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Sweeney JC, Trivedi JR, Endo T, Ankem A, Pahwa SV, Slaughter MS, Ganzel BL. Cannula Placement for Cerebral Protection Without Circulatory Arrest in Patients Undergoing Hemiarch Aortic Aneurysm Repair. Tex Heart Inst J 2024; 51:e228026. [PMID: 38345901 DOI: 10.14503/thij-22-8026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2024]
Abstract
BACKGROUND Aortic aneurysms involving the proximal aortic arch, which require hemiarch-type repair, typically require circulatory arrest with antegrade cerebral perfusion. Left carotid antegrade cerebral perfusion (LCP) via distal arch cannulation without circulatory arrest was used in this study's patient population. The goal was to assess the operative efficiency and clinical outcomes of using a distal arch cannulation technique that would not require any hypothermic circulatory arrest (HCA) time compared with more traditional brachiocephalic artery cannulation with right-sided unilateral antegrade cerebral perfusion (RCP) and HCA. METHODS A single-center retrospective review of patients with replacement of the distal ascending aorta involving the proximal arch was performed. Patients with an intramural hematoma or dissection were excluded. Between January 2015 and December 2019, 68 adult patients had undergone a hemiarch repair because of aneurysmal disease. Analysis of baseline demographics, operative data, and clinical outcomes was performed. RESULTS Comparing the 68 patients: 21 patients were treated with RCP (via brachiocephalic artery graft with HCA), and 47 patients were treated with LCP (via distal aortic arch cannulation with cross-clamp between the brachiocephalic and left common carotid arteries without HCA). Baseline characteristics and outcomes were evaluated for both groups. The LCP group was younger (LCP median [IQR] age, 60 [53-65] years vs RCP median [IQR] age, 67 [59-71] years]. Sex, race, body mass index, comorbidities, and ejection fraction were similar between the groups. Cardiopulmonary bypass time (LCP, 123 minutes vs RCP, 149 minutes) and unilateral cerebral perfusion time (LCP, 17 minutes vs RCP, 22 minutes) were longer in the RCP group. Bleeding, prolonged ventilatory support, kidney failure, and length of stay were similar. In-hospital mortality was 2% in the LCP group vs 0% in the RCP group. Stroke occurred in 2 patients (4.2%) in the LCP group and in 0% of the RCP group. Mortality at 6 months in the LCP and RCP groups was 3% and 10%, respectively. CONCLUSION Distal arch cannulation with LCP without HCA is a reasonable and safe alternative strategy for patients requiring hemiarch replacement for aneurysmal disease. This technique may provide additional benefits by avoiding circulatory arrest in these complex cases.
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Affiliation(s)
- Joseph C Sweeney
- Department of General Surgery, University of Louisville, Louisville, Kentucky
| | - Jaimin R Trivedi
- Department of Cardiovascular and Thoracic Surgery, University of Louisville, Louisville, Kentucky
| | - Toyokazu Endo
- Department of General Surgery, University of Louisville, Louisville, Kentucky
| | - Akhila Ankem
- School of Medicine, University of Louisville, Louisville, Kentucky
| | - Siddharth V Pahwa
- Department of Cardiovascular and Thoracic Surgery, University of Louisville, Louisville, Kentucky
| | - Mark S Slaughter
- Department of Cardiovascular and Thoracic Surgery, University of Louisville, Louisville, Kentucky
| | - Brian L Ganzel
- Department of Cardiovascular and Thoracic Surgery, University of Louisville, Louisville, Kentucky
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Ibekwe SO, Mondal S. "Right vs Right"-Respect Patient's Rights or Do the Right Course of Treatment: A Commentary Surrounding a Patient's Refusal of Emergent Aortic Surgery. J Cardiothorac Vasc Anesth 2024; 38:549-551. [PMID: 38071147 DOI: 10.1053/j.jvca.2023.11.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 11/03/2023] [Indexed: 01/27/2024]
Affiliation(s)
| | - Samhati Mondal
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD
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3
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Cuko B, Pernot M, Busuttil O, Baudo M, Rosati F, Taymoor S, Modine T, Labrousse L. Frozen elephant trunk technique for aortic arch surgery: the Bordeaux University Hospital experience with Thoraflex hybrid prosthesis. THE JOURNAL OF CARDIOVASCULAR SURGERY 2023; 64:668-677. [PMID: 37335280 DOI: 10.23736/s0021-9509.23.12706-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/21/2023]
Abstract
BACKGROUND Aortic arch surgery still represents a challenge, and the frozen elephant trunk (FET) allows a one-step surgery for complex aortic diseases. The aim of the study was to analyze the results of patients undergoing FET procedure for aortic arch surgery at Bordeaux University Hospital. METHODS Patients undergoing FET procedure for multisegmented aortic arch pathologies were analyzed in this single-center retrospective study. Further subgroup analyses were performed according to the degree of urgency of the operation (elective versus emergent surgery) and cerebral protection technique: bilateral selective antegrade cerebral perfusion (B-SACP) versus the unilateral one (U-SACP), regardless of the degree of urgency. RESULTS From August 2018 to August 2022, 77 consecutive patients (64.1±9.9 years, 54 males) were enrolled: 43 (55.8%) for elective surgery and 34 (44.2%) in emergency. Technical success was 100%. 30-day mortality was 15.6% (N.=12, 7% elective vs. 26.5% emergent, P=0.043). Six (7.8%) non-disabling strokes occurred (1.9% B-SACP vs. 20% U-SACP, P=0.021). Median follow-up was 1.11 years (interquartile range, 0.62-2.07). The 1-year overall survival was 81.6±4.45%. The elective group showed a survival trend when compared to the emergency one (P=0.054). However, further examination at landmark analysis elective surgery showed a better survival trend compared to emergency surgery up to 1.78 years (P=0.034), after which significance was lost (P=0.521). CONCLUSIONS Thoraflex hybrid prosthesis for FET technique demonstrated feasibility and satisfactory short-term clinical outcomes, even in emergent settings. In our practice B-SACP seems to offer better protection and less neurological complications compared to U-SACP, nevertheless further analyses are warranted.
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Affiliation(s)
- Besart Cuko
- Department of Cardiology and Cardio-Vascular Surgery, Hopital Cardiologique de Haut-Leveque, University Hospital of Bordeaux, Bordeaux, France -
| | - Mathieu Pernot
- Department of Cardiology and Cardio-Vascular Surgery, Hopital Cardiologique de Haut-Leveque, University Hospital of Bordeaux, Bordeaux, France
| | - Olivier Busuttil
- Department of Cardiology and Cardio-Vascular Surgery, Hopital Cardiologique de Haut-Leveque, University Hospital of Bordeaux, Bordeaux, France
| | - Massimo Baudo
- Department of Cardiac Surgery, ASST Spedali Civili di Brescia, University of Brescia, Brescia, Italy
| | - Fabrizio Rosati
- Department of Cardiac Surgery, ASST Spedali Civili di Brescia, University of Brescia, Brescia, Italy
| | - Saud Taymoor
- Department of Cardiology and Cardio-Vascular Surgery, Hopital Cardiologique de Haut-Leveque, University Hospital of Bordeaux, Bordeaux, France
| | - Thomas Modine
- Department of Cardiology and Cardio-Vascular Surgery, Hopital Cardiologique de Haut-Leveque, University Hospital of Bordeaux, Bordeaux, France
| | - Louis Labrousse
- Department of Cardiology and Cardio-Vascular Surgery, Hopital Cardiologique de Haut-Leveque, University Hospital of Bordeaux, Bordeaux, France
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Kim TH, Oh J, Lee H, Kim MS, Sim SA, Min S, Song SW, Kim JJ. The impact of circulatory arrest with selective antegrade cerebral perfusion on brain functional connectivity and postoperative cognitive function. Sci Rep 2023; 13:13803. [PMID: 37612347 PMCID: PMC10447502 DOI: 10.1038/s41598-023-40726-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 08/16/2023] [Indexed: 08/25/2023] Open
Abstract
Aortic surgery is one of the most challenging types of surgeries, which is possibly related to cognitive sequelae. We aimed to investigate the changes in resting-state functional connectivity (rsFC) associated with intraoperative circulatory arrest (CA) in aortic surgery, exploring the relationship between the altered connectivity and postoperative cognitive functions. Thirty-eight patients participated in this study (14 with CA, 24 without). Functional magnetic resonance imaging was scanned on the fifth day after surgery or after the resolution of delirium if it was developed. We assessed the differences in the development of postoperative cognitive changes and rsFC between patients with and without CA. The occurrence of postoperative delirium and postoperative cognitive dysfunction was not significantly different between the patients with and without the application of CA. However, patients with CA showed increased in posterior cingulate cortex-based connectivity with the right superior temporal gyrus, right precuneus, and right hippocampus, and medial prefrontal cortex-based connectivity with the dorsolateral prefrontal cortex. The application of moderate hypothermic CA with unilateral antegrade cerebral perfusion is unlikely to affect aspects of postoperative cognitive changes, whereas it may lead to increased rsFC of the default mode network at a subclinical level following acute brain insults.
