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Hughes GC, Chen EP, Browndyke JN, Szeto WY, DiMaio JM, Brinkman WT, Gaca JG, Blumenthal JA, Karhausen JA, Bisanar T, James ML, Yanez D, Li YJ, Mathew JP. Cognitive Effects of Body Temperature During Hypothermic Circulatory Arrest Trial (GOT ICE): A Randomized Clinical Trial Comparing Outcomes After Aortic Arch Surgery. Circulation 2024; 149:658-668. [PMID: 38084590 PMCID: PMC10922813 DOI: 10.1161/circulationaha.123.067022] [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: 09/04/2023] [Accepted: 11/10/2023] [Indexed: 02/28/2024]
Abstract
BACKGROUND Deep hypothermia has been the standard for hypothermic circulatory arrest (HCA) during aortic arch surgery. However, centers worldwide have shifted toward lesser hypothermia with antegrade cerebral perfusion. This has been supported by retrospective data, but there has yet to be a multicenter, prospective randomized study comparing deep versus moderate hypothermia during HCA. METHODS This was a randomized single-blind trial (GOT ICE [Cognitive Effects of Body Temperature During Hypothermic Circulatory Arrest]) of patients undergoing arch surgery with HCA plus antegrade cerebral perfusion at 4 US referral aortic centers (August 2016-December 2021). Patients were randomized to 1 of 3 hypothermia groups: DP, deep (≤20.0 °C); LM, low-moderate (20.1-24.0 °C); and HM, high-moderate (24.1-28.0 °C). The primary outcome was composite global cognitive change score between baseline and 4 weeks postoperatively. Analysis followed the intention-to-treat principle to evaluate if: (1) LM noninferior to DP on global cognitive change score; (2) DP superior to HM. The secondary outcomes were domain-specific cognitive change scores, neuroimaging findings, quality of life, and adverse events. RESULTS A total of 308 patients consented; 282 met inclusion and were randomized. A total of 273 completed surgery, and 251 completed the 4-week follow-up (DP, 85 [34%]; LM, 80 [34%]; HM, 86 [34%]). Mean global cognitive change score from baseline to 4 weeks in the LM group was noninferior to the DP group; likewise, no significant difference was observed between DP and HM. Noninferiority of LM versus DP, and lack of difference between DP and HM, remained for domain-specific cognitive change scores, except structured verbal memory, with noninferiority of LM versus DP not established and structured verbal memory better preserved in DP versus HM (P = 0.036). There were no significant differences in structural or functional magnetic resonance imaging brain imaging between groups postoperatively. Regardless of temperature, patients who underwent HCA demonstrated significant reductions in cerebral gray matter volume, cortical thickness, and regional brain functional connectivity. Thirty-day in-hospital mortality, major morbidity, and quality of life were not different between groups. CONCLUSIONS This randomized multicenter study evaluating arch surgery HCA temperature strategies found low-moderate hypothermia noninferior to traditional deep hypothermia on global cognitive change 4 weeks after surgery, although in secondary analysis, structured verbal memory was better preserved in the deep group. The verbal memory differences in the low- and high-moderate groups and structural and functional connectivity reductions from baseline merit further investigation and suggest opportunities to further optimize brain perfusion during HCA. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT02834065.
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Affiliation(s)
- G Chad Hughes
- Department of Surgery, Division of Thoracic and Cardiovascular Surgery (G.C.H., E.P.C., J.G.G.), Duke University Medical Center, Durham, NC
| | - Edward P Chen
- Department of Surgery, Division of Thoracic and Cardiovascular Surgery (G.C.H., E.P.C., J.G.G.), Duke University Medical Center, Durham, NC
| | - Jeffrey N Browndyke
- Department of Psychiatry & Behavioral Sciences, Division of Behavioral Medicine & Neurosciences (J.N.B., J.A.B.), Duke University Medical Center, Durham, NC
| | - Wilson Y Szeto
- Department of Surgery, Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia (W.Y.S.)
| | - J Michael DiMaio
- The Heart Hospital, Baylor Scott and White, Plano, TX (J.M.D., W.T.B.)
| | | | - Jeffrey G Gaca
- Department of Surgery, Division of Thoracic and Cardiovascular Surgery (G.C.H., E.P.C., J.G.G.), Duke University Medical Center, Durham, NC
| | - James A Blumenthal
- Department of Psychiatry & Behavioral Sciences, Division of Behavioral Medicine & Neurosciences (J.N.B., J.A.B.), Duke University Medical Center, Durham, NC
| | - Jorn A Karhausen
- Department of Anesthesiology (J.A.K., T.B., M.L.J., J.P.M.), Duke University School of Medicine, Durham, NC
| | - Tiffany Bisanar
- Department of Anesthesiology (J.A.K., T.B., M.L.J., J.P.M.), Duke University School of Medicine, Durham, NC
| | - Michael L James
- Department of Anesthesiology (J.A.K., T.B., M.L.J., J.P.M.), Duke University School of Medicine, Durham, NC
- Department of Neurology (M.L.J.), Duke University School of Medicine, Durham, NC
| | - David Yanez
- Department of Biostatistics and Bioinformatics (D.Y., Y.-J.L.), Duke University School of Medicine, Durham, NC
| | - Yi-Ju Li
- Department of Biostatistics and Bioinformatics (D.Y., Y.-J.L.), Duke University School of Medicine, Durham, NC
| | - Joseph P Mathew
- Department of Anesthesiology (J.A.K., T.B., M.L.J., J.P.M.), Duke University School of Medicine, Durham, NC
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Chen Y, Dong K, Fang C, Shi H, Luo W, Tang CE, Luo F. The predictive values of monocyte-lymphocyte ratio in postoperative acute kidney injury and prognosis of patients with Stanford type A aortic dissection. Front Immunol 2023; 14:1195421. [PMID: 37554321 PMCID: PMC10404983 DOI: 10.3389/fimmu.2023.1195421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 07/03/2023] [Indexed: 08/10/2023] Open
Abstract
Objectives Postoperative acute kidney injury (pAKI) is a serious complication of Stanford type A aortic dissection (TAAD) surgery, which is significantly associated with the inflammatory response. This study aimed to explore the relationship between blood count-derived inflammatory markers (BCDIMs) and pAKI and to construct a predictive model for pAKI. Methods Patients who underwent TAAD surgery were obtained from our center and the Medical Information Mart for Intensive Care (MIMIC)-IV database. The differences in preoperative BCDIMs and clinical outcomes of patients with and without pAKI were analyzed. Logistic regression was used to construct predictive models based on preoperative BCDIMs or white cell counts (WCCs). The performance of the BCDIMs and WCCs models was evaluated and compared using the receiver operating characteristic (ROC) curve, area under the ROC curve (AUC), Hosmer-Lemeshow test, calibration plot, net reclassification index (NRI), integrated discrimination improvement index (IDI), and decision curve analysis (DCA). The Kaplan-Meier curves were applied to compare the survival rate between different groups. Results The overall incidence of pAKI in patients who underwent TAAD surgery from our center was 48.63% (124/255). The presence of pAKI was associated with longer ventilation time, higher incidence of cerebral complications and postoperative hepatic dysfunction, and higher in-hospital mortality. The results of the logistic regression indicated that the monocyte-lymphocyte ratio (MLR) was an independent risk factor for pAKI. The BCDIMs model had good discriminating ability, predictive ability, and clinical utility. In addition, the performance of the BCDIMs model was significantly better than that of the WCCs model. Analysis of data from the MIMIC-IV database validated that MLR was an independent risk factor for pAKI and had predictive value for pAKI. Finally, data from the MIMIC-IV database demonstrated that patients with a high MLR had a significantly poor 28-day survival rate when compared to patients with a low MLR. Conclusion Our study suggested that the MLR is an independent risk factor for pAKI. A predictive model based on BCDIMs had good discriminating ability, predictive ability, and clinical utility. Moreover, the performance of the BCDIMs model was significantly better than that of the WCCs model. Finally, a high MLR was significantly associated with poor short-term survival of patients who underwent TAAD surgery.
