1
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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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2
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Ghia S, Savadjian A, Shin D, Diluozzo G, Weiner MM, Bhatt HV. Hypothermic Circulatory Arrest in Adult Aortic Arch Surgery: A Review of Hypothermic Circulatory Arrest and its Anesthetic Implications. J Cardiothorac Vasc Anesth 2023; 37:2634-2645. [PMID: 37723023 DOI: 10.1053/j.jvca.2023.08.139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 08/11/2023] [Accepted: 08/20/2023] [Indexed: 09/20/2023]
Abstract
Diseases affecting the aortic arch often require surgical intervention. Hypothermic circulatory arrest (HCA) enables a safe approach during open aortic arch surgeries. Additionally, HCA provides neuroprotection by reducing cerebral metabolism and oxygen requirements. However, HCA comes with significant risks (eg, neurologic dysfunction, stroke, and coagulopathy), and the cardiac anesthesiologist must completely understand the surgical techniques, possible complications, and management strategies.
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Affiliation(s)
- Samit Ghia
- Department of Anesthesiology, Critical Care and Perioperative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Andre Savadjian
- Department of Anesthesiology and Critical Care, Duke University School of Medicine, Durham, NC
| | - DaWi Shin
- Department of Anesthesiology, Critical Care and Perioperative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Gabriele Diluozzo
- Department of Cardiovascular Surgery, Yale School of Medicine, Bridgeport, CT
| | - Menachem M Weiner
- Department of Anesthesiology, Critical Care and Perioperative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY.
| | - Himani V Bhatt
- Department of Anesthesiology, Critical Care and Perioperative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
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3
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Finnigan LEM, Lotto R, Jones H, Lotto A. Cerebral blood flow velocity and oxygenation in neonatal aortic arch repair at two perfusion temperatures. Eur J Cardiothorac Surg 2023; 63:ezad220. [PMID: 37280071 PMCID: PMC10824556 DOI: 10.1093/ejcts/ezad220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 05/10/2023] [Accepted: 06/05/2023] [Indexed: 06/08/2023] Open
Abstract
OBJECTIVES (i) To monitor cerebral blood flow velocity (CBFv) throughout aortic arch repair surgery and during the recovery period. (ii) To examine the relationship between transcranial doppler ultrasound (TCD) and near-infrared spectroscopy (NIRS) during cardiac surgery. (iii) To examine CBFv in patients cooled to 20°C and 25°C. METHODS During aortic arch repair and after surgery, measurements of TCD, NIRS, blood pH, pO2, pCO2, HCO3, lactate, Hb, haematocrit (%) and temperature (core and rectal) were recorded in 24 neonates. General linear mixed models were used to examine differences over time and between two cooling temperatures. Repeated measures correlations were used to determine the relationship between TCD and NIRS. RESULTS CBFv changed during arch repair (main effect of time: P = 0.001). During cooling, CBFv increased by 10.0 cm/s (5.97, 17.7) compared to normothermia (P = 0.019). Once recovering in paediatric intensive care unit (PICU), CBFv had increased from the preoperative measurement by 6.2 cm/s (0.21, 13.4; P = 0.045). CBFv changes were similar between patients cooled to 20°C and 25°C (main effect of temperature: P = 0.22). Repeated measures correlations (rmcorr) identified a statistically significant but weak positive correlation between CBFv and NIRS (r = 0.25, P≤0.001). CONCLUSIONS Our data suggested that CBFv changed throughout aortic arch repair and was higher during the cooling period. A weak relationship was found between NIRS and TCD. Overall, these findings could provide clinicians with information on how to optimise long-term cerebrovascular health.