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Affiliation(s)
- Tae-Hoon Kim
- Department of Cardiovascular Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jooyoung Oh
- Department of Psychiatry, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
- Institute of Behavioral Sciences in Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Ha Lee
- Department of Cardiovascular Surgery, Ewha Womans University Aorta and Vascular Hospital, Seoul, Republic of Korea
| | - Myeong Su Kim
- Department of Cardiovascular Surgery, Ewha Womans University Aorta and Vascular Hospital, Seoul, Republic of Korea
| | - Seo-A Sim
- Department of Cardiovascular Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sarang Min
- Institute of Behavioral Sciences in Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Suk-Won Song
- Department of Cardiovascular Surgery, Ewha Womans University Aorta and Vascular Hospital, Seoul, Republic of Korea.
| | - Jae-Jin Kim
- Department of Psychiatry, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea.
- Institute of Behavioral Sciences in Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea.
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5
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Ram E, Lau C, Dimagli A, Chu NQ, Soletti G, Gaudino M, Girardi LN. Short- and long-term results of total arch replacement: Comparison between island and debranching techniques. JTCVS Tech 2023; 20:10-19. [PMID: 37555035 PMCID: PMC10405193 DOI: 10.1016/j.xjtc.2023.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 04/28/2023] [Accepted: 05/09/2023] [Indexed: 08/10/2023] Open
Abstract
OBJECTIVE The 2 most acceptable techniques for reimplantation of the supra-aortic vessels in total arch replacement include the branched graft technique (debranching) or en bloc technique (island). We aim to review our experience with total arch replacement and report short- and long-term outcomes from a high-volume center dedicated to surgery for the thoracic aorta. METHODS The aortic surgery database was queried to identify all consecutive patients undergoing total arch replacement between 1997 and 2022. Of the 426 patients who underwent total arch replacement, 303 (71%) received the island technique and 123 (29%) received the debranching approach. Operative and long-term outcomes were compared using multivariable models. RESULTS The debranching group was younger (64 ± 14 years vs 69 ± 12 years, P = .001), had undergone more previous cardiac operations (54.5% vs 27.4%, P < .001), and had more connective tissue disorder (20.3% vs 4.6%, P < .001). The debranching approach was associated with longer total circulatory arrest time (47 ± 15 minutes vs 37 ± 10 minutes, P < .001) and cardiac ischemic time (116 ± 41 minutes vs 100 ± 37 minutes, P < .001). More patients in the debranching group received blood products intraoperatively or postoperatively (56.1% vs 42.9%, P = .018). All other early outcomes did not differ between groups. Overall operative mortality was 1.4% (2.4% vs 1%, P = .486); the incidence of major postoperative complications was 6.3% (5.7% vs 6.6%, P = .897). Ten-year survival was 80% (78% vs 80.9%, log-rank P = .356). Multivariable Cox regression analysis demonstrated that neither surgical approach was associated with survival advantage (hazard ratio, 1.18; 0.73-1.89; P = .495). CONCLUSIONS Debranching requires a longer operative time, with similar early and long-term outcomes. Preoperative comorbidity, not surgical technique, predicts major adverse events and long-term survival.
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Affiliation(s)
- Eilon Ram
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Christopher Lau
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Arnaldo Dimagli
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Ngoc-Quynh Chu
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Giovanni Soletti
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Leonard N. Girardi
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
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Cui Y, Liu X, Xiong J, Tan Z, Du L, Lin J. Cardiopulmonary bypass for total aortic arch replacement surgery: A review of three techniques. Front Cardiovasc Med 2023; 10:1109401. [PMID: 37063959 PMCID: PMC10098116 DOI: 10.3389/fcvm.2023.1109401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Accepted: 03/09/2023] [Indexed: 03/31/2023] Open
Abstract
One treatment for acute type A aortic dissection is to replace the ascending aorta and aortic arch with a graft during circulatory arrest of the lower body, but this is associated with high mortality and morbidity. Maintaining the balance between oxygen supply and demand during circulatory arrest is the key to reducing morbidity and is the primary challenge during body perfusion. The aim of this review is to summarize current knowledge of body perfusion techniques and to predict future development of this field. We present three perfusion techniques based on deep hypothermic circulatory arrest (DHCA): DHCA alone, DHCA with selective cerebral perfusion, and DHCA with total body perfusion. DHCA was first developed to provide a clear surgical field, but it may contribute to stroke in 4%–15% of patients. Antegrade or retrograde cerebral perfusion can provide blood flow for the brain during circulatory arrest, and it is associated with much lower stroke incidence of 3%–9%. Antegrade cerebral perfusion may be better than retrograde perfusion during longer arrest. In theory, blood flow can be provided to all vital organs through total body perfusion, which can be implemented via either arterial or venous systems, or by combining retrograde inferior vena caval perfusion with antegrade cerebral perfusion. However, whether total body perfusion is better than other techniques require further investigation in large, multicenter studies. Current techniques for perfusion during circulatory arrest remain imperfect, and a technique that effectively perfuses the upper and lower body effectively during circulatory arrest is missing. Total body perfusion should be systematically compared against selective cerebral perfusion for improving outcomes after circulatory arrest.
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7
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Rapid cooling is a safe technique in patients undergoing circulatory arrest for aortic repair. JTCVS Tech 2022; 16:1-7. [PMID: 36510530 PMCID: PMC9737039 DOI: 10.1016/j.xjtc.2022.09.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 09/13/2022] [Accepted: 09/27/2022] [Indexed: 11/06/2022] Open
Abstract
Objective To evaluate our institutional experience with rapid cooling for hypothermic circulatory arrest in proximal aortic repair. Methods We retrospectively reviewed data from 2171 patients who underwent proximal aortic surgery requiring hypothermic circulatory arrest between 1991 and 2020. Cooling times were divided into quartiles and clinical outcome event rates were compared across quartiles using contingency table methods. Incremental effect of cooling time was assessed in the context of other perfusion time variables using multiple logistic regression analysis. Results Median age was 61 years (interquartile range, 49-70 years) and 34.1% of patients were women. The procedure was emergent in 33.5% of patients, 22.9% had a previous sternotomy. The median circulatory arrest time was 22 minutes, with retrograde cerebral perfusion used in 94% of cases. Median cardiopulmonary bypass time was 149 minutes, with an aortic crossclamp time of 90 minutes. Patients were cooled to deep hypothermia. The first quartile had cooling times ranging from 5 to 13 minutes, second 14 to 18 minutes, third 19-23 minutes, and fourth 24-81 minutes. Overall, 30-day mortality was 9.4%, and was not significantly different across quartiles. There was a statistically significant trend toward lower rates of postoperative encephalopathy, gastrointestinal complications, and respiratory failure with shorter cooling times (P < .001, .006, and < .001, respectively). There was no significant difference in rates of postoperative stroke or dialysis. Conclusions Rapid cooling can be performed safely in patients undergoing aortic surgery requiring circulatory arrest without increasing mortality or stroke. There were significantly lower rates of coagulopathy, respiratory failure, and postoperative encephalopathy with shorter cooling times.
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8
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Demal TJ, Sitzmann FW, Bax L, von Kodolitsch Y, Brickwedel J, Konertz J, Gaekel DM, Sadeq AJ, Kölbel T, Vettorazzi E, Reichenspurner H, Detter C. Risk factors for impaired neurological outcome after thoracic aortic surgery. J Thorac Dis 2022; 14:1840-1853. [PMID: 35813705 PMCID: PMC9264055 DOI: 10.21037/jtd-21-1591] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 03/17/2022] [Indexed: 11/06/2022]
Abstract
Background We aimed to identify risk factors for an impaired postoperative neurological outcome after thoracic aortic surgery. Methods Data from all patients undergoing thoracic aortic surgery between 2010 and 2020 at our institution were collected and analyzed retrospectively. Logistic regression analysis was used to identify independent risk factors for permanent postoperative neurological deficit (ND) (stroke), which was defined as a ND lasting at least seven days. Results Thoracic aortic surgery was performed in 1,334 patients. Of these, 286 (21.4%) underwent emergency surgery. The mean EuroSCORE II was 8.6±10.1. A perioperative stroke occurred in 94 patients (7.0%). Of all strokes, 62.8% (n=59) were considered of embolic and 24.5% (n=23) of hemodynamic origin. In elective procedures, stroke rates ranged from 0.5% after valve-sparing root replacement to 8.1% after arch surgery. Adjusted logistic regression identified advanced age [>70 years; odds ratio (OR), 1.83; P=0.009], acute type A dissection (ATAD) (OR, 1.69; P=0.0495), aortic arch surgery (OR, 3.24; P<0.001), concomitant coronary artery bypass grafting (CABG) (OR, 2.19; P=0.005), and high extracorporeal circulation (ECC) time (>230 min; OR, 1.70; P=0.034) as independent risk factors for all strokes. Secondary endpoint analyses revealed that risk factors for hemodynamic stroke were arch surgery, advanced age (>70 years), atherosclerosis, and ATAD. Risk factors for embolic stroke were arch surgery, concomitant CABG and preoperative cerebral malperfusion. Conclusions Identified independent risk factors for all strokes were advanced age, ATAD, arch surgery, concomitant CABG, and high ECC time. Hemodynamic and embolic strokes show distinct risk profiles.
