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Honkanen HP, Mustonen C, Tuominen H, Kiviluoma K, Anttila V, Juvonen T. Spinal cord injury during selective cerebral perfusion and segmental artery occlusion: an experimental study. Interact Cardiovasc Thorac Surg 2022; 34:145-152. [PMID: 34999799 PMCID: PMC8923407 DOI: 10.1093/icvts/ivab219] [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: 05/21/2021] [Accepted: 06/14/2021] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES Since selective cerebral perfusion (SCP) has been used in aortic arch surgical procedures, the core temperature during lower body circulatory arrest (LBCA) has been steadily rising. Simultaneously, the use of a frozen elephant trunk (FET) graft has been increasing. The safe period of LBCA in relation to spinal cord ischaemic tolerance in combination with segmental artery occlusion by the FET procedure has not been defined. METHODS Sixteen pigs were assigned to undergo 65 (n = 10) or 90 min (n = 6) of SCP at 28°C with LBCA in combination with occlusion of the 8 uppermost segmental arteries in the thoracic (Th) aorta (15-20 cm FET, Th8-level). The follow-up period consisted of a 6-h intensive period and a 5-day observation period. Near-infrared spectroscopy of the collateral network was used to determine spinal cord oxygenation. The neurological status of the patients was evaluated daily, and the brain and the spinal cord were harvested for a histopathological analysis. RESULTS Five out of 6 pigs after 90 min and 1 out of 10 pigs after 65 min of LBCA died within 48 h of multiorgan failure. Of the survivors in the 65-min group, 6 out of 9 had paraparesis/paraplegia; the remaining 3 reached normal function. The lone survivor after 90 min of LBCA was paraplegic. Nadir near-infrared spectroscopy of the collateral network values at Th8 and Th10 were 34 (±5) and 39 (±4), and they were reached within 35 min of SCP in both groups. CONCLUSIONS An extended FET graft with LBCA and SCP durations >65 min at 28°C results in a poor outcome.
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Affiliation(s)
- Hannu-Pekka Honkanen
- Department of Surgery, Research Unit of Surgery, Anaesthesia and Intensive Care, University of Oulu, Medical Research Center, Oulu, Finland
| | - Caius Mustonen
- Department of Surgery, Research Unit of Surgery, Anaesthesia and Intensive Care, University of Oulu, Medical Research Center, Oulu, Finland
| | - Hannu Tuominen
- Department of Pathology, Oulu University Hospital, Oulu, Finland
| | - Kai Kiviluoma
- Department of Surgery, Research Unit of Surgery, Anaesthesia and Intensive Care, University of Oulu, Medical Research Center, Oulu, Finland
| | - Vesa Anttila
- Department of Surgery, Heart Center, University of Turku and Turku University Hospital, Turku, Finland
| | - Tatu Juvonen
- Department of Surgery, Research Unit of Surgery, Anaesthesia and Intensive Care, University of Oulu, Medical Research Center, Oulu, Finland
- Department of Cardiac Surgery, Heart and Lung Center, Helsinki University Central Hospital, Helsinki, Finland
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Mustonen C, Honkanen HP, Lehtonen S, Tuominen H, Mäkelä T, Kaakinen T, Kiviluoma K, Anttila V, Juvonen T. Moderate hypothermia with remote ischaemic preconditioning improves cerebral protection compared to deep hypothermia: a study using a surviving porcine model. Eur J Cardiothorac Surg 2021; 58:269-276. [PMID: 32236538 DOI: 10.1093/ejcts/ezaa065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Revised: 01/30/2020] [Accepted: 02/05/2020] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES The optimal temperature management of hypothermic circulatory arrest is still controversial. Moderate hypothermia preserves cerebral autoregulation and shortens cardiopulmonary bypass (CPB) duration. However, moderate hypothermia alone has inferior organ protection to deep hypothermia, so adjuncts that increase the ischaemic tolerance are needed. Thus, we hypothesized that a combination of remote ischaemic preconditioning (RIPC) and moderate hypothermia would be superior to deep hypothermia alone. METHODS Sixteen pigs were randomized to either RIPC or control groups (8 + 8). The RIPC group underwent 4 cycles of transient hind limb ischaemia. The RIPC group underwent cooling with CPB to 24°C, and the control group underwent cooling with CPB to 18°C, followed by a 30-min arrest period and subsequent rewarming to 36°C. Measurements of cerebral metabolism were made from sagittal sinus blood samples and common carotid artery blood flow. The permissible periods of hypothermic circulatory arrest were calculated based on these measurements. Neurological recovery was evaluated daily during a 7-day follow-up, and the brain was harvested for histopathological analysis. RESULTS Six pigs in the RIPC group reached normal neurological function, but none in the control group reached normal neurological function (P = 0.007). The composite neurological score of all postoperative days was higher in the RIPC group than in the control group [55 (52-58) vs 45 (39-51), P = 0.026]. At 24°C, the estimated permissible periods of hypothermic circulatory arrest were 21 (17-25) min in the RIPC group and 11 (9-13) min in the control group (P = 0.007). CONCLUSIONS RIPC combined with moderate hypothermia provides superior cerebral protection.
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Affiliation(s)
- Caius Mustonen
- Research Unit of Surgery, Anaesthesia and Intensive Care, University of Oulu, Medical Research Center, Oulu, Finland
| | - Hannu-Pekka Honkanen
- Research Unit of Surgery, Anaesthesia and Intensive Care, University of Oulu, Medical Research Center, Oulu, Finland
| | - Siri Lehtonen
- Department of Obstetrics and Gynecology, Oulu University Hospital, Oulu, Finland
| | - Hannu Tuominen
- Department of Pathology, Oulu University Hospital, Oulu, Finland
| | - Tuomas Mäkelä
- Research Unit of Surgery, Anaesthesia and Intensive Care, University of Oulu, Medical Research Center, Oulu, Finland
| | - Timo Kaakinen
- Research Unit of Surgery, Anaesthesia and Intensive Care, University of Oulu, Medical Research Center, Oulu, Finland
| | - Kai Kiviluoma
- Research Unit of Surgery, Anaesthesia and Intensive Care, University of Oulu, Medical Research Center, Oulu, Finland
| | - Vesa Anttila
- Research Unit of Surgery, Anaesthesia and Intensive Care, University of Oulu, Medical Research Center, Oulu, Finland.,Heart Center, University of Turku, Turku University Hospital, Turku, Finland
| | - Tatu Juvonen
- Research Unit of Surgery, Anaesthesia and Intensive Care, University of Oulu, Medical Research Center, Oulu, Finland.,Department of Cardiac Surgery, Heart and Lung Center, Helsinki University Central Hospital, Helsinki University Hospital, Helsinki, Finland
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