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Affiliation(s)
- Lucy E M Finnigan
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Robyn Lotto
- Allied Health and Nursing, Liverpool John Moores University, Liverpool, UK
| | - Helen Jones
- Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UK
| | - Attilio Lotto
- Heart Centre, Alder Hey Children’s NHS Foundation, Liverpool, UK
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4
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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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5
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Luis GOJ, Alicia RF. Perspectives: Regional brain oxygen saturation: beyond the brain there is also life. Curr Pharm Des 2022; 28:1589-1591. [DOI: 10.2174/1381612828666220318120311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 02/01/2022] [Indexed: 11/22/2022]
Abstract
Abstract:
Some procedures, such as cardiovascular surgery, may compromise brain perfusion and require careful management to preserve the integrity of the central nervous system. In this setting, regional cerebral oxygen saturation [rSO2] emerges as an alternative, minimally invasive, monitoring system. The mechanism by which regional oxygen is measured is based on the refraction and absorption of a signal with a specific wavelength. Diagnostic and therapeutic algorithms for these settings. This would allow for a more rational use of goal-directed therapies that reduce morbidity and mortality in these patients.
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Affiliation(s)
- Guerrero Orriach Jose Luis
- Institute of Biomedical Research in Malaga, Malaga, Spain
- Department of Anesthesiology, Virgen de la Victoria University Hospital, Malaga, Spain
- Department of Pharmacology and Pediatrics, School of Medicine, University of Malaga, Malaga, Spain
| | - Ramirez Fernandez Alicia
- Institute of Biomedical Research in Malaga, Malaga, Spain
- Department of Anesthesiology, Virgen de la Victoria University Hospital, Malaga, Spain
- Department of Pharmacology and Pediatrics, School of Medicine, University of Malaga, Malaga, Spain
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6
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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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7
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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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8
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Contemporary Neuroprotection Strategies during Cardiac Surgery: State of the Art Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph182312747. [PMID: 34886474 PMCID: PMC8657178 DOI: 10.3390/ijerph182312747] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 11/22/2021] [Accepted: 11/30/2021] [Indexed: 12/30/2022]
Abstract
Open-heart surgery is the leading cause of neuronal injury in the perioperative state, with some patients complicating with cerebrovascular accidents and delirium. Neurological fallout places an immense burden on the psychological well-being of the person affected, their family, and the healthcare system. Several randomised control trials (RCTs) have attempted to identify therapeutic and interventional strategies that reduce the morbidity and mortality rate in patients that experience perioperative neurological complications. However, there is still no consensus on the best strategy that yields improved patient outcomes, such that standardised neuroprotection protocols do not exist in a significant number of anaesthesia departments. This review aims to discuss contemporary evidence for preventing and managing risk factors for neuronal injury, mechanisms of injury, and neuroprotection interventions that lead to improved patient outcomes. Furthermore, a summary of existing RCTs and large observational studies are examined to determine which strategies are supported by science and which lack definitive evidence. We have established that the overall evidence for pharmacological neuroprotection is weak. Most neuroprotective strategies are based on animal studies, which cannot be fully extrapolated to the human population, and there is still no consensus on the optimal neuroprotective strategies for patients undergoing cardiac surgery. Large multicenter studies using universal standardised neurological fallout definitions are still required to evaluate the beneficial effects of the existing neuroprotective techniques.
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9
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Tveita T, Sieck GC. Physiological Impact of Hypothermia: The Good, the Bad and the Ugly. Physiology (Bethesda) 2021; 37:69-87. [PMID: 34632808 DOI: 10.1152/physiol.00025.2021] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Hypothermia is defined as a core body temperature of < 35°C, and as body temperature is reduced the impact on physiological processes can be beneficial or detrimental. The beneficial effect of hypothermia enables circulation of cooled experimental animals to be interrupted for 1-2 h without creating harmful effects, while tolerance of circulation arrest in normothermia is between 4 and 5 min. This striking difference has attracted so many investigators, experimental as well as clinical, to this field, and this discovery was fundamental for introducing therapeutic hypothermia in modern clinical medicine in the 1950's. Together with the introduction of cardiopulmonary bypass, therapeutic hypothermia has been the cornerstone in the development of modern cardiac surgery. Therapeutic hypothermia also has an undisputed role as a protective agent in organ transplantation and as a therapeutic adjuvant for cerebral protection in neonatal encephalopathy. However, the introduction of therapeutic hypothermia for organ protection during neurosurgical procedures or as a scavenger after brain and spinal trauma has been less successful. In general, the best neuroprotection seems to be obtained by avoiding hyperthermia in injured patients. Accidental hypothermia occurs when endogenous temperature control mechanisms are incapable of maintaining core body temperature within physiologic limits and core temperature becomes dependent on ambient temperature. During hypothermia spontaneous circulation is considerably reduced and with deep and/or prolonged cooling, circulatory failure may occur, which may limit safe survival of the cooled patient. Challenges that limit safe rewarming of accidental hypothermia patients include cardiac arrhythmias, uncontrolled bleeding, and "rewarming shock".