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Affiliation(s)
- Till J Demal
- Department of Cardiovascular Surgery, German Aortic Center Hamburg, University Heart Center Hamburg, Hamburg, Germany
| | - Franziska W Sitzmann
- Department of Cardiovascular Surgery, German Aortic Center Hamburg, University Heart Center Hamburg, Hamburg, Germany
| | - Lennart Bax
- Department of Cardiovascular Surgery, German Aortic Center Hamburg, University Heart Center Hamburg, Hamburg, Germany
| | - Yskert von Kodolitsch
- Department of Vascular Medicine, German Aortic Center Hamburg, University Heart Center Hamburg, Hamburg, Germany
| | - Jens Brickwedel
- Department of Cardiovascular Surgery, German Aortic Center Hamburg, University Heart Center Hamburg, Hamburg, Germany
| | - Johanna Konertz
- Department of Cardiovascular Surgery, German Aortic Center Hamburg, University Heart Center Hamburg, Hamburg, Germany
| | - Daniel M Gaekel
- Department of Cardiovascular Surgery, German Aortic Center Hamburg, University Heart Center Hamburg, Hamburg, Germany
| | - Ahmed J Sadeq
- Department of Cardiovascular Surgery, German Aortic Center Hamburg, University Heart Center Hamburg, Hamburg, Germany
| | - Tilo Kölbel
- Department of Vascular Medicine, German Aortic Center Hamburg, University Heart Center Hamburg, Hamburg, Germany
| | - Eik Vettorazzi
- Department of Medical Biometry and Epidemiology, University Hospital Eppendorf, Hamburg, Germany
| | - Hermann Reichenspurner
- Department of Cardiovascular Surgery, German Aortic Center Hamburg, University Heart Center Hamburg, Hamburg, Germany
| | - Christian Detter
- Department of Cardiovascular Surgery, German Aortic Center Hamburg, University Heart Center Hamburg, Hamburg, Germany
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9
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Sule J, Chua CR, Teo C, Choong A, Sazzad F, Kofidis T, Sorokin V. Hybrid type II and frozen elephant trunk in acute Stanford type A aortic dissections. SCAND CARDIOVASC J 2022; 56:91-99. [PMID: 35546567 DOI: 10.1080/14017431.2022.2074095] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Objectives. Composite frozen elephant trunk is an increasingly popular solution for complex aortic pathologies. This review aims to compare outcomes of zone 0 type II hybrid (hybrid II) with the composite frozen elephant trunk (FET) technique in managing acute Stanford type A aortic dissections. Methods. PubMed and Embase were systematically searched using PRISMA protocol. 11 relevant studies describing the outcomes of hybrid II arch repair and FET techniques in patients with type A aortic dissection were included in the meta-analysis. The study focused on early post-operative 30-day outcomes analysing mortality, stroke, spinal cord injury, renal impairment requiring dialysis, bleeding and lung infection. Results. 1305 patients were included in the analysis - 343 receiving hybrid II repair and 962 treated with the FET. Meta-analysis of proportions showed Hybrid II was associated with less early mortality [5.0 (CI 3.1-7.8) vs 8.1 (CI 6.5-10.0) %], stroke [2.3 (CI 1.1-4.6) vs 7.0 (CI 5.5-8.8) %], spinal cord injury [2.0 (CI 0.9-4.3) vs 3.8 (CI 2.8-5.3) %], renal impairment requiring dialysis [7.9 (CI 5.5-11.2) vs 11.8 (CI 9.8-14.0) %], reoperation for bleeding [3.9 (CI 1.8-8.4) vs 10.6 (CI 8.1-13.8) %] and lung infection [14.8 (CI 10.8-20.0) vs 20.7 (CI 16.9-25.1) %]. Conclusion. Hybrid II should be considered in favour of FET technique in acute Stanford type A dissection patients who are at higher risk due to age and comorbidities.
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Affiliation(s)
- Jai Sule
- Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, National University Health System, Singapore
| | - Cher Rui Chua
- Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Caven Teo
- Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Andrew Choong
- Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, National University Health System, Singapore.,Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Faizus Sazzad
- Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Theo Kofidis
- Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, National University Health System, Singapore.,Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Vitaly Sorokin
- Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, National University Health System, Singapore.,Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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10
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Patel PM, Chen EPC. Optimal brain protection in aortic arch surgery. Indian J Thorac Cardiovasc Surg 2022; 38:36-43. [PMID: 35463699 PMCID: PMC8980966 DOI: 10.1007/s12055-021-01212-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 05/03/2021] [Accepted: 05/05/2021] [Indexed: 10/20/2022] Open
Abstract
There is considerable debate with regard to the optimal cerebral protection strategy during aortic arch surgery. There are three contemporary techniques in use which include straight deep hypothermic circulatory arrest (DHCA), DHCA with retrograde cerebral perfusion (DHCA + RCP), and moderate hypothermic circulatory arrest with antegrade cerebral perfusion (MHCA + ACP). Appropriate application of these methods ensures appropriate cerebral, myocardial, and visceral protection. Each of these techniques has benefits and drawbacks and ensuring coordinated circulation management strategy is critical to safe performance of aortic arch surgery. In this report, we will review various cannulation strategies, review logistics of hypothermia, and review the relevant literature to outline the strengths and weaknesses of these various cerebral protection strategies.
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López Gómez A, Rodríguez R, Zebdi N, Ríos Barrera R, Forteza A, Legarra Calderón JJ, Garrido Martín P, Hernando B, Sanjuan A, González Bardanca S, Varela Martínez MÁ, Fernández FE, Llorens R, Valera Martínez FJ, Gómez Felices A, Aranda Granados PJ, Sádaba Sagredo R, Echevarría JR, Vicente Guillén R, Silva Guisasola J. Anaesthetic-surgical guide in the treatment of ascending aorta and surgery of the ascending aorta and aortic arch. Consensus document of the Spanish Society of Cardiovascular and Endovascular Surgery and the Sociedad of Anaesthesiology, Resuscitation and Pain Therapy. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2022; 69:143-178. [PMID: 35288050 DOI: 10.1016/j.redare.2021.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 02/09/2021] [Indexed: 06/14/2023]
Abstract
Aortic pathology is always a challenge for the clinician, and must be diagnosed and treated by a multidisciplinary team due to the technical and technological complexity of the resources used. Ongoing efforts to implement a systematic, protocolized approach involving "Aortic teams" made up of cardiologists, cardiac surgeons, vascular surgeons, anaesthesiologists and radiologists, among others are now leading to improved outcomes. The aim of this consensus document drawn up by the Aortic working groups of the Spanish Society of Anaesthesiology, Resuscitation and Pain Therapy (SEDAR) and the Spanish Society of Thoracic and Cardiovascular Surgery (SECTCV) is to disseminate a set of working protocols. The latest consensus document of the European Association for Cardio-Thoracic Surgery (EACTS) and the European Society for Vascular Surgery (ESVS) define the concept of "AORTIC TEAM"(1). The aortic team should be closely involved from diagnosis to treatment and finally follow-up, and should be formed of cardiac and vascular surgeons working together with anaesthesiologists, cardiologists, radiologists and geneticists. Treatment of aortic pathologies should be centralised in large centres, because this is the only way to effectively understand the natural course of the disease, provide the entire range of treatment options under one umbrella and treat potential complications. A streamlined emergent care pathway (24/7 availability), adequate transportation and transfer capabilities, as well as rapid activation of the multidisciplinary team must be available. In light of the complexity and constant evolution of therapeutic options, we present this first version of the Anaesthesiology and surgical guidelines for surgery of the ascending aorta and aortic arch. Some questions will no doubt remain unanswered, and future versions will include new techniques that, though implemented in some centres, are still not widely recommended.