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Affiliation(s)
- Yubin Chen
- Department of Cardiac Surgery, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Kaiyi Dong
- Department of Cardiac Surgery, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Cheng Fang
- Department of Cardiac Surgery, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Hui Shi
- Department of Cardiac Surgery, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Wenjie Luo
- Department of Cardiac Surgery, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Can-e Tang
- Department of Endocrinology, Xiangya Hospital, Central South University, Changsha, Hunan, China
- The Institute of Medical Science Research, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Fanyan Luo
- Department of Cardiac Surgery, Xiangya Hospital, Central South University, Changsha, Hunan, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, China
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Zhang P, Bai L, Tong Y, Guo S, Lu W, Yuan Y, Wang W, Jin Y, Gao P, Liu J. CIRP attenuates acute kidney injury after hypothermic cardiovascular surgery by inhibiting PHD3/HIF-1α-mediated ROS-TGF-β1/p38 MAPK activation and mitochondrial apoptotic pathways. Mol Med 2023; 29:61. [PMID: 37127576 PMCID: PMC10152741 DOI: 10.1186/s10020-023-00655-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 04/18/2023] [Indexed: 05/03/2023] Open
Abstract
BACKGROUND The ischemia-reperfusion (IR) environment during deep hypothermic circulatory arrest (DHCA) cardiovascular surgery is a major cause of acute kidney injury (AKI), which lacks preventive measure and treatment. It was reported that cold inducible RNA-binding protein (CIRP) can be induced under hypoxic and hypothermic stress and may have a protective effect on multiple organs. The purpose of this study was to investigate whether CIRP could exert renoprotective effect during hypothermic IR and the potential mechanisms. METHODS Utilizing RNA-sequencing, we compared the differences in gene expression between Cirp knockout rats and wild-type rats after DHCA and screened the possible mechanisms. Then, we established the hypothermic oxygen-glucose deprivation (OGD) model using HK-2 cells transfected with siRNA to verify the downstream pathways and explore potential pharmacological approach. The effects of CIRP and enarodustat (JTZ-951) on renal IR injury (IRI) were investigated in vivo and in vitro using multiple levels of pathological and molecular biological experiments. RESULTS We discovered that Cirp knockout significantly upregulated rat Phd3 expression, which is the key regulator of HIF-1α, thereby inhibiting HIF-1α after DHCA. In addition, deletion of Cirp in rat model promoted apoptosis and aggravated renal injury by reactive oxygen species (ROS) accumulation and significant activation of the TGF-β1/p38 MAPK inflammatory pathway. Then, based on the HK-2 cell model of hypothermic OGD, we found that CIRP silencing significantly stimulated the expression of the TGF-β1/p38 MAPK inflammatory pathway by activating the PHD3/HIF-1α axis, and induced more severe apoptosis through the mitochondrial cytochrome c-Apaf-1-caspase 9 and FADD-caspase 8 death receptor pathways compared with untransfected cells. However, silencing PHD3 remarkably activated the expression of HIF-1α and alleviated the apoptosis of HK-2 cells in hypothermic OGD. On this basis, by pretreating HK-2 and rats with enarodustat, a novel HIF-1α stabilizer, we found that enarodustat significantly mitigated renal cellular apoptosis under hypothermic IR and reversed the aggravated IRI induced by CIRP defect, both in vitro and in vivo. CONCLUSION Our findings indicated that CIRP may confer renoprotection against hypothermic IRI by suppressing PHD3/HIF-1α-mediated apoptosis. PHD3 inhibitors and HIF-1α stabilizers may have clinical value in renal IRI.
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Affiliation(s)
- Peiyao Zhang
- State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 102308, China
- Department of Cardiopulmonary Bypass, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No.167, North Lishi Road, Xicheng District, Beijing, 100037, China
| | - Liting Bai
- Department of Anesthesiology, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, China
| | - Yuanyuan Tong
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, China
| | - Shengwen Guo
- Department of Anesthesiology, Xiamen Cardiovascular Hospital, Xiamen University, Xiamen, Fujian, 361000, China
| | - Wenlong Lu
- State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 102308, China
| | - Yue Yuan
- Department of Endocrinology, Drum Tower Hospital affiliated to Nanjing University Medical School, Branch of National Clinical Research Centre for Metabolic Diseases, Nanjing, Jiangsu, 210008, China
| | - Wenting Wang
- Department of Cardiopulmonary Bypass, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No.167, North Lishi Road, Xicheng District, Beijing, 100037, China
| | - Yu Jin
- Department of Cardiopulmonary Bypass, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No.167, North Lishi Road, Xicheng District, Beijing, 100037, China
| | - Peng Gao
- Department of Cardiopulmonary Bypass, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No.167, North Lishi Road, Xicheng District, Beijing, 100037, China
| | - Jinping Liu
- Department of Cardiopulmonary Bypass, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No.167, North Lishi Road, Xicheng District, Beijing, 100037, China.
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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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Chen CH, Peterson MD, Mazer CD, Hibino M, Beaudin AE, Chu MWA, Dagenais F, Teoh H, Quan A, Dickson J, Verma S, Smith EE. Acute Infarcts on Brain MRI Following Aortic Arch Repair With Circulatory Arrest: Insights From the ACE CardioLink-3 Randomized Trial. Stroke 2023; 54:67-77. [PMID: 36315249 DOI: 10.1161/strokeaha.122.041612] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND to investigate the frequency and distribution of new ischemic brain lesions detected by diffusion-weighted imaging on brain magnetic resonance imaging after aortic arch surgery. METHODS This preplanned secondary analysis of the randomized, controlled ACE (Aortic Surgery Cerebral Protection Evaluation) CardioLink-3 trial compared the safety and efficacy of innominate versus axillary artery cannulation during elective proximal aortic arch surgery. Participants underwent pre and postoperative magnetic resonance imaging. New ischemic lesions were defined as lesions visible on postoperative, but not preoperative diffusion weighted imaging. RESULTS Of the 111 trial participants, 102 had complete magnetic resonance imaging data. A total of 391 new ischemic lesions were observed on diffusion-weighted imaging in 71 (70%) patients. The average number of lesions in patients with ischemic lesion were 5.5±4.9 with comparable numbers in the right (2.9±2.0) and left (3.0±2.3) hemispheres (P=0.49). Half the new lesions were in the middle cerebral artery territory; 63% of the cohort had ischemic lesions in the anterior circulation, 49% in the posterior circulation, 42% in both, and 20% in watershed areas. A probability mask of all diffusion-weighted imaging lesions revealed that the cerebellum was commonly involved. More severe white matter hyperintensity on preoperative magnetic resonance imaging (odds ratio, 1.80 [95% CI, 1.10-2.95]; P=0.02) and lower nadir nasopharyngeal temperature during surgery (odds ratio per 1°C decrease, 1.15 [95% CI, 1.00-1.32]; P=0.05) were associated with the presentation of new ischemic lesion; older age (risk ratio per 1-year increase, 1.02 [95% CI, 1.00-1.04]; P=0.03) and lower nadir temperature (risk ratio per 1°C decrease, 1.06 [95% CI, 1.00-1.14]; P=0.06) were associated with greater number of lesions. CONCLUSIONS In patients who underwent elective proximal aortic arch surgery, new ischemic brain lesions were common, and predominantly involved the middle cerebral artery territory or cerebellum. Underlying small vessel disease, lower temperature nadir during surgery, and advanced age were risk factors for perioperative ischemic lesions. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT02554032.