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Affiliation(s)
- Torkjel Tveita
- Anesthesia and Critical Care Research Group, Department of Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway.,Division of Surgical Medicine and Intensive Care, University Hospital of North Norway, Tromsø, Norway
| | - Gary C Sieck
- Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, Minnesota, United States
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10
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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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Benedetto U, Dimagli A, Cooper G, Uppal R, Mariscalco G, Krasopoulos G, Goodwin A, Trivedi U, Kendall S, Sinha S, Fudulu D, Angelini GD, Tsang G, Akowuah E. Neuroprotective strategies in acute aortic dissection: an analysis of the UK National Adult Cardiac Surgical Audit. Eur J Cardiothorac Surg 2021; 60:1437-1444. [PMID: 33963362 PMCID: PMC8643475 DOI: 10.1093/ejcts/ezab192] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 03/11/2021] [Accepted: 03/30/2021] [Indexed: 01/16/2023] Open
Abstract
OBJECTIVES The risk of brain injury following surgery for type A aortic dissection (TAAD) remains substantial and no consensus has still been reached on which neuroprotective technique should be preferred. We aimed to investigate the association between neuroprotective strategies and clinical outcomes following TAAD repair. METHODS Using the UK National Adult Cardiac Surgical Audit, we identified 1929 patients undergoing surgery for TAAD (2011-2018). Deep hypothermic circulatory arrest (DHCA) only, unilateral (uACP), bilateral antegrade cerebral perfusion (bACP) and retrograde cerebral perfusion were used in 830, 117, 760 and 222 patients, respectively. The primary end point was a composite of death and/or cerebrovascular accident (CVA). Generalized linear mixed model was used to adjust the effect of neuroprotective strategies for other confounders. RESULTS The use of bACP was associated with longer circulatory arrest (CA) compared to other strategies. There was a trend towards lower incidence of death and/or CVA using uACP only for shorter CA. In particular, primary end point rate was 27.7% overall and 26.5%, 12.5%, 28.0% and 22.9% for CA <30 min and 28.6%, 30.4%, 33.3% and 33.0% for CA ≥30 min with DHCA only, uACP, bACP and retrograde cerebral perfusion, respectively. The use of DHCA only was associated with five-fold [odds ratio (OR) 5.35, 95% confidence interval (CI) 1.36-21.02] and two-fold (OR 1.77, 95% CI 1.01-3.09) increased risk of death and/or CVA compared to uACP and bACP, respectively, but the effect of uACP was significantly associated with CA duration (hazard ratio 0.97, 95% CI 0.94-0.99; P = 0.04). CONCLUSIONS In TAAD repair, the use of uACP and bACP was associated with a lower adjusted risk of death and/or CVA when compared to DHCA. uACP can offer some advantage but only for a shorter CA duration.