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Affiliation(s)
- A López Gómez
- Servicio de Anestesiología, Reanimación y Terapéutica del dolor, Hospital Universitario y Politécnico La Fe, Valencia, Spain.
| | - R Rodríguez
- Servicio de Cirugía Cardiaca, Hospital Universitario Vall d'Hebron, Barcelona, Spain
| | - N Zebdi
- Servicio de Anestesiología, Reanimación y Terapéutica del dolor, Hospital Universitario Vall d'Hebron, Barcelona, Spain
| | - R Ríos Barrera
- Servicio de Cirugía Cardiaca, Hospital Universitario Vall d'Hebron, Barcelona, Spain
| | - A Forteza
- Servicio de Cirugía Cardiaca, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain
| | | | - P Garrido Martín
- Servicio de Cirugía Cardiaca, Hospital Universitario de Canarias, San Cristobal de La Laguna, Spain
| | - B Hernando
- Servicio de Anestesiología, Reanimación y Terapéutica del dolor, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - A Sanjuan
- Servicio de Anestesiología, Reanimación y Terapéutica del dolor, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - S González Bardanca
- Servicio de Anestesiología, Reanimación y Terapéutica del dolor, Complejo Hospitalario Universitario de A Coruña, A Coruña, Spain
| | - M Á Varela Martínez
- Servicio de Anestesiología, Reanimación y Terapéutica del dolor, Hospital Álvaro Cunqueiro, Vigo, Spain
| | - F E Fernández
- Servicio de Anestesiología, Reanimación y Terapéutica del dolor, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - R Llorens
- Servicio de Cirugía Cardiaca, Hospital Hospiten Rambla, Tenerife, Spain
| | - F J Valera Martínez
- Servicio de Cirugía Cardiaca, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - A Gómez Felices
- Servicio de Anestesiología, Reanimación y Terapéutica del dolor, Hospital Universitario Vall d'Hebron, Barcelona, Spain
| | - P J Aranda Granados
- Servicio de Cirugía Cardiaca, Hospital Universitario Carlos Haya, Málaga, Spain
| | - R Sádaba Sagredo
- Servicio de Cirugía Cardiaca, Complejo Hospitalario de Navarra, Pamplona, Spain
| | - J R Echevarría
- Servicio de Cirugía Cardíaca, Hospital Universitario de Valladolid, Valladolid, Spain
| | - R Vicente Guillén
- Servicio de Anestesiología, Reanimación y Terapéutica del dolor, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - J Silva Guisasola
- Servicio de Cirugía Cardíaca, Hospital Universitario Central de Asturias, Oviedo, Spain
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12
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Manoly I, Uzzaman M, Karangelis D, Kuduvalli M, Georgakarakos E, Quarto C, Ravishankar R, Mitropoulos F, Nasir A. Neuroprotective strategies with circulatory arrest in open aortic surgery - A meta-analysis. Asian Cardiovasc Thorac Ann 2022; 30:635-644. [PMID: 35014877 PMCID: PMC9260478 DOI: 10.1177/02184923211069186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective Deep hypothermic circulatory arrest (DHCA) in aortic surgery is associated
with morbidity and mortality despite evolving strategies. With the advent of
antegrade cerebral perfusion (ACP), moderate hypothermic circulatory arrest
(MHCA) was reported to have better outcomes than DHCA. There is no
standardised guideline or consensus regarding the hypothermic strategies to
be employed in open aortic surgery. Meta-analysis was performed comparing
DHCA with MHCA + ACP in patients having aortic surgery. Methods A systematic review of the literature was undertaken. Any studies with DHCA
versus MHCA + ACP in aortic surgeries were selected according to specific
inclusion criteria and analysed to generate summative data. Statistical
analysis was performed using STATS Direct. The primary outcomes were
hospital mortality and post-operative stroke. Secondary outcomes were
cardiopulmonary bypass time (CPB), post-operative blood transfusion, length
of ICU stay, respiratory complications, renal failure and length of hospital
stay. Subgroup analysis of primary outcomes for Arch surgery alone was also
performed. Results Fifteen studies were included with a total of 5869 patients. There was
significantly reduced mortality (Pooled OR = +0.64, 95% CI = +0.49 to +0.83;
p = 0.0006) and stroke rate (Pooled OR = +0.62, 95%
CI = +0.49 to +0.79; p < 0.001) in the MHCA group. MHCA
was associated significantly with shorter CPB times, shorter duration in
ICU, less pulmonary complications, and reduced rates of sepsis. There was no
statistical difference between the two groups in terms of circulatory arrest
times, X-Clamp times, total operation duration, transfusion requirements,
renal failure and post-op hospital stay. Conclusion MHCA + ACP are associated with significantly better post-operative outcomes
compared with DHCA for both mortality and stroke and majority of the
secondary outcomes.
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Affiliation(s)
| | | | - Dimos Karangelis
- Department of Cardiac Surgery, Democritus University of Thrace, 69026University Hospital of Alexandroupolis, Alexandroupolis, Greece
| | | | - Efstratios Georgakarakos
- Department of Vascular Surgery, Democritus University of Thrace, University Hospital of Alexandroupolis, Alexandroupolis, Greece
| | | | | | | | - Abdul Nasir
- Peshawar Institute of Cardiology, Peshawar, Pakistan
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13
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Abjigitova D, Veen KM, van Tussenbroek G, Mokhles MM, Bekkers JA, Takkenberg JJM, Bogers AJJC. OUP accepted manuscript. Interact Cardiovasc Thorac Surg 2022; 35:6580224. [PMID: 35512204 PMCID: PMC9419700 DOI: 10.1093/icvts/ivac128] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 04/30/2022] [Indexed: 11/12/2022] Open
Abstract
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Consensus regarding optimal cerebral protection strategy in aortic arch surgery is lacking. We therefore performed a systematic review and meta-analysis to assess outcome differences between unilateral antegrade cerebral perfusion (ACP), bilateral ACP, retrograde cerebral perfusion (RCP) and deep hypothermic circulatory arrest (DHCA). A systematic literature search was performed in Embase, Medline, Web of Science, Cochrane and Google Scholar for all papers published till February 2021 reporting on early clinical outcome after aortic arch surgery utilizing either unilateral, bilateral ACP, RCP or DHCA. The primary outcome was operative mortality. Other key secondary endpoints were occurrence of postoperative disabling stroke, paraplegia, renal and respiratory failure. Pooled outcome risks were estimated using random-effects models. A total of 222 studies were included with a total of 43 720 patients. Pooled postoperative mortality in unilateral ACP group was 6.6% [95% confidence interval (CI) 5.3–8.1%], 9.1% (95% CI 7.9–10.4%), 7.8% (95% CI 5.6–10.7%), 9.2% (95% CI 6.7–12.7%) in bilateral ACP, RCP and DHCA groups, respectively. The incidence of postoperative disabling stroke was 4.8% (95% CI 3.8–6.1%) in the unilateral ACP group, 7.3% (95% CI 6.2–8.5%) in bilateral ACP, 6.4% (95% CI 4.4–9.1%) in RCP and 6.3% (95% CI 4.4–9.1%) in DHCA subgroups. The present meta-analysis summarizes the clinical outcomes of different cerebral protection techniques that have been used in clinical practice over the last decades. These outcomes may be used in advanced microsimulation model. These findings need to be placed in the context of the underlying aortic disease, the extent of the aortic disease and other comorbidities. Prospero registration number: CRD42021246372 METC: MEC-2019-0825
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Affiliation(s)
- Djamila Abjigitova
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
- Corresponding author. Department of Cardiothoracic Surgery, Erasmus University Medical Center, Room Rg-619, P.O. Box 2040, 3000 CA Rotterdam, Netherlands. Tel: +31 10 703 54 11; e-mail: (D. Abjigitova)
| | - Kevin M Veen
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | | | - Mostafa M Mokhles
- Department of Cardiothoracic Surgery, Utrecht University Medical Center, Utrecht, Netherlands
| | - Jos A Bekkers
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Johanna J M Takkenberg
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Ad J J C Bogers
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
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14
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Song J, Wu J, Sun X, Qian X, Wei B, Wang W, Wang D, Qiu J, Cao F, Gao W, Zhao R, Dai L, Fan S, Xie E, Qiu J, Luo X, Yu C. It Is Advisable to Control the Duration of Hypothermia Circulatory Arrest During Aortic Dissection Surgery: Single-Center Experience. Front Cardiovasc Med 2021; 8:773268. [PMID: 34957256 PMCID: PMC8702722 DOI: 10.3389/fcvm.2021.773268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Accepted: 11/02/2021] [Indexed: 11/13/2022] Open
Abstract
Objective: The duration of hypothermic circulatory arrest (HCA) is one of the important factors affecting the prognosis of arch surgery, which is still controversial. The purpose of this study was to investigate the effect of HCA duration on early prognosis in type A aortic dissection (TAAD) patients who underwent arch surgery in our center. Methods: All consecutive patients who underwent surgical treatment for TAAD in Fuwai Hospital from January 2013 to December 2018 were included in this study and divided into four quartile groups based on HCA time. Baseline characteristics, perioperative indicators, and early mortality were statistically analyzed by propensity score matching (PSM) and restricted cubic spline (RCS) method. Perioperative adverse events were confirmed according to the American STS database and Penn classification. Results: About 1,018 consecutive patients (mean age 49.11 ± 1.4 years, male 74.7%) with TAAD treated surgically were eventually included in this study. After PSM, with the prolongation of HCA time, the surgical mortality rates of group [2,15], (15,18], (18,22], and (22,73] were 4.1, 6.6, 7.8, and 10.9% with p = 0.041, respectively. As shown in RCS, the mortality rate increased sharply after the HCA time exceeded 22 min. And from the subgroup analysis, the HCA time of 22 min or less was associated with better clinical outcomes (OR 2.09, 95%CI 1.25–3.45, p = 0.004). Conclusions: The early mortality increases significantly with the duration of HCA time when arch surgery was performed. And multiple systems throughout the body can be adversely affected.