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Affiliation(s)
- Chih-Hao Chen
- Department of Clinical Neurosciences, University of Calgary, AB, Canada (C.-H.C., A.E.B., E.E.S.).,Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan (C.-H.C.)
| | - Mark D Peterson
- Division of Cardiac Surgery, St. Michael's Hospital, Toronto, ON, Canada (M.D.P., H.T., A.Q., S.V.).,Department of Surgery, University of Toronto, ON, Canada (M.D.P., S.V.)
| | - C David Mazer
- Department of Anesthesia, St. Michael's Hospital, Toronto, ON, Canada (C.D.M., J.D.).,Departments of Anesthesiology and Pain Medicine, University of Toronto, ON, Canada (C.D.M., J.D.).,Department of Physiology, University of Toronto, ON, Canada (C.D.M.)
| | - Makoto Hibino
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, GA (M.H.)
| | - Andrew E Beaudin
- Department of Clinical Neurosciences, University of Calgary, AB, Canada (C.-H.C., A.E.B., E.E.S.).,Hotchkiss Brain Institute, University of Calgary, AB, Canada (A.E.B., E.E.S.)
| | - Michael W A Chu
- Division of Cardiac Surgery, London Health Sciences Centre and the Western University, ON, Canada (M.W.A.C.)
| | - François Dagenais
- Quebec Heart and Lung Institute, Université Laval, Quebec City, QC, Canada (F.D.)
| | - Hwee Teoh
- Division of Cardiac Surgery, St. Michael's Hospital, Toronto, ON, Canada (M.D.P., H.T., A.Q., S.V.).,Division of Endocrinology and Metabolism, St. Michael's Hospital, Toronto, ON, Canada (H.T.)
| | - Adrian Quan
- Division of Cardiac Surgery, St. Michael's Hospital, Toronto, ON, Canada (M.D.P., H.T., A.Q., S.V.)
| | - Jeffrey Dickson
- Department of Anesthesia, St. Michael's Hospital, Toronto, ON, Canada (C.D.M., J.D.).,Departments of Anesthesiology and Pain Medicine, University of Toronto, ON, Canada (C.D.M., J.D.)
| | - Subodh Verma
- Division of Cardiac Surgery, St. Michael's Hospital, Toronto, ON, Canada (M.D.P., H.T., A.Q., S.V.).,Department of Surgery, University of Toronto, ON, Canada (M.D.P., S.V.).,Department of Pharmacology and Toxicology, University of Toronto, ON, Canada (S.V.)
| | - Eric E Smith
- Department of Clinical Neurosciences, University of Calgary, AB, Canada (C.-H.C., A.E.B., E.E.S.).,Hotchkiss Brain Institute, University of Calgary, AB, Canada (A.E.B., E.E.S.)
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Malvindi PG, Alfonsi J, Berretta P, Cefarelli M, Gatta E, Di Eusanio M. Normothermic frozen elephant trunk: our experience and literature review. Cardiovasc Diagn Ther 2022; 12:262-271. [PMID: 35800357 PMCID: PMC9253169 DOI: 10.21037/cdt-22-73] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 05/17/2022] [Indexed: 09/10/2023]
Abstract
BACKGROUND AND OBJECTIVE The frozen elephant trunk (FET) technique has undoubtable advantages in treating complex and extensive disease of the aortic arch and the thoracic descending aorta. Despite several improvements in cardiopulmonary bypass conduction and surgical strategy, operative times and the institution of systemic circulatory arrest remain the main determinants of early mortality, cerebral/spinal cord injury and visceral organs dysfunction. We have conducted this review to highlight the recent technical advances in arch and FET surgery aiming at the reduction/avoidance of systemic circulatory arrest, and their impact on early outcomes. METHODS A literature search (from origin to January 2022), limited to publications in English, was performed on online platforms and database (PubMed, Google, ResearchGate). After a further review of associated or similar papers, we found 4 experiences, described by 11 peer-reviewed published papers, which focused on minimising or avoiding systemic circulatory arrest during total arch replacement plus stenting of the descending thoracic aorta. KEY CONTENT AND FINDINGS Recent experiences reported the use of an antegrade endoaortic balloon, advanced and inflated into the stent graft, to provide an early systemic reperfusion soon after the deployment of the stented portion of the FET prosthesis and minimize the circulatory arrest time (down to a mean of 5 minutes), thus avoiding the need of moderate or deep hypothermia (mean systemic temperature 28-30 °C) while allowing a complete arch and FET repair. Our approach, based on off-pump retrograde vascular stent graft deployment in distal arch/descending thoracic aorta, and the use of a retrograde endoballoon, allows the repair of extensive aortic pathologies during uninterrupted normothermic cerebral and lower body perfusion. CONCLUSIONS The use of endoballoon occlusion has emerged in recent years as a safe and effective strategy to allow distal perfusion during FET repair. This technique minimizes or avoids the detrimental effects of hypothermia and systemic circulatory arrest and significantly reduces the operative times.
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Affiliation(s)
- Pietro Giorgio Malvindi
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Polytechnic University of Marche, Ancona, Italy
| | - Jacopo Alfonsi
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Polytechnic University of Marche, Ancona, Italy
| | - Paolo Berretta
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Polytechnic University of Marche, Ancona, Italy
| | - Mariano Cefarelli
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Polytechnic University of Marche, Ancona, Italy
| | - Emanuele Gatta
- Vascular Surgery Department, Lancisi Cardiovascular Center, Ancona, Italy
| | - Marco Di Eusanio
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Polytechnic University of Marche, Ancona, Italy
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Du Y, Fang Z, Sun Y, Zhang C, Lei G, Chen Y, Yang L, Yang X, Li J, Wang G. Moderate and Deep Hypothermic Circulatory Arrest Have Comparable Effects on Severe Systemic Inflammatory Response Syndrome After Total Aortic Arch Replacement in Patients With Type A Aortic Dissection. Front Surg 2021; 8:758854. [PMID: 34938767 PMCID: PMC8685200 DOI: 10.3389/fsurg.2021.758854] [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: 08/15/2021] [Accepted: 11/12/2021] [Indexed: 11/13/2022] Open
Abstract
Background: The objective of this study was to compare the incidence of severe systemic inflammatory response syndrome (sSIRS) after total aortic arch replacement between patients who underwent moderate hypothermic circulatory arrest (MHCA) and those who underwent deep hypothermic circulatory arrest (DHCA). Methods: At Fuwai Hospital, 600 patients who underwent total aortic arch replacement with MHCA or DHCA from January 2013 to December 2016 were consecutively enrolled and divided into DHCA (14.1-20.0°C) and MHCA (20.1-28.0°C) groups. Preliminary statistical analysis revealed that some baseline indicators differed between the two groups; therefore, propensity score matching (PSM) was used to balance the covariates. Post-operative sSIRS as the primary outcome was compared between the groups both before and after PSM. Results: A total of 275 (45.8%) patients underwent MHCA, and 325 (54.2%) patients underwent DHCA. After PSM analysis, a total of 191 matched pairs were obtained. The overall incidence of sSIRS was 27.3%. There was no significant difference in post-operative sSIRS between the MHCA group and the DHCA group in either the overall cohort or the PSM cohort (no-PSM: P = 0.188; PSM: P = 0.416); however, post-operative sSIRS was increased by ~4% in the DHCA group compared with the MHCA group in both the no-PSM and PSM cohorts (no-PSM: 29.5 vs. 24.7%; PSM: 29.3 vs. 25.1%). Both before and after PSM, the rates of gastrointestinal hemorrhage and pulmonary infection and post-operative length of stay were significantly increased in the DHCA group compared with the MHCA group (P < 0.05), and the remaining secondary outcomes were not significantly different between the groups. Conclusions: MHCA and DHCA are associated with comparable incidences of sSIRS in patients following total aortic arch replacement for type A aortic dissection. However, the MHCA group had a shorter cardiopulmonary bypass time, a shorter post-operative length of stay and lower pulmonary infection and gastrointestinal hemorrhage rates than the DHCA group. We cautiously recommend the use of MHCA for most total arch replacements in patients with type A aortic dissection.