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Affiliation(s)
| | | | - Graham Cooper
- Sheffield Teaching Hospitals Foundation Trust, Sheffield, UK
| | - Rakesh Uppal
- Barts Heart Centre, William Harvey Research Institute, London, UK
| | | | | | | | - Uday Trivedi
- Sussex Cardiac Center, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | | | - Shubhra Sinha
- Bristol Heart Institute, University of Bristol, Bristol, UK
| | - Daniel Fudulu
- Bristol Heart Institute, University of Bristol, Bristol, UK
| | | | - Geoffrey Tsang
- Wessex Cardiothoracic Center, University Hospital Southampton NHS Trust, Southampton, UK
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12
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Mauduit M, Anselmi A, Tomasi J, Belhaj Soulami R, Le Bars F, Flecher E, Verhoye JP. Does Hypothermic Circulatory Arrest for Aortic Surgery Trigger Near-Death Experience? Incidence of Near-Death Experiences after Aortic Surgeries Performed under Hypothermic Circulatory Arrest. AORTA (STAMFORD, CONN.) 2021; 9:76-82. [PMID: 34666377 PMCID: PMC8526149 DOI: 10.1055/s-0041-1725091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 11/11/2020] [Indexed: 10/26/2022]
Abstract
BACKGROUND Understanding near-death experiences (NDE) could provide a new insight into the analysis of human consciousness and the neurocognitive processes happening upon the approach of death. With a temporary interruption of systemic perfusion, aortic surgery under hypothermic circulatory arrest (HCA) may be the only available model of reversible clinical death. We present, herein, the results of an observational study designed to assess the incidence of NDE after aortic surgery. METHODS We performed a prospective study including consecutive patients who underwent thoracic aortic surgery between July 2018 and September 2019 at our institution. Procedures without HCA were included to constitute a control group. The primary outcome was the incidence of NDE assessed with the Greyson NDE scale during the immediate postoperative course, via a standardized interview of the patients in the surgical ward. RESULTS One hundred and one patients were included. Twenty-one patients (20.8%) underwent nonelective interventions for aortic dissection. Ninety-one patients had hemiarch replacement (90.1%). Sixty-seven (66.3%) interventions were performed with HCA, with an average circulatory arrest duration of 26.9 ± 25.5 minutes, and a mean body temperature of 23.7 ± 3.8°C. None of the patients reported any recollection from their period of unconsciousness. There was no NDE experiencer in the study cohort. CONCLUSION Several confounding factors regarding anesthesia, or NDE evaluation, might have impaired the chance of NDE recollections, and might have contributed to this negative result. Whether HCA may trigger NDE remains unknown.
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Affiliation(s)
- Marion Mauduit
- Department of Thoracic and Cardiovascular Surgery, Rennes University Hospital Center, Rennes, France
| | - Amedeo Anselmi
- Department of Thoracic and Cardiovascular Surgery, Rennes University Hospital Center, Rennes, France
| | - Jacques Tomasi
- Department of Thoracic and Cardiovascular Surgery, Rennes University Hospital Center, Rennes, France
| | - Reda Belhaj Soulami
- Department of Thoracic and Cardiovascular Surgery, Rennes University Hospital Center, Rennes, France
| | - Florent Le Bars
- Department of Thoracic and Cardiovascular Surgery, Rennes University Hospital Center, Rennes, France
| | - Erwan Flecher
- Department of Thoracic and Cardiovascular Surgery, Rennes University Hospital Center, Rennes, France
| | - Jean-Philippe Verhoye
- Department of Thoracic and Cardiovascular Surgery, Rennes University Hospital Center, Rennes, France
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Xia Q, Cao Y, Xie B, Qiu D, Deng L, Wang M, Han H. Cannulation strategies in type A aortic dissection: a novel insight narrative review. J Thorac Dis 2021; 13:2551-2562. [PMID: 34012600 PMCID: PMC8107572 DOI: 10.21037/jtd-21-411] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
This review highlights vital details that can be easily overlooked and discuss how to identify and fix failed cannulation from another novel insight. Appropriate arterial cannulation strategy during cardiopulmonary bypass (CPB) in Stanford type A aortic dissection (AAD) is highly necessary to reach satisfactory perfusion effects and appreciable clinical outcomes. Despite several previously published reviews on cannulation strategies in AAD, most focus on the advantages and disadvantages by comparing various cannulation strategies. In fact, most of evidence came from retrospective studies. More importantly, however, some important details and novel approaches maybe overlooked due to variety reasons. These overlooked details also make sense in clinical practice. Papers related to cannulation refer to type AAD were retrieved and analyzed from the PubMed and Medline database. The key words such as “aortic dissection”, “cannula”, “cannulation”, “cannulation strategy”, “cerebral perfusion”, “type I aortic dissection” were conducted and analyzed. In addition, we looked at some new and very significant specific perfusion techniques such as anterograde cerebral perfusion combined with retrograde inferior vena caval perfusion (RIVP) and reperfusion via the right carotid artery before surgery. The arterial cannulation site and strategy should be determined individually. Monitoring measures are very necessary in the whole procedure.