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Affiliation(s)
- Jian Song
- Department of Vascular Surgery, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jinlin Wu
- Department of Cardiac Surgery, Guangdong Provincial People's Hospital, Guangdong Cardiovascular Institute, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Xiaogang Sun
- Department of Vascular Surgery, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiangyang Qian
- Department of Vascular Surgery, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Bo Wei
- Department of Vascular Surgery, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wei Wang
- Department of Cardiac Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - De Wang
- Department of Vascular Surgery, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jiawei Qiu
- Department of Vascular Surgery, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Fangfang Cao
- Department of Intensive Care Unit, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wei Gao
- Department of Vascular Surgery, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Rui Zhao
- Department of Vascular Surgery, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lu Dai
- Department of Vascular Surgery, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shuya Fan
- Department of Vascular Surgery, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Enzehua Xie
- Department of Vascular Surgery, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Juntao Qiu
- Department of Vascular Surgery, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xinjin Luo
- Department of Cardiac Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Cuntao Yu
- Department of Vascular Surgery, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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15
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López Gómez A, Rodríguez R, Zebdi N, Ríos Barrera R, Forteza A, Legarra Calderón JJ, Garrido Martín P, Hernando B, Sanjuan A, González Bardanca S, Varela Martínez MÁ, Fernández FE, Llorens R, Valera Martínez FJ, Gómez Felices A, Aranda Granados PJ, Sádaba Sagredo R, Echevarría JR, Vicente Guillén R, Silva Guisasola J. Anaesthetic-surgical guide in the treatment of ascending aorta and surgery of the ascending aorta and aortic arch. Consensus document of the Spanish Society of Cardiovascular and Endovascular Surgery and the Sociedad of Anaesthesiology, Resuscitation and Pain Therapy. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2021; 69:S0034-9356(21)00104-3. [PMID: 34304902 DOI: 10.1016/j.redar.2021.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 11/03/2020] [Accepted: 02/09/2021] [Indexed: 10/20/2022]
Abstract
Aortic pathology is always a challenge for the clinician, and must be diagnosed and treated by a multidisciplinary team due to the technical and technological complexity of the resources used. Ongoing efforts to implement a systematic, protocolized approach involving "Aortic teams" made up of cardiologists, cardiac surgeons, vascular surgeons, anaesthesiologists and radiologists, among others are now leading to improved outcomes. The aim of this consensus document drawn up by the Aortic working groups of the Spanish Society of Anaesthesiology, Resuscitation and Pain Therapy (SEDAR) and the Spanish Society of Thoracic and Cardiovascular Surgery (SECTCV) is to disseminate a set of working protocols. The latest consensus document of the European Association for Cardio-Thoracic Surgery (EACTS) and the European Society for Vascular Surgery (ESVS) define the concept of "AORTIC TEAM"(1). The aortic team should be closely involved from diagnosis to treatment and finally follow-up, and should be formed of cardiac and vascular surgeons working together with anaesthesiologists, cardiologists, radiologists and geneticists. Treatment of aortic pathologies should be centralised in large centres, because this is the only way to effectively understand the natural course of the disease, provide the entire range of treatment options under one umbrella and treat potential complications. A streamlined emergent care pathway (24/7 availability), adequate transportation and transfer capabilities, as well as rapid activation of the multidisciplinary team must be available. In light of the complexity and constant evolution of therapeutic options, we present this first version of the Anaesthesiology and surgical guidelines for surgery of the ascending aorta and aortic arch. Some questions will no doubt remain unanswered, and future versions will include new techniques that, though implemented in some centres, are still not widely recommended.
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Affiliation(s)
- A López Gómez
- Servicio de Anestesiología, Reanimación y Terapéutica del dolor, Hospital Universitario y Politécnico La Fe, Valencia, España.
| | - R Rodríguez
- Servicio de Cirugía Cardiaca, Hospital Universitario Vall d'Hebron, Barcelona, España
| | - N Zebdi
- Servicio de Anestesiología, Reanimación y Terapéutica del dolor, Hospital Universitario Vall d'Hebron, Barcelona, España
| | - R Ríos Barrera
- Servicio de Cirugía Cardiaca, Hospital Universitario Vall d'Hebron, Barcelona, España
| | - A Forteza
- Servicio de Cirugía Cardiaca, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, España
| | | | - P Garrido Martín
- Servicio de Cirugía Cardiaca, Hospital Universitario de Canarias, San Cristobal de La Laguna, España
| | - B Hernando
- Servicio de Anestesiología, Reanimación y Terapéutica del dolor, Hospital Universitario Miguel Servet, Zaragoza, España
| | - A Sanjuan
- Servicio de Anestesiología, Reanimación y Terapéutica del dolor, Hospital Universitario Miguel Servet, Zaragoza, España
| | - S González Bardanca
- Servicio de Anestesiología, Reanimación y Terapéutica del dolor, Complejo Hospitalario Universitario de A Coruña, A Coruña, España
| | - M Á Varela Martínez
- Servicio de Anestesiología, Reanimación y Terapéutica del dolor, Hospital Álvaro Cunqueiro, Vigo, España
| | - F E Fernández
- Servicio de Anestesiología, Reanimación y Terapéutica del dolor, Hospital Universitario Central de Asturias, Oviedo, España
| | - R Llorens
- Servicio de Cirugía Cardiaca, Hospital Hospiten Rambla, Tenerife, España
| | - F J Valera Martínez
- Servicio de Cirugía Cardiaca, Hospital Universitario y Politécnico La Fe, Valencia, España
| | - A Gómez Felices
- Servicio de Anestesiología, Reanimación y Terapéutica del dolor, Hospital Universitario Vall d'Hebron, Barcelona, España
| | - P J Aranda Granados
- Servicio de Cirugía Cardiaca, Hospital Universitario Carlos Haya, Málaga, España
| | - R Sádaba Sagredo
- Servicio de Cirugía Cardiaca. Complejo Hospitalario de Navarra, Pamplona, España
| | - J R Echevarría
- Servicio de Cirugía Cardíaca. Hospital Universitario de Valladolid, Valladolid, España
| | - R Vicente Guillén
- Servicio de Anestesiología, Reanimación y Terapéutica del dolor, Hospital Universitario y Politécnico La Fe, Valencia, España
| | - J Silva Guisasola
- Servicio de Cirugía Cardíaca. Hospital Universitario Central de Asturias, Oviedo, España
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16
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Alnajar A, Lamelas J. Commentary: Does facilitating left subclavian artery revascularization matter during zone 2 thoracic endovascular aortic repair? JTCVS Tech 2021; 7:41-42. [PMID: 34318201 PMCID: PMC8312129 DOI: 10.1016/j.xjtc.2021.03.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 03/30/2021] [Accepted: 03/31/2021] [Indexed: 11/02/2022] Open
Affiliation(s)
- Ahmed Alnajar
- Division of Cardiothoracic Surgery, DeWitt Daughtry Department of Surgery, University of Miami Miller School of Medicine, Miami, Fla
| | - Joseph Lamelas
- Division of Cardiothoracic Surgery, DeWitt Daughtry Department of Surgery, University of Miami Miller School of Medicine, Miami, Fla
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17
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Wojnarski CM. Commentary: Thoracoabdominal aneurysm repair: Not for the faint of heart-or is it? JTCVS Tech 2021; 7:49-50. [PMID: 34318203 PMCID: PMC8311670 DOI: 10.1016/j.xjtc.2021.02.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 02/07/2021] [Accepted: 02/17/2021] [Indexed: 11/17/2022] Open
Affiliation(s)
- Charles M. Wojnarski
- Address for reprints: Charles M. Wojnarski, MD, MS, Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, 2301 Erwin Rd, Durham, NC 27710.
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18
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Qu JZ, Kao LW, Smith JE, Kuo A, Xue A, Iyer MH, Essandoh MK, Dalia AA. Brain Protection in Aortic Arch Surgery: An Evolving Field. J Cardiothorac Vasc Anesth 2020; 35:1176-1188. [PMID: 33309497 DOI: 10.1053/j.jvca.2020.11.035] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Revised: 11/10/2020] [Accepted: 11/16/2020] [Indexed: 12/11/2022]
Abstract
Despite advances in cardiac surgery and anesthesia, the rates of brain injury remain high in aortic arch surgery requiring circulatory arrest. The mechanisms of brain injury, including permanent and temporary neurologic dysfunction, are multifactorial, but intraoperative brain ischemia is likely a major contributor. Maintaining optimal cerebral perfusion during cardiopulmonary bypass and circulatory arrest is the key component of intraoperative management for aortic arch surgery. Various brain monitoring modalities provide different information to improve cerebral protection. Electroencephalography gives crucial data to ensure minimal cerebral metabolism during deep hypothermic circulatory arrest, transcranial Doppler directly measures cerebral arterial blood flow, and near-infrared spectroscopy monitors regional cerebral oxygen saturation. Various brain protection techniques, including hypothermia, cerebral perfusion, pharmacologic protection, and blood gas management, have been used during interruption of systemic circulation, but the optimal strategy remains elusive. Although deep hypothermic circulatory arrest and retrograde cerebral perfusion have their merits, there have been increasing reports about the use of antegrade cerebral perfusion, obviating the need for deep hypothermia. With controversy and variability of surgical practices, moderate hypothermia, when combined with unilateral antegrade cerebral perfusion, is considered safe for brain protection in aortic arch surgery performed with circulatory arrest. The neurologic outcomes of brain protection in aortic arch surgery largely depend on the following three major components: cerebral temperature, circulatory arrest time, and cerebral perfusion during circulatory arrest. The optimal brain protection strategy should be individualized based on comprehensive monitoring and stems from well-executed techniques that balance the major components contributing to brain injury.