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Affiliation(s)
- Yinejie Du
- Department of Anesthesiology, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Zhongrong Fang
- Department of Anesthesiology, National Center of Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, Beijing, China
| | - Yanhua Sun
- Department of Anesthesiology, The Affiliated Drum Tower Hospital of Nanjing, University Medical School, Nanjing, China
| | - Congya Zhang
- Department of Anesthesiology, Beijing Tongren Hospital, Capital Medical University, Beijing, China.,Department of Anesthesiology, National Center of Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, Beijing, China
| | - Guiyu Lei
- Department of Anesthesiology, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Yimeng Chen
- Department of Anesthesiology, Beijing Tongren Hospital, Capital Medical University, Beijing, China.,Department of Anesthesiology, National Center of Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, Beijing, China
| | - Lijing Yang
- Department of Anesthesiology, National Center of Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, Beijing, China
| | - Xiying Yang
- Department of Anesthesiology, National Center of Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, Beijing, China
| | - Jun Li
- Department of Anesthesiology, National Center of Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, Beijing, China
| | - Guyan Wang
- Department of Anesthesiology, Beijing Tongren Hospital, Capital Medical University, Beijing, China
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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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Vekstein AM, Yerokun BA, Jawitz OK, Doberne JW, Anand J, Karhausen J, Ranney DN, Benrashid E, Wang H, Keenan JE, Schroder JN, Gaca JG, Hughes GC. Does deeper hypothermia reduce the risk of acute kidney injury after circulatory arrest for aortic arch surgery? Eur J Cardiothorac Surg 2021; 60:314-321. [PMID: 33624004 DOI: 10.1093/ejcts/ezab044] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 12/18/2020] [Accepted: 12/29/2020] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVES The impact of hypothermic circulatory arrest (HCA) temperature on postoperative acute kidney injury (AKI) has not been evaluated. This study examined the association between circulatory arrest temperatures and AKI in patients undergoing proximal aortic surgery with HCA. METHODS A total of 759 consecutive patients who underwent proximal aortic surgery (ascending ± valve ± root) including arch replacement requiring HCA between July 2005 and December 2016 were identified from a prospectively maintained institutional aortic surgery database. The primary outcome was AKI as defined by Risk, Injury, Failure, Loss, End Stage Renal Disease (ESRD) criteria. The association between minimum nasopharyngeal (NP) and bladder temperatures during HCA and postoperative AKI was assessed, adjusting for patient-level factors using multivariable logistic regression. RESULTS A total of 85% (n = 645) of patients underwent deep hypothermia (14.1-20.0°C), 11% (n = 83) low-moderate hypothermia (20.1-24.0°C) and 4% (n = 31) high-moderate hypothermia (24.1-28.0°C) as classified by NP temperature. When analysed by bladder temperature, 59% (n = 447) underwent deep hypothermia, 22% (n = 170) low-moderate, 16% (n = 118) high-moderate and 3% mild (n = 24) (28.1-34.0°C) hypothermia. The median systemic circulatory arrest time was 17 min. The incidence of AKI did not differ between hypothermia groups, whether analysed using minimum NP or bladder temperature. In the multivariable analysis, the association between degree of hypothermia and AKI remained non-significant whether analysed as a categorical variable (hypothermia group) or as a continuous variable (minimum NP or bladder temperature) (all P > 0.05). CONCLUSIONS In patients undergoing proximal aortic surgery including arch replacement requiring HCA, degree of systemic hypothermia was not associated with the risk of AKI. These data suggest that moderate hypothermia does not confer increased risk of AKI for patients requiring circulatory arrest, although additional prospective data are needed.
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Affiliation(s)
- Andrew M Vekstein
- Department of Surgery, Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Babtunde A Yerokun
- Department of Surgery, Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Oliver K Jawitz
- Department of Surgery, Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Julie W Doberne
- Department of Surgery, Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Jatin Anand
- Department of Surgery, Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Jorn Karhausen
- Department of Surgery, Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, NC, USA
| | - David N Ranney
- Department of Surgery, Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Ehsan Benrashid
- Department of Surgery, Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Hanghang Wang
- Department of Surgery, Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Jeffrey E Keenan
- Department of Surgery, Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Jacob N Schroder
- Department of Surgery, Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Jeffrey G Gaca
- Department of Surgery, Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, NC, USA
| | - G Chad Hughes
- Department of Surgery, Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, NC, USA
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The Role of Deep Hypothermia in Cardiac Surgery. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18137061. [PMID: 34280995 PMCID: PMC8297075 DOI: 10.3390/ijerph18137061] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 06/27/2021] [Accepted: 06/28/2021] [Indexed: 12/24/2022]
Abstract
Hypothermia is defined as a decrease in body core temperature to below 35 °C. In cardiac surgery, four stages of hypothermia are distinguished: mild, moderate, deep, and profound. The organ protection offered by deep hypothermia (DH) enables safe circulatory arrest as a prerequisite to carrying out cardiac surgical intervention. In adult cardiac surgery, DH is mainly used in aortic arch surgery, surgical treatment of pulmonary embolism, and acute type-A aortic dissection interventions. In surgery treating congenital defects, DH is used to assist aortic arch reconstructions, hypoplastic left heart syndrome interventions, and for multi-stage treatment of infants with a single heart ventricle during the neonatal period. However, it should be noted that a safe duration of circulatory arrest in DH for the central nervous system is 30 to 40 min at most and should not be exceeded to prevent severe neurological adverse events. Personalized therapy for the patient and adequate blood temperature monitoring, glycemia, hematocrit, pH, and cerebral oxygenation is a prerequisite and indispensable part of DH.
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Benedikt P, Gottsberger J, Zierer AF. Temperatur- und Perfusionsmanagement bei akuter Typ-A-Aortendissektion. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2021. [DOI: 10.1007/s00398-021-00422-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
ZusammenfassungDie chirurgische Versorgung der akuten Typ-A-Aortendissektion erfuhr in den letzten Jahrzehnten v. a. im Hinblick auf das Perfusions- und Temperaturmanagement eine ständige Entwicklung. Neurologische Komplikationen sind die Hauptursache der postoperativen Morbidität und Mortalität. Die Verwendung einer Herz-Lungen-Maschine, des Kreislaufstillstands in tiefer Hypothermie, die temporäre Unterbrechung der zerebralen Perfusion oder Hypoperfusion des Gehirns und die Manipulation an der Aorta können zu neurologischen Schäden führen. Der Kreislaufstillstand in tiefer Hypothermie ermöglicht Eingriffe an der thorakalen Aorta, die für die Sanierung einer akuten Dissektion notwendig sein können. Dies hat allerdings Limitationen: Einerseits ist die Eingriffszeit begrenzt, andererseits führt die tiefe Hypothermie selbst zu Schäden. Experimentelle und klinische Studien konnten zeigen, dass der Grad der Hypothermie einen Einfluss auf die Komplikationsrate hat. Auch über den Nutzen der retrograden Hirnperfusion besteht noch Uneinigkeit. Das Konzept des Kreislaufstillstands mit zusätzlicher Hirnperfusion, besonders wenn der Grad der Hypothermie entsprechend der erwarteten Kreislaufstillstandzeit angepasst wird, erwies sich als sichere Methode. Es ermöglicht komplexe Eingriffe an der Aorta bei geringen Komplikationsraten und wird zunehmend als Standardverfahren bei der Versorgung der akuten Typ-A-Dissektion angewandt.
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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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13
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Dong SB, Zhang K, Zhu K, Wang LF, Zheng J, Li JR, Liu YM, Sun LZ, Pan XD. Mild hypothermic circulatory arrest with selective cerebral perfusion in open arch surgery. J Thorac Dis 2021; 13:1151-1161. [PMID: 33717588 PMCID: PMC7947532 DOI: 10.21037/jtd-20-3550] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Background This study aimed to evaluate whether the use of mild hypothermic circulatory arrest (HCA) with selective cerebral perfusion (SCP) in open arch procedure provides comparable perioperative results to moderate HCA for patients with dissected or degenerative arch pathologies. Methods Between January 2017 and September 2020, a total of 88 consecutive patients (mean age 47±11 years, 71 males) underwent open arch repair under a single surgeon at our institution with mild or moderate systemic hypothermia assisted by unilateral or bilateral SCP. Patients were divided into groups according to the nasopharyngeal temperature at the beginning of HCA: a moderate HCA group (n=47, 53.4%) and a mild HCA group (n=41, 46.6%). The postoperative mortality, morbidity, and visceral organ functions between these groups were analyzed retrospectively. Results Compared to the moderate HCA group, the mild HCA group had a significantly higher core temperature (nasopharynx: 24.4±0.8 vs. 28.5±2, P<0.001; bladder 25.9±0.9 vs. 30±1.2, P<0.001), and the incidence of major adverse events (MAE) in this group was markedly lower (21.3% vs. 4.9%, P=0.031). No differences were identified between the two groups refer to in-hospital mortality, permanent neurological deficit (PND), temporary neurological deficit (TND), and paraplegia (8.5% vs. 2.4%, P=0.366; 8.5% vs. 0, P=0.120; 6.4% vs. 7.3%, P=1.0; 4.3% vs. 2.4%, P=1.0, respectively). In the moderate HCA group, 6 patients (12.8%) developed acute renal failure needing replacement therapy, which did not occur in the mild HCA group (P=0.028). The duration of ventilator support and intensive care unit stay was shorter in the mild HCA group, as well as a decreased volume of drainage during the first 24 h and reduced platelet transfusion. Conclusions The preliminary results of the mild HCA group with SCP applied in open arch repair, mainly in total arch replacement (TAR) and stented elephant trunk (SET) implantation for aortic dissection, were satisfactory. Furthermore, comparable inferior outcomes were obtained with mild HCA compared with that of the conventional moderate HCA strategy. These encouraging surgical and postoperative results favor this more aggressive hypothermia strategy in open arch repair.
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Affiliation(s)
- Song-Bo Dong
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, and Beijing Institute of Heart, Lung, and Blood Vessel Diseases, Beijing, China
| | - Kai Zhang
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, and Beijing Institute of Heart, Lung, and Blood Vessel Diseases, Beijing, China
| | - Kai Zhu
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, and Beijing Institute of Heart, Lung, and Blood Vessel Diseases, Beijing, China
| | - Long-Fei Wang
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, and Beijing Institute of Heart, Lung, and Blood Vessel Diseases, Beijing, China
| | - Jun Zheng
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, and Beijing Institute of Heart, Lung, and Blood Vessel Diseases, Beijing, China
| | - Jian-Rong Li
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, and Beijing Institute of Heart, Lung, and Blood Vessel Diseases, Beijing, China
| | - Yong-Min Liu
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, and Beijing Institute of Heart, Lung, and Blood Vessel Diseases, Beijing, China
| | - Li-Zhong Sun
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, and Beijing Institute of Heart, Lung, and Blood Vessel Diseases, Beijing, China
| | - Xu-Dong Pan
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, and Beijing Institute of Heart, Lung, and Blood Vessel Diseases, Beijing, China
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Salem M, Friedrich C, Thiem A, Salem MA, Erdal Y, Puehler T, Rusch R, Berndt R, Cremer J, Haneya A. Influence of moderate hypothermic circulatory arrest on outcome in patients undergoing elective replacement of thoracic aorta. J Thorac Dis 2020; 12:5756-5764. [PMID: 33209407 PMCID: PMC7656372 DOI: 10.21037/jtd-19-4166] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background The ideal technique of cerebral protection in the surgical operation of the ascending aorta.is currently controversial. The current analysis evaluates the influence of moderate hypothermic circulatory arrest (MHCA) on elective replacement of the ascending aorta. Methods The study included 905 consecutive patients between 2001 and 2015, who underwent replacement of ascending aorta in MHCA. Patients were divided according to the postoperative 30-day mortality into survivor und non-survivor group. Results The average age was 66.5±11.1 in survivors vs. 70.0±10.5 years in non-survivors (P=0.057). The survivor group had a significantly lower Euro-SCORE II than non-survivors [4.0% (2.3, 6.6) vs. 9.5% (4.8, 20.9); P<0.001)]. The incidence of coronary heart disease (38.0% vs. 58.3%; P=0.022) and chronic renal failure (10.0% vs. 33.3%, P<0.001 was significantly higher in non-survivors. Intraoperatively, the cardiopulmonary bypass time [140 min (112, 185) vs. 194 min (164, 271); P<0.001] and cross-clamping time [91 min (64, 124) vs.119 min (94, 157); P<0.001] were significantly longer in non-survivors. However, the MHCA time was similar in both groups with statistical significance (P=0.023). Postoperatively, re-exploration due to bleeding was highly significant in non-survivors (5.4% vs. 33.3%; P<0.001) with a higher incidence of stroke (4.6% vs. 33.3%; P<0.001). The duration of mechanical ventilation was significantly shorter in survivors than in non-survivors [17 h (12, 26) vs. 147 h (49, 337); P<0.001] with a lower incidence of pulmonary infection (6.0% vs.16.7%; P=0.023). The multivariable logistic regression analysis showed age, female gender, aortic aneurysm, additional CABG, total arch replacement and cardiopulmonary bypass time were independent risk factors for 30-day mortality. Conclusions The acceptable morbidity and mortality rates show that MHCA can be considered as a safe technique for cerebral protection in surgical replacement of thoracic aorta.
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Affiliation(s)
- Mohamed Salem
- Department of Cardiovascular Surgery, University of Schleswig-Holstein, Campus Kiel, Germany
| | - Christine Friedrich
- Department of Cardiovascular Surgery, University of Schleswig-Holstein, Campus Kiel, Germany
| | - Alexander Thiem
- Department of Cardiovascular Surgery, University of Schleswig-Holstein, Campus Kiel, Germany
| | - Mostafa Ahmed Salem
- Department of Cardiovascular Surgery, University of Schleswig-Holstein, Campus Kiel, Germany
| | - Yasemin Erdal
- Department of Cardiovascular Surgery, University of Schleswig-Holstein, Campus Kiel, Germany
| | - Thomas Puehler
- Department of Cardiovascular Surgery, University of Schleswig-Holstein, Campus Kiel, Germany
| | - Rene Rusch
- Department of Cardiovascular Surgery, University of Schleswig-Holstein, Campus Kiel, Germany
| | - Rouven Berndt
- Department of Cardiovascular Surgery, University of Schleswig-Holstein, Campus Kiel, Germany
| | - Jochen Cremer
- Department of Cardiovascular Surgery, University of Schleswig-Holstein, Campus Kiel, Germany
| | - Assad Haneya
- Department of Cardiovascular Surgery, University of Schleswig-Holstein, Campus Kiel, Germany
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Mazzeffi M, Ghoreishi M, Alejo D, Fonner CE, Tanaka K, Abernathy JH, Whitman G, Salenger R, Lawton J, Ad N, Brown J, Gammie J, Taylor B. Clinical Practice Variation and Outcomes for Stanford Type A Aortic Dissection Repair Surgery in Maryland: Report from a Statewide Quality Initiative. AORTA : OFFICIAL JOURNAL OF THE AORTIC INSTITUTE AT YALE-NEW HAVEN HOSPITAL 2020; 8:66-73. [PMID: 33152787 PMCID: PMC7644293 DOI: 10.1055/s-0040-1714121] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Background
Stanford Type A aortic dissection repair surgery is associated with high mortality and clinical practice remains variable among hospitals. Few studies have examined statewide practice variation.
Methods
Patients who had Stanford Type A aortic dissection repair surgery in Maryland between July 1, 2014 and June 30, 2018 were identified using the Maryland Cardiac Surgery Quality Initiative (MCSQI) database. Patient demographics, comorbidities, surgery details, and outcomes were compared between hospitals. We also explored the impact of arterial cannulation site and brain protection technique on outcome.
Results
A total of 233 patients were included from eight hospitals during the study period. Seventy-six percent of surgeries were done in two high-volume hospitals (≥10 cases per year), while the remaining 24% were done in low-volume hospitals. Operative mortality was 12.0% and varied between 0 and 25.0% depending on the hospital. Variables that differed significantly between hospitals included patient age, the percentage of patients in shock, left ventricular ejection fraction, creatinine level, arterial cannulation site, brain protection technique, tobacco use, and intraoperative blood transfusion. The percentage of patients who underwent aortic valve repair or replacement procedures differed significantly between hospitals (
p
< 0.001), although the prevalence of moderate-to-severe aortic insufficiency was not significantly different (
p
= 0.14). There were no significant differences in clinical outcomes including mortality, renal failure, stroke, or gastrointestinal complications between hospitals or based on arterial cannulation site (all
p
> 0.05). Patients who had aortic cross-clamping or endovascualr repair had more embolic strokes when compared with patients who had hypothermic circulatory arrest (
p
= 0.03).
Conclusion
There remains considerable practice variation in Stanford Type A aortic dissection repair surgery within Maryland including some modifiable factors such as intraoperative blood transfusion, arterial cannulation site, and brain protection technique. Continued efforts are needed within MCSQI and nationally to evaluate and employ the best practices for patients having acute aortic dissection repair surgery.
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Affiliation(s)
- Michael Mazzeffi
- Department of Anesthesiology, University of Maryland, Baltimore, Maryland
| | - Mehrdad Ghoreishi
- Division of Cardiothoracic Surgery, Department of Surgery, University of Maryland, Baltimore, Maryland
| | - Diane Alejo
- Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Clifford E Fonner
- Division of Cardiothoracic Surgery, Maryland Cardiac Surgery Quality Initiative Inc., Baltimore, Maryland
| | - Kenichi Tanaka
- Department of Anesthesiology, University of Maryland, Baltimore, Maryland
| | - James H Abernathy
- Department of Anesthesiology, Johns Hopkins University, Baltimore, Maryland
| | - Glenn Whitman
- Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Rawn Salenger
- Department of Cardiothoracic surgery, St. Joseph Medical Center, Towson, Maryland
| | - Jennifer Lawton
- Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Niv Ad
- Department of Cardiothoracic Surgery, Washington Adventist Hospital, Takoma Park, Maryland
| | - James Brown
- Department of Surgery, University of Maryland, Capital Region Health, Cheverly, Maryland
| | - James Gammie
- Division of Cardiothoracic Surgery, Department of Surgery, University of Maryland, Baltimore, Maryland
| | - Bradley Taylor
- Division of Cardiothoracic Surgery, Department of Surgery, University of Maryland, Baltimore, Maryland
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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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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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18
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Salem M, Friedrich C, Thiem A, Salem MA, Puehler T, Rusch R, Berndt R, Cremer J, Haneya A. Effect of moderate hypothermic circulatory arrest on neurological outcomes in elderly patients undergoing replacement of the thoracic aorta. Egypt Heart J 2020; 72:14. [PMID: 32232606 PMCID: PMC7105549 DOI: 10.1186/s43044-020-00043-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Accepted: 02/14/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Various studies evaluated the relationship between hypothermic circulatory arrest and neurological outcome in patients undergoing replacement of ascending aorta. The current analysis focuses on the effect of moderate hypothermic circulatory arrest (MHCA) on elderly patients. The aim of our study was to evaluate the impact of MHCA on neurological outcomes in elderly patients undergoing replacement of the ascending aorta. RESULTS We retrospectively analyzed 905 consecutive patients, who underwent elective replacement of ascending aorta in MHCA (24 ± 2 °C, nasopharyngeal) between 2001 and 2015. Patients with acute aortic dissection were excluded from this study. Patients were divided into two groups: those aged 75 years and older (elderly group 22.4%, n = 203) and those younger than 75 years (younger group 77.6%, n = 702). The average age was 63.2 ± 10.2 in the young group vs. 78.7 ± 3.0 years in elderly group (p < 0.001). The elderly group had a significantly higher EuroSCORE II [26.7% (18.1, 36.3) vs. 11.6% (7.4, 19.9); p < 0.001)]. The incidence of coronary heart disease (49.8% vs. 35.6%, p < 0.001) and chronic renal failure (17.2% vs. 9.1%, p = 0.001) was significantly higher in the elderly group. Intraoperatively, the time of MHCA [14 min (12, 17) vs. 15 min (12, 18); p = 0.42], cardiopulmonary bypass [139 min (110, 183) vs. 144 min (113, 189); p = 0.225], and cross-clamping [91 min (63, 116) vs. 92 min (65, 127); p = 0.348] was similar in both groups. Postoperatively, a higher incidence of delirium was significantly reported in the elderly group (24.1% vs. 9.0%, p < 0.001). However, there was no significant difference regarding neurological complications between both groups. A 30-day mortality was acceptable for the elderly group, but significantly higher compared with the younger group (7.1% vs. 3.5%, p = 0.031). CONCLUSIONS Our study suggests that surgical replacement of the ascending aorta in MHCA can also be applied safely in elderly patients without increasing the risk of severe neurological complications.
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Affiliation(s)
- Mohamed Salem
- Department of Cardiovascular Surgery, University Hospital of Schleswig-Holstein, Campus Kiel, Arnold-Heller-Straße 3, 24105, Kiel, Germany.
| | - Christine Friedrich
- Department of Cardiovascular Surgery, University Hospital of Schleswig-Holstein, Campus Kiel, Arnold-Heller-Straße 3, 24105, Kiel, Germany
| | - Alexander Thiem
- Department of Cardiovascular Surgery, University Hospital of Schleswig-Holstein, Campus Kiel, Arnold-Heller-Straße 3, 24105, Kiel, Germany
| | - Mostafa Ahmed Salem
- Department of Cardiovascular Surgery, University Hospital of Schleswig-Holstein, Campus Kiel, Arnold-Heller-Straße 3, 24105, Kiel, Germany
| | - Thomas Puehler
- Department of Cardiovascular Surgery, University Hospital of Schleswig-Holstein, Campus Kiel, Arnold-Heller-Straße 3, 24105, Kiel, Germany
| | - Rene Rusch
- Department of Cardiovascular Surgery, University Hospital of Schleswig-Holstein, Campus Kiel, Arnold-Heller-Straße 3, 24105, Kiel, Germany
| | - Rouven Berndt
- Department of Cardiovascular Surgery, University Hospital of Schleswig-Holstein, Campus Kiel, Arnold-Heller-Straße 3, 24105, Kiel, Germany
| | - Jochen Cremer
- Department of Cardiovascular Surgery, University Hospital of Schleswig-Holstein, Campus Kiel, Arnold-Heller-Straße 3, 24105, Kiel, Germany
| | - Assad Haneya
- Department of Cardiovascular Surgery, University Hospital of Schleswig-Holstein, Campus Kiel, Arnold-Heller-Straße 3, 24105, Kiel, Germany
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19
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Hypothermia during Surgical Treatment of Type A Aortic Dissection: A 16 Years' Experience. Int J Vasc Med 2020; 2020:3893261. [PMID: 34367694 PMCID: PMC8339990 DOI: 10.1155/2020/3893261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 09/02/2019] [Accepted: 10/15/2019] [Indexed: 11/25/2022] Open
Abstract
Acute aortic dissection (AAD) is among the most challenging cases for surgical treatment and requires procedural expertise for its safe conduct. Aortic surgery has undergone several changes over the last years, especially concerning cerebral protection. The brilliant results obtained with the aid of selective anterograde cerebral perfusion led to a progressive increase of circulatory arrest temperature, with the rise of safe time along with a reduction of the extracorporeal circulation time and hypothermia-related side effects. However, there is still no definitive consensus concerning the optimal range of temperature to be used during circulatory arrest. Objectives. This is a retrospective observational study, and we examined 16-year trends in the presentation, diagnosis, hospital outcome and treatment of A AAD type. In our Cardiac Surgery Unit in Policlinico Umberto I of Rome, our analysis focused on patients, who received ACP during aortic surgery and we analyzed the differences between two distinct groups based on the lowest temperature reached during CPB conduction: Lower Temperature Group (LT) (T < 24°C) versus Higher Temperature Group (HT) (T ≥ 24°C) arrest circulation temperature. Methods. Data from 241 patients enrolled between August 2002 and March 2018 were analyzed. Patients were divided according to the lowest temperature reached into 2 groups: Lower Temperature group (LT) (94 patients) and Higher Temperature Group (HT) (147 patients). Results. Our results showed a significant reduction of in-hospital mortality and in-hospital results in patients with higher CPB temperature. The global incidence of complications was statistically reduced in HT group: we found a statistical significant reduction of intestinal ischemia, and a similar trend also for other complications analyzed, such as infections. Since the two groups were similar for type of surgical procedures, we considered these differences depending on the lower temperature value reached, according to the current literature. Conclusions. We found a significantly higher mortality in patients with lower temperature during CPB and a global reduction of complications and in particular a significant reduction of intestinal ischemia in patients with higher temperature during CPB. We found a similar trend in other fields of investigations, so we can conclude that circulatory arrest performed at temperature ≥24°C nasopharyngeal temperature associated with ACP is a safe strategy for aortic surgery for AAD.
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20
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Vaughan BC, Jones MER, Browne IL, Olshavsky JM, Schultz RD. Selective retrograde cerebral cooling in complete cerebral circulatory arrest. Brain Circ 2019; 5:234-240. [PMID: 31950100 PMCID: PMC6950516 DOI: 10.4103/bc.bc_60_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 12/09/2019] [Accepted: 12/16/2019] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND AND PURPOSE: Cerebral hypothermia is a known neuroprotectant with promising applications in the treatment of ischemic events. Although systemic cooling is standard in post-cardiac arrest care, the deleterious effects of whole-body cooling have precluded it from translation into a viable treatment option for acute ischemic stroke (AIS). Selective cerebral cooling has been proposed as a method to minimize these risks while granting the neuroprotection of therapeutic hypothermia in AIS. METHODS: In a porcine model (n = 3), the efficacy of selective retrograde cerebral cooling through the internal jugular vein was evaluated in the setting of complete cerebral circulatory arrest. Furthermore, a novel endovascular device and cooling system enabling selective retrograde cerebral cooling were studied in a normothermic perfused cadaver. RESULTS AND CONCLUSION: Neurologic assessment of animals receiving this therapy reflected substantial neuroprotection in animals undergoing both 15 min and 30 min of otherwise catastrophic complete cerebral circulatory arrest. The novel endovascular device and cooling system were validated in human anatomy, demonstrating successful cerebral cooling, and feasibility of this mechanism of selective retrograde cerebral cooling.
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Affiliation(s)
| | - Melissa E R Jones
- Voyage Biomedical Inc., Berkeley, CA, United States.,Undergraduate Medical Education, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Ikennah L Browne
- Voyage Biomedical Inc., Berkeley, CA, United States.,Department of Surgery, Division of General Surgery, University of Calgary, Calgary, AB, Canada
| | | | - Robert D Schultz
- Voyage Biomedical Inc., Berkeley, CA, United States.,Section of Cardiac Surgery, Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada
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21
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Jabagi H, Wells G, Boodhwani M. COMMENCE trial (Comparing hypOtherMic teMperaturEs duriNg hemiarCh surgEry): a randomized controlled trial of mild vs moderate hypothermia on patient outcomes in aortic hemiarch surgery with anterograde cerebral perfusion. Trials 2019; 20:691. [PMID: 31815641 PMCID: PMC6902484 DOI: 10.1186/s13063-019-3713-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Accepted: 09/09/2019] [Indexed: 12/29/2022] Open
Abstract
Background Aortic arch surgery remains the only viable life-saving treatment for aortic arch disease. However, the necessity for cessation of systemic blood flow with hypothermic cardiac arrest carries substantial risk of morbidity and mortality, including poor neurological outcomes and kidney failure. While uncontrolled studies have suggested the safety of operating at warmer temperatures, significant variables remain un-investigated, supporting the need for a randomized clinical trial (RCT) to produce evidence-based guidelines for perfusion strategies in aortic surgery. This study proposes a multi-center RCT in order to compare outcomes of warmer hypothermic strategies during aortic hemiarch surgery on a composite endpoint of neurologic and acute kidney injury (AKI). Methods/design This is a prospective multi-center, single-blind two-arm RCT comparing mild (32 °C) versus moderate (26 °C) hypothermic cardiac arrest in patients (n = 282) undergoing hemiarch surgery with antegrade cerebral perfusion (ACP). The primary endpoint is a composite of neurological injury (incidence of transient ischemic attack and/or stroke) and Kidney Disease Improving Global Outcomes (KDIGO) stage 1 or higher AKI. Secondary outcomes include death, cardiopulmonary bypass time, bleeding, transfusion rates, prolonged mechanical ventilation, myocardial infarction, length of stay, and quality of life measures. Patients will undergo 1:1 block randomization to each treatment arm on day of surgery. Sequence of operation will be at the surgeon’s discretion with mandatory guidelines for temperature and ACP administration. Perioperative management will occur as per enrolling center standard of care. Neurocognitive function will be assessed for neurological injury using validated neurological screening tests: NIHSS, MOCA, BI, and MRS throughout patient follow-up. Diagnosis and classification of AKI will be based on rising creatinine values as per the KDIGO criteria. Study duration for each patient will be 60 ± 14 days. Discussion It is hoped that performing hemiarch surgery using mild hypothermia (32 °C) and selective ACP will result in a 15% absolute risk reduction in the composite outcomes. The potential of this risk reduction will translate into improved patient outcomes, survival, and long-term financial savings to the health care system. In addition, the results of this trial will be used to create the first-ever guidelines for temperature management strategy during aortic surgery. Trial registration This trial is registered on ClinicalTrials.gov with the registration number NCT02860364. Registration date August 9th, 2016.
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Affiliation(s)
- Habib Jabagi
- Divisions of Cardiac Surgery, University of Ottawa Heart Institute, 40 Ruskin Street, Room H-34058A, Ottawa, ON, K1Y 4W7, Canada.
| | - George Wells
- Cardiovascular Research Methods Centre, University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa, ON, K1Y 4W7, Canada
| | - Munir Boodhwani
- Divisions of Cardiac Surgery, University of Ottawa Heart Institute, 40 Ruskin Street, Room H-34058A, Ottawa, ON, K1Y 4W7, Canada
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22
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Leshnower BG. Cannulation strategies, circulation management and neuroprotection for type A intramural hematoma: tips and tricks. Ann Cardiothorac Surg 2019; 8:561-566. [PMID: 31667155 DOI: 10.21037/acs.2019.08.08] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
The circulation management strategies and operative techniques that are essential for the successful surgical repair of acute type A intramural hematoma (ATAIMH) are similar to those utilized for acute type A aortic dissection. This article reviews the neuroprotection strategies and arterial cannulation sites used in the treatment of patients with ATAIMH.
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Affiliation(s)
- Bradley G Leshnower
- Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
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23
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Lu Y, Zeng X, Jing X, Yin M, Chang MMP, Wei H, Yang Y, Liao X, Dai G, Hu C. Pre-arrest hypothermia improved cardiac function of rats by ameliorating the myocardial mitochondrial injury after cardiac arrest. Exp Biol Med (Maywood) 2019; 244:1186-1192. [PMID: 31530020 DOI: 10.1177/1535370219875434] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
This study investigated the effects of hypothermia induced before cardiac arrest or after return of spontaneous circulation (ROSC) on cardiac function and myocardial mitochondrial injury after ROSC in a rat cardiac arrest model. Sixty healthy, male Wistar rats were randomly divided into the Normothermia group, pre-arrest hypothermia (Pre-HT) group, and post-resuscitation hypothermia (Post-HT) group. The rats underwent 8 min of untreated ventricular fibrillation followed by cardiopulmonary resuscitation. Twelve rats in each group were used to evaluate the left ventricular ejection fraction before ventricular fibrillation and 4 h after ROSC. Survival was determined at 24 h after ROSC. The remaining eight rats in each group were used to detect for heart malondialdehyde, reduced glutathione, adenosine triphosphate levels and mitochondrial histology. Oxygen consumption rate and mitochondrial membrane potential were evaluated 4 h after ROSC; 10 of 12 rats in Pre-HT group, 5 of 12 in Post-HT group, and 6 of 12 in normothermia group were successfully resuscitated. The survival rate of each group was 66.7%, 33.3%, and 25%, respectively. Rats in the Pre-HT group showed less alteration of the mitochondrial ultrastructure and oxidative stress injury, better maintenance of adenine nucleotides, and more preservation of the mitochondrial membrane potential and respiratory function when compared with rats in the Post-HT and normothermia groups. Transient hypothermia is an effective preconditioning stimulus to induce ischemic tolerance in a cardiac arrest model and worthy of further evaluation for potential clinical use. Impact statement In this paper, we investigated the effects of hypothermia induced before ischemia or after ROSC on cardiac function, oxidative stress damage, and myocardial mitochondrial ischemia–reperfusion injury after cardiac arrest in a rat model with VF. We demonstrated that pre-arrest hypothermia conferred greater cardio-protective benefits than delayed post-resuscitation hypothermia, reduced the number of defibrillations required and dosages of epinephrine during CPR, decreased oxidative stress, ameliorated mitochondrial dysfunction, and subsequently improved survival rate.
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Affiliation(s)
- Yuanzheng Lu
- Department of Emergency Medicine, Sun Yat-sen University/The First Affiliated Hospital, Guangzhou 510080, China.,Department of Emergency Medicine, Sun Yat-sen University/The Seventh Affiliated Hospital, Shenzhen 518107, China.,NHC Key Laboratory of Assisted Circulation (Sun Yat-sen University), Guangzhou 510080, China
| | - Xiaoyun Zeng
- Department of Emergency Medicine, Sun Yat-sen University/The First Affiliated Hospital, Guangzhou 510080, China.,NHC Key Laboratory of Assisted Circulation (Sun Yat-sen University), Guangzhou 510080, China
| | - Xiaoli Jing
- Department of Emergency Medicine, Sun Yat-sen University/The First Affiliated Hospital, Guangzhou 510080, China
| | - Meixian Yin
- Department of Emergency Medicine, Sun Yat-sen University/The First Affiliated Hospital, Guangzhou 510080, China.,NHC Key Laboratory of Assisted Circulation (Sun Yat-sen University), Guangzhou 510080, China
| | - Mms Mary P Chang
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas 75205, USA
| | - Hongyan Wei
- Department of Emergency Medicine, Sun Yat-sen University/The First Affiliated Hospital, Guangzhou 510080, China
| | - Yan Yang
- Department of Emergency Medicine, Sun Yat-sen University/The First Affiliated Hospital, Guangzhou 510080, China.,NHC Key Laboratory of Assisted Circulation (Sun Yat-sen University), Guangzhou 510080, China
| | - Xiaoxing Liao
- Department of Emergency Medicine, Sun Yat-sen University/The First Affiliated Hospital, Guangzhou 510080, China.,Department of Emergency Medicine, Sun Yat-sen University/The Seventh Affiliated Hospital, Shenzhen 518107, China
| | - Gang Dai
- NHC Key Laboratory of Assisted Circulation (Sun Yat-sen University), Guangzhou 510080, China
| | - Chunlin Hu
- Department of Emergency Medicine, Sun Yat-sen University/The First Affiliated Hospital, Guangzhou 510080, China.,NHC Key Laboratory of Assisted Circulation (Sun Yat-sen University), Guangzhou 510080, China
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24
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Greco R, Tsappa I, Mihai R, Petrou M. Surgical management of adrenal tumours extending into the right atrium. Gland Surg 2019; 8:S53-S59. [PMID: 31404189 DOI: 10.21037/gs.2019.06.03] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
This paper discusses the surgical approach for the treatment of adrenal tumours extending into the right atrium (RA), using a cardio-pulmonary bypass (CPB) associated with deep hypothermic circulatory arrest (DHCA). Pre-operative planning and surgical steps are described in details. The association of CPB with hypothermic circulatory arrest (HCA) provides a bloodless operating field, direct intra-vascular vision, reduces the risk of embolization and allows extensive inferior vena cava (IVC) or RA repair in cases of infiltration of the vascular wall. Establishing a dedicated multidisciplinary team with experience in managing these challenging cases is fundamental to offer treatment to patients with advanced disease