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Affiliation(s)
- Qingping Xia
- Department of Science and Education, The People's Hospital of Gaozhou, Gaozhou, China
| | - Yong Cao
- Department of Cardiovascular Surgery, The People's Hospital of Gaozhou, Gaozhou, China
| | - Baodong Xie
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Dongyun Qiu
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Li Deng
- Department of Cardiovascular Surgery, The People's Hospital of Gaozhou, Gaozhou, China.,Department of Cardiovascular Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Maosheng Wang
- Department of Cardiovascular Surgery, The People's Hospital of Gaozhou, Gaozhou, China
| | - Hongguang Han
- Department of Cardiovascular Surgery, The General Hospital of Northern Theater Command, Shenyang, China
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14
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Garcia-Ballestas E, Murlimanju BV, Durango-Espinosa YA, Joaquim AF, Vasquez HE, Moscote-Salazar LR, Agrawal A. Collateral Circulation in Spinal Cord Injury: A Comprehensive Review. INDIAN JOURNAL OF NEUROTRAUMA 2020. [DOI: 10.1055/s-0040-1713724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
AbstractSurgery is the most common cause of spinal cord ischemia; it is also caused by hemodynamic changes, which disrupt the blood flow. Direct ligation of the spinal arteries, especially the Adamkiewicz artery is involved as well. Other causes of spinal cord ischemia include arteriography procedures, thoracic surgery, epidural and rachianesthesia, foraminal infiltration, arterial dissection, systemic hypotension, emboligenic heart disease, thoracic disc herniation, and compression. Understanding the vascular anatomy of the spinal cord is essential to develop optimal strategies for preventing ischemic injuries to the spinal cord. During ischemia, a rich network of intra and paraspinal collaterals allow enough blood flow to compensate the intensity of spinal cord ischemia. In case of interruption of flow of a main artery, the collateral artery increases its flow to maintain perfusion to the tissues. Avoiding spinal cord ischemia by using collateral circulation is necessary to prevent the establishment of hypovolemia, hyperthermia and elevations in venous pressures. The objective of this narrative review is to present the current concepts of spinal collateral circulation and its role in the setting of ischemic events, affecting the vascular supply of the spinal cord.
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Affiliation(s)
- Ezequiel Garcia-Ballestas
- Faculty of Medicine, Center for Biomedical Research (CIB), University of Cartagena, Cartagena, Colombia
| | - B. V. Murlimanju
- Department of Anatomy, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | | | - Andrei F. Joaquim
- Neurosurgery Division, Cartagena de Indias, Bolivar Department of Neurology, State University of Campinas, Campinas-Sao Paulo, Brazil
| | - Harold E. Vasquez
- Universidad del Sinu, Cartagena de Indias, Consejo Latinoamericano de Neurointensivismo (CLaNi), Cartagena de Indias, Colombia
| | - Luis Rafael Moscote-Salazar
- Neurosurgeon-Critical Care, Center for Biomedical Research (CIB), Cartagena Neurotrauma Research Group, Faculty of Medicine, University of Cartagena, Cartagena, Colombia
| | - Amit Agrawal
- Department of Neurosurgery, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
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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 S, Varela Martíne MÁ, Fernández FE, Llorens R, Valera Martínez FJ, Gómez Felices A, Aranda Granados PJ, Rafael Sádaba Sagredo, Echevarría JR, Silva Guisasola J. Guía anestésico-quirúrgica en el tratamiento de la cirugía de la aorta ascendente y del arco aórtico. Documento de consenso de las Sociedades Española de Cirugía Cardiovascular y Endovascular y la Sociedad Española de Anestesiología, Reanimación y Terapeútica del Dolor. CIRUGIA CARDIOVASCULAR 2020. [DOI: 10.1016/j.circv.2020.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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16
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Burggren W, Bautista N. Invited review: Development of acid-base regulation in vertebrates. Comp Biochem Physiol A Mol Integr Physiol 2019; 236:110518. [DOI: 10.1016/j.cbpa.2019.06.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2019] [Revised: 06/24/2019] [Accepted: 06/25/2019] [Indexed: 12/26/2022]
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