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Affiliation(s)
- Jason Z Qu
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Lee-Wei Kao
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Jennifer E Smith
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Alexander Kuo
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Albert Xue
- Department of Cardiac Surgery, Nanjing Drum Tower Hospital, Nanjing, China
| | - Manoj H Iyer
- Department of Anesthesiology, The Ohio State University Medical Center, Columbus, OH
| | - Michael K Essandoh
- Department of Anesthesiology, The Ohio State University Medical Center, Columbus, OH
| | - Adam A Dalia
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA.
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19
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O’Hara D, McLarty A, Sun E, Itagaki S, Tannous H, Chu D, Egorova N, Chikwe J. Type-A Aortic Dissection and Cerebral Perfusion: The Society of Thoracic Surgeons Database Analysis. Ann Thorac Surg 2020; 110:1461-1467. [DOI: 10.1016/j.athoracsur.2020.04.144] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 04/06/2020] [Accepted: 04/30/2020] [Indexed: 10/24/2022]
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20
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Cao L, Guo X, Jia Y, Yang L, Wang H, Yuan S. Effect of Deep Hypothermic Circulatory Arrest Versus Moderate Hypothermic Circulatory Arrest in Aortic Arch Surgery on Postoperative Renal Function: A Systematic Review and Meta-Analysis. J Am Heart Assoc 2020; 9:e017939. [PMID: 32990132 PMCID: PMC7792363 DOI: 10.1161/jaha.120.017939] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Moderate hypothermic circulatory arrest (MHCA) has been widely used in aortic arch surgery. However, the renal function after MHCA remains controversial. We performed a systematic review and meta‐analysis direct comparison of the postoperative renal function of MHCA versus deep hypothermic circulatory arrest (DHCA) in aortic arch surgery. Methods and Results We searched PubMed, Embase, and the Cochrane Library for postoperative renal function after aortic arch surgery with using MHCA and DHCA, published from inception to January 31, 2020. The primary outcome was renal failure. Secondary outcomes were the need for renal therapy and other major postoperative outcomes. The random‐effects model was used for all comparisons to pool the estimates. A total of 14 observational studies with 4142 patients were included. Compared with DHCA, MHCA significantly reduced the incidence of renal failure (odds ratio [OR], 0.76; 95% CI, 0.61–0.94; P=0.011; I2=0.0%) and the need of renal replacement (OR, 0.68; 95% CI, 0.48–0.97; P=0.034; I2=0.0%). Subgroup analysis showed that when the hypothermic circulatory arrest time was <30 minutes, the incidence of renal failure in MHCA group was significantly lower than that in DHCA group (OR, 0.73; 95% CI, 0.54–0.99; P=0.040; I2=1.1%), whereas an insignificant difference between 2 groups when hypothermic circulatory arrest time was >30 minutes (OR, 0.76; 95% CI, 0.51–1.13; P=0.169; I2=17.3%). Conclusions MHCA compared with DHCA reduces the incidence of renal failure and the need for renal replacement. Registration URL: https://www.crd.york.ac.uk/prospero; Unique identifier: CRD42020169348.
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Affiliation(s)
- Liang Cao
- Department of Anesthesiology Fuwai Hospital National Center for Cardiovascular Diseases Chinese Academy of Medical Sciences and Peking Union Medical College Beijing China
| | - Xiaoxiao Guo
- Department of Cardiology Peking Union Medical College Hospital Peking Union Medical College and Chinese Academy of Medical Sciences Beijing China
| | - Yuan Jia
- Department of Anesthesiology Fuwai Hospital National Center for Cardiovascular Diseases Chinese Academy of Medical Sciences and Peking Union Medical College Beijing China
| | - Lijing Yang
- Department of Anesthesiology Fuwai Hospital National Center for Cardiovascular Diseases Chinese Academy of Medical Sciences and Peking Union Medical College Beijing China
| | - Hongbai Wang
- Department of Anesthesiology Fuwai Hospital National Center for Cardiovascular Diseases Chinese Academy of Medical Sciences and Peking Union Medical College Beijing China
| | - Su Yuan
- Department of Anesthesiology Fuwai Hospital National Center for Cardiovascular Diseases Chinese Academy of Medical Sciences and Peking Union Medical College Beijing China
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21
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Gaudino M, Benesch C, Bakaeen F, DeAnda A, Fremes SE, Glance L, Messé SR, Pandey A, Rong LQ. Considerations for Reduction of Risk of Perioperative Stroke in Adult Patients Undergoing Cardiac and Thoracic Aortic Operations: A Scientific Statement From the American Heart Association. Circulation 2020; 142:e193-e209. [DOI: 10.1161/cir.0000000000000885] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Perioperative stroke is one of the most severe and feared complications of cardiac surgery. Based on the timing of onset and detection, perioperative stroke can be classified as intraoperative or postoperative. The pathogenesis of perioperative stroke is multifactorial, which makes prediction and prevention challenging. However, information on its incidence, mechanisms, diagnosis, and treatment can be helpful in minimizing the perioperative neurological risk for individual patients. We herein provide suggestions on preoperative, intraoperative, and postoperative strategies aimed at reducing the risk of perioperative stroke and at improving the outcomes of patients who experience a perioperative stroke.
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22
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Iannacone E, Robinson B, Rahouma M, Girardi L. Management of malperfusion: New York approach and outcomes. J Card Surg 2020; 36:1757-1765. [PMID: 32949048 DOI: 10.1111/jocs.15025] [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: 07/31/2020] [Accepted: 09/03/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND AND AIM Aortic branch malperfusion complicates up to one-third of acute type A aortic dissection (ATAAD), and it is a strong predictor of poor outcomes. We analyzed our results for the surgical management of this high-risk cohort. METHODS We queried our aortic database for consecutive patients undergoing ATAAD repair. Those presenting with malperfusion were compared with those without. Outcomes were compared using univariate and multivariate analysis. RESULTS From 1997 to 2019, a total of 336 patients underwent ATAAD repair. A total of 97 ATAAD patients presented with malperfusion. Malperfusion patients were more likely to be male (54.8% vs. 75.3%; p = .001), have had a prior myocardial infarction (11.9% vs. 26.8%; p = .001), to present with preoperative renal dysfunction (22.2% vs. 54.6%; p < .001), and to present with shock (12.6% vs. 28.9%; p = .001). The malperfusion group more often underwent coronary artery bypass grafting (5.4% vs. 24.7%; p < .001), and required additional noncardiac procedures 10.3% of the time. Operative mortality (0.8% vs. 15.5%; p < .001) and major adverse events (MAEs) (7.6% vs. 20.6%; p = .001) were both greater for the malperfusion patients. Ejection fraction, diabetes, and malperfusion were predictors of MAEs. Cerebral, coronary, mesenteric, and multiple vascular bed malperfusion were predictors of MAEs, while extremity, renal, and spinal were not. CONCLUSION Improving outcomes for this high-risk cohort requires rapid diagnosis and reversal of ischemia while minimizing the risk of aortic rupture, irrespective of the strategic approach.
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Affiliation(s)
- Erin Iannacone
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Bryce Robinson
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Mohamed Rahouma
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Leonard Girardi
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York, USA
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23
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Frankel WC, Green SY, Orozco-Sevilla V, Preventza O, Coselli JS. Contemporary Surgical Strategies for Acute Type A Aortic Dissection. Semin Thorac Cardiovasc Surg 2020; 32:617-629. [PMID: 32615305 DOI: 10.1053/j.semtcvs.2020.06.025] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 05/21/2020] [Accepted: 06/13/2020] [Indexed: 11/11/2022]
Abstract
Surgical techniques and organ protection strategies for acute type A aortic dissection (ATAAD) have evolved considerably over the years. Nonetheless, open surgical repair remains a complex procedure, and there is a lack of consensus regarding many aspects of repair. In patients with dissection limited to the ascending aorta (DeBakey type II), repair typically involves replacement of only the affected segment, barring substantial aortic dilation to address elsewhere. In contrast, most patients with ATAAD have dissection extending into the thoracoabdominal aorta (DeBakey type I); in these cases, consideration must be given as to how much of the aortic arch and distal aorta to incorporate into the index repair, and several open and hybrid options exist. Herein, we review contemporary surgical strategies for ATAAD and clarify specific areas of controversy, in an effort to elucidate the optimal operative approach. In general, a limited index repair aimed at ensuring operative survival is typically the best option, whereas extended repair should be reserved for carefully selected patients who are most likely to benefit.
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Affiliation(s)
- William C Frankel
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Susan Y Green
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Vicente Orozco-Sevilla
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas; Section of Adult Cardiac Surgery, Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Texas; CHI St Luke's Health-Baylor St Luke's Medical Center, Houston, Texas
| | - Ourania Preventza
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas; Section of Adult Cardiac Surgery, Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Texas; CHI St Luke's Health-Baylor St Luke's Medical Center, Houston, Texas
| | - Joseph S Coselli
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas; Section of Adult Cardiac Surgery, Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Texas; CHI St Luke's Health-Baylor St Luke's Medical Center, Houston, Texas; Cardiovascular Research Institute, Baylor College of Medicine, Houston, Texas.
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24
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Lou X, Chen EP. Goal-directed cerebral perfusion in aortic arch surgery: scientific leap or hype? Asian Cardiovasc Thorac Ann 2020; 29:605-611. [PMID: 32438816 DOI: 10.1177/0218492320929212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Although significant advancements in cerebral protection strategies in aortic surgery have been achieved in recent years, controversy remains on what constitutes the optimal strategy. Deep hypothermic circulatory arrest alone is a viable approach in many instances, but the need for a prolonged duration of circulatory arrest and increasing case complexity have led to the utilization of adjunctive cerebral perfusion strategies. In this review, we discuss the efficacy of deep hypothermic circulatory arrest and its limitations, the role of retrograde cerebral perfusion and unilateral and bilateral antegrade cerebral perfusion, and the trend towards goal-directed perfusion strategies, all emphasizing the pressing need for randomized clinical trials to better define the optimal strategy.
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Affiliation(s)
- Xiaoying Lou
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, USA
| | - Edward P Chen
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, USA
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25
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Xie L, Xu Y, Huang G, Ye M, Hu X, Shu S, Lynn H. MHCA with SACP versus DHCA in Pediatric Aortic Arch Surgery: A Comparative Study. Sci Rep 2020; 10:4439. [PMID: 32157148 PMCID: PMC7064562 DOI: 10.1038/s41598-020-61428-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Accepted: 02/24/2020] [Indexed: 12/31/2022] Open
Abstract
The safety and efficacy of selective antegrade cerebral perfusion (SACP) in children undergoing aortic arch surgery are unclear. In this retrospective analysis, we compared moderate hypothermic circulatory arrest (MHCA; n = 61) plus SACP vs deep hypothermic circulatory arrest (DHCA; n = 53) in children undergoing aortic arch surgery during a period from January 2008 to December 2017. Demographic characteristics and the underlying anomalies were comparable between the two groups. The MHCA + SACP group had shorter cardiopulmonary bypass (CPB) time (146.9 ± 40.6 vs 189.6 ± 41.2 min for DHCA; p < 0.05) and higher nasopharyngeal temperature (26.0 ± 2.1 vs 18.9 ± 1.6 °C; p < 0.01). The MHCA + SACP group had lower rate of neurologic complications (3/61 vs 10/53 for DHCA; p < 0.05) but not complications in other organ systems. The MHCA + SACP group also had less 24-hour chest drainage (median, interquartile rage: 28.9, 12.6–150.0 vs 47.4, 15.2–145.0 ml/kg for DHCA; p < 0.05), shorter duration of postoperative mechanical ventilation (35.0, 15.4–80.3 vs 94.0, 42.0–144.0 h; p < 0.01), and shorter stay in intensive care unit (3.9, 3.0–7.0 vs 7.7, 5.0–15.0 d; p < 0.05). In regression analysis, in-hospital mortality was associated with longer CPB time. In conclusion, MHCA + SACP is associated with better short-term outcomes in children receiving aortic arch surgery under CPB.
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Affiliation(s)
- Ling Xie
- Department of Anesthesiology, Ministry of Education Key Laboratory of Child Development and Disorders; National Clinical Research Center for Child Health and Disorders; China International Science and Technology Cooperation base of Child development and Critical Disorders; Children's Hospital of Chongqing Medical University, Chongqing, P.R. China
| | - Yan Xu
- Department of Anesthesiology, Ministry of Education Key Laboratory of Child Development and Disorders; National Clinical Research Center for Child Health and Disorders; China International Science and Technology Cooperation base of Child development and Critical Disorders; Children's Hospital of Chongqing Medical University, Chongqing, P.R. China
| | - Guijin Huang
- Department of Anesthesiology, Ministry of Education Key Laboratory of Child Development and Disorders; National Clinical Research Center for Child Health and Disorders; China International Science and Technology Cooperation base of Child development and Critical Disorders; Children's Hospital of Chongqing Medical University, Chongqing, P.R. China
| | - Mao Ye
- Department of Anesthesiology, Ministry of Education Key Laboratory of Child Development and Disorders; National Clinical Research Center for Child Health and Disorders; China International Science and Technology Cooperation base of Child development and Critical Disorders; Children's Hospital of Chongqing Medical University, Chongqing, P.R. China
| | - Xiao Hu
- Department of Anesthesiology, Eye & ENT Hospital of Fudan University, Shanghai, China
| | - Shiyu Shu
- Department of Anesthesiology, Eye & ENT Hospital of Fudan University, Shanghai, China.
| | - Harness Lynn
- Division of Cardiac Surgery, Johns Hopkins Hospital, School of Medicine, Baltimore, Maryland, USA
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26
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Xiong J, Tan Z, Liu X, Yu X, Lin J, Du L. Total body retrograde perfusion during hypothermic circulatory arrest is unsafe. Perfusion 2020; 35:707-709. [PMID: 32090681 DOI: 10.1177/0267659120906959] [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: 02/05/2023]
Abstract
Retrograde cerebral perfusion and retrograde inferior vena cava perfusion at a pressure of 25 mmHg can protect brain and visceral organs during hypothermic circulatory arrest. Total body retrograde perfusion has been proposed as an alternative during aortic arch surgery. We describe two patients who received total body retrograde perfusion during hemi-arch replacement. The procedure had to be terminated at 8 and 15 minutes due to severe fluid retention and decline in cerebral oxygen saturation. Delirium occurred in one patient after surgery. We concluded that total body retrograde perfusion may be associated with high risk of hypoperfusion and should not be recommended.
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Affiliation(s)
- Jiyue Xiong
- Department of Anesthesiology and Translational Neuroscience Center, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Zhaoxia Tan
- Department of Anesthesiology and Translational Neuroscience Center, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Xinhao Liu
- Department of Anesthesiology and Translational Neuroscience Center, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Xiang Yu
- Department of Anesthesiology and Translational Neuroscience Center, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Jing Lin
- Department of Anesthesiology and Translational Neuroscience Center, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Lei Du
- Department of Anesthesiology and Translational Neuroscience Center, West China Hospital, Sichuan University, Chengdu, People's Republic of China
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27
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Hage A, Stevens LM, Ouzounian M, Chung J, El-Hamamsy I, Chauvette V, Dagenais F, Cartier A, Peterson MD, Boodhwani M, Guo M, Bozinovski J, Moon MC, White A, Kumar K, Lodewyks C, Bittira B, Payne D, Chu MWA. Impact of brain protection strategies on mortality and stroke in patients undergoing aortic arch repair with hypothermic circulatory arrest: evidence from the Canadian Thoracic Aortic Collaborative. Eur J Cardiothorac Surg 2020; 58:95-103. [DOI: 10.1093/ejcts/ezaa023] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 12/26/2019] [Accepted: 01/04/2020] [Indexed: 11/14/2022] Open
Abstract
Abstract
OBJECTIVES
The aim of this study was to investigate the impact of various brain perfusion techniques and nadir temperature cooling strategies on outcomes after aortic arch repair in a contemporary, multicentre cohort.
METHODS
A total of 2520 patients underwent aortic arch repair with hypothermic circulatory arrest (HCA) between 2002 and 2018 in 11 centres of the Canadian Thoracic Aortic Collaborative. Primary outcomes included mortality; stroke; a composite of mortality or stroke; and a Society of Thoracic Surgeons-defined composite (STS-COMP) end point for mortality or major morbidity including stroke, reoperation, renal failure, prolonged ventilation and deep sternal wound infection. Multivariable logistic regression and propensity score matching were performed for cerebral perfusion and nadir temperature practices.
RESULTS
Antegrade cerebral perfusion was found on multivariable analysis to be protective against mortality [odds ratio (OR) 0.64, 95% confidence interval (CI) 0.48–0.86; P = 0.005], stroke (OR 0.55, 95% CI 0.37–0.81; P = 0.006), composite of mortality or stroke (OR 0.57, 95% CI 0.45–0.72; P = 0.0001) and STS-COMP (OR 0.53, 95% CI 0.41–0.67; P < 0.0001), as compared to HCA alone. Retrograde cerebral perfusion yielded similar outcomes as compared to antegrade cerebral perfusion. When compared to HCA with nadir temperature <24°C, a propensity score analysis of 647 matched pairs identified nadir temperature ≥24°C as predictor of lower mortality (OR 0.62, 95% CI 0.40–0.98; P = 0.04), stroke (OR 0.51, 95% CI 0.31–0.84; P = 0.008), composite of mortality or stroke (OR 0.62, 95% CI 0.43–0.89; P = 0.01) and STS-COMP (OR 0.64, 95% CI 0.49–0.85; P = 0.002).
CONCLUSIONS
Antegrade cerebral perfusion and nadir temperature ≥24°C during HCA for aortic arch repair are predictors of improved survival and neurological outcomes.
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Affiliation(s)
- Ali Hage
- Division of Cardiac Surgery, Department of Surgery, Western University, London, ON, Canada
| | - Louis-Mathieu Stevens
- Division of Cardiac Surgery, Department of Surgery, University of Montreal, Montreal, QC, Canada
| | - Maral Ouzounian
- Division of Cardiac Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Jennifer Chung
- Division of Cardiac Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Ismail El-Hamamsy
- Division of Cardiac Surgery, Department of Surgery, University of Montreal, Montreal, QC, Canada
| | - Vincent Chauvette
- Division of Cardiac Surgery, Department of Surgery, University of Montreal, Montreal, QC, Canada
| | - Francois Dagenais
- Division of Cardiac Surgery, Department of Surgery, Laval University, Quebec, QC, Canada
| | - Andreanne Cartier
- Division of Cardiac Surgery, Department of Surgery, Laval University, Quebec, QC, Canada
| | - Mark D Peterson
- Division of Cardiac Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Munir Boodhwani
- Division of Cardiac Surgery, Department of Surgery, University of Ottawa, Ottawa, ON, Canada
| | - Ming Guo
- Division of Cardiac Surgery, Department of Surgery, University of Ottawa, Ottawa, ON, Canada
| | | | - Michael C Moon
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Abigail White
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Kanwal Kumar
- Division of Cardiac Surgery, Department of Surgery, University of Manitoba, Winnipeg, MB, Canada
| | - Carly Lodewyks
- Division of Cardiac Surgery, Department of Surgery, University of Manitoba, Winnipeg, MB, Canada
| | - Bindu Bittira
- Division of Cardiac Surgery, Department of Surgery, Health Sciences North, Sudbury, ON, Canada
| | - Darrin Payne
- Division of Cardiac Surgery, Department of Surgery, Queen’s University, Kingston, ON, Canada
| | - Michael W A Chu
- Division of Cardiac Surgery, Department of Surgery, Western University, London, ON, Canada
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28
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Haunschild J, Borger MA, Etz CD. Zerebrale Protektionsstrategien und Monitoring im hypothermen Kreislaufstillstand. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2019. [DOI: 10.1007/s00398-019-00340-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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29
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Arch repair: Brachial artery cannulation is as effective, but less invasive and more practical. J Thorac Cardiovasc Surg 2019; 158:e165. [PMID: 31255342 DOI: 10.1016/j.jtcvs.2019.05.042] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Accepted: 05/13/2019] [Indexed: 11/21/2022]
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30
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Lin J, Tan Z, Yao H, Hu X, Zhang D, Zhao Y, Xiong J, Dou B, Zhu X, Wu Z, Guo Y, Kang D, Du L. Retrograde Inferior Vena caval Perfusion for Total Aortic arch Replacement Surgery (RIVP-TARS): study protocol for a multicenter, randomized controlled trial. Trials 2019; 20:232. [PMID: 31014386 PMCID: PMC6480889 DOI: 10.1186/s13063-019-3319-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2018] [Accepted: 03/25/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND During total aortic arch replacement surgery (TARS) for patients with acute type A aortic dissection, the organs in the lower body, such as the viscera and spinal cord, are at risk of ischemia even when antegrade cerebral perfusion (ACP) is performed. Combining ACP with retrograde inferior vena caval perfusion (RIVP) during TARS may improve outcomes by providing the lower body with oxygenated blood. METHODS This study is designed as a multicenter, computer-generated, randomized controlled, assessor-blind, parallel-group study with a superiority framework in patients scheduled for TARS. A total of 636 patients will be randomized on a 1:1 basis to a moderate hypothermia circulatory arrest (MHCA) group, which will receive selective ACP with moderate hypothermia during TARS; or to an RIVP group, which will receive the combination of RIVP and selective ACP under moderate hypothermia during TARS. The primary outcome will be a composite of early mortality and major complications, including paraplegia, postoperative renal failure, severe liver dysfunction, and gastrointestinal complications. All patients will be analyzed according to the intention-to-treat protocol. DISCUSSION This study aims to assess whether RIVP combined with ACP leads to superior outcomes than ACP alone for patients undergoing TARS under moderate hypothermia. This study seeks to provide high-quality evidence for RIVP to be used in patients with acute type A aortic dissection undergoing TARS. TRIAL REGISTRATION Clinicaltrials.gov, ID: NCT03607786 . Registered on 30 July 2018.
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Affiliation(s)
- Jing Lin
- Department of Anesthesiology, West China Hospital, Sichuan University, No. 37 Guo Xue Alley, Chengdu, 610041 Sichuan Province China
| | - Zhaoxia Tan
- Department of Anesthesiology, West China Hospital, Sichuan University, No. 37 Guo Xue Alley, Chengdu, 610041 Sichuan Province China
| | - Hao Yao
- Cardiovascular Center of the Second Affiliated Hospital, Nanjing Medical University, No. 121, Jiangjiaruan Road, Gulou District, Nanjing, 210000 Jiangsu Province China
| | - Xiaolin Hu
- Department of Anesthesiology, First Affiliated Hospital of University of South China, No. 151, Yanjiang West Road, Yuexiu District, Guangzhou, 510000 Guangdong Province China
| | - Dafa Zhang
- Department of Thoracic Cardiovascular Surgery, First Affiliated Hospital, Wannan Medical University, No. 2, Chushan West Road, Jinghu District, Wuhu, 230000 Anhui Province China
| | - Yuan Zhao
- Department of Cardiovascular Surgery, The Second Xiangya Hospital, Central South University, No. 139, People’s Road, Furong District, Changsha, 410000 Hunan Province China
| | - Jiyue Xiong
- Department of Anesthesiology, West China Hospital, Sichuan University, No. 37 Guo Xue Alley, Chengdu, 610041 Sichuan Province China
| | - Bo Dou
- Department of Anesthesiology, First Affiliated Hospital of University of South China, No. 151, Yanjiang West Road, Yuexiu District, Guangzhou, 510000 Guangdong Province China
| | - Xueshuang Zhu
- Department of Thoracic Cardiovascular Surgery, First Affiliated Hospital, Wannan Medical University, No. 2, Chushan West Road, Jinghu District, Wuhu, 230000 Anhui Province China
| | - Zhong Wu
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, No. 37, Guo Xue Alley, Chengdu, 610041 Sichuan Province China
| | - Yingqiang Guo
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, No. 37, Guo Xue Alley, Chengdu, 610041 Sichuan Province China
| | - Deying Kang
- Department of Evidence-based Medicine and Clinical Epidemiology, West China Hospital, Sichuan University, No. 37, Guo Xue Alley, Chengdu, 610041 Sichuan Province China
| | - Lei Du
- Department of Anesthesiology, West China Hospital, Sichuan University, No. 37 Guo Xue Alley, Chengdu, 610041 Sichuan Province China
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31
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Wojnarski CM, Vekstein AM. Commentary: Use it or lose it-Cerebral perfusion and aortic arch surgery. J Thorac Cardiovasc Surg 2019; 159:34-35. [PMID: 31053439 DOI: 10.1016/j.jtcvs.2019.03.078] [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: 03/18/2019] [Accepted: 03/18/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Charles M Wojnarski
- Duke University Medical Center; Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University, Durham, NC.
| | - Andrew M Vekstein
- Duke University Medical Center; Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University, Durham, NC
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32
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Coselli JS, Le Huu A. Commentary: Horseshoes and hand grenades. J Thorac Cardiovasc Surg 2019; 159:32-33. [PMID: 30981527 DOI: 10.1016/j.jtcvs.2019.02.103] [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: 02/27/2019] [Accepted: 02/28/2019] [Indexed: 10/27/2022]
Affiliation(s)
- Joseph S Coselli
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Department of Cardiovascular Surgery, Texas Heart Institute, Texas Medical Center, Houston, Tex; CHI St Luke's Health-Baylor St Luke's Medical Center, Houston, Tex.
| | - Alice Le Huu
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Department of Cardiovascular Surgery, Texas Heart Institute, Texas Medical Center, Houston, Tex; CHI St Luke's Health-Baylor St Luke's Medical Center, Houston, Tex
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