selective cerebral perfusion during repair of aortic arch pathology in children. One method combining cerebral with myocardial perfusion has also been proposed. A novel technique is reported here for selective and independent cerebro-myocardial perfusion for neonatal and infant arch surgery. Technical aspects and potential advantages are discussed.
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De Rita F, Lucchese G, Barozzi L, Menon T, Faggian G, Mazzucco A, Luciani GB. Selective cerebro-myocardial perfusion in complex congenital aortic arch pathology: a novel technique. Artif Organs 2011; 35:1029-35. [PMID: 21995675 DOI: 10.1111/j.1525-1594.2011.01355.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Simultaneous cerebro-myocardial perfusion has been described in neonatal and infant arch surgery, suggesting a reduction in cardiac morbidity. Here reported is a novel technique for selective cerebral perfusion combined with controlled and independent myocardial perfusion during surgery for complex or recurrent aortic arch lesions. From April 2008 to April 2011, 10 patients with arch pathology underwent surgery (two hypoplastic left heart syndrome [HLHS], four recurrent arch obstruction, two aortic arch hypoplasia + ventricular septal defect [VSD], one single ventricle + transposition of the great arteries + arch hypoplasia, one interrupted aortic arch type B + VSD). Median age was 63 days (6 days-36 years) and median weight 4.0 kg (1.6-52). Via midline sternotomy, an arterial cannula (6 or 8 Fr for infants) was directly inserted into the innominate artery or through a polytetrafluoroethylene (PTFE) graft (for neonates <2.0 kg). A cardioplegia delivery system was inserted into the aortic root. Under moderate hypothermia, ascending and descending aorta were cross-clamped, and "beating heart and brain" aortic arch repair was performed. Arch repair was composed of patch augmentation in five, end-to-side anastomosis in three, and replacement in two patients. Average cardiopulmonary bypass time was 163 ± 68 min (71-310). In two patients only (one HLHS, one complex single ventricle), a period of cardiac arrest was required to complete intracardiac repair. In such cases, antegrade blood cardioplegia was delivered directly via the same catheter used for selective myocardial perfusion. Average time of splanchnic ischemia during cerebro-myocardial perfusion was 39 ± 18 min (17-69). Weaning from cardiopulmonary bypass was achieved without inotropic support in three and with low dose in seven patients. One patient required veno-arterial extracorporeal membrane oxygenation. Four patients, body weight <3.0 kg, needed delayed sternal closure. No neurologic dysfunction was noted. Renal function proved satisfactory in all, while liver function was adequate in all but one. The present experience suggests that selective and independent cerebro-myocardial perfusion is feasible in patients with complex or recurrent aortic arch disease, starting from premature newborn less than 2.0 kg of body weight to adults. The technique is as safe as previously reported methods of cerebro-myocardial perfusion and possibly more versatile.
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Affiliation(s)
- Fabrizio De Rita
- Division of Cardiac Surgery, University of Verona, Verona, Italy
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Is Regional High-Flow Perfusion Safe for Cerebral Function in Pediatric Patients During Deep Hyperthermia? Ann Thorac Surg 2011; 91:1650-1. [DOI: 10.1016/j.athoracsur.2010.12.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2010] [Revised: 11/01/2010] [Accepted: 12/09/2010] [Indexed: 11/19/2022]
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Invited Commentary. Ann Thorac Surg 2010; 90:57. [DOI: 10.1016/j.athoracsur.2010.04.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2010] [Revised: 04/04/2010] [Accepted: 04/13/2010] [Indexed: 11/21/2022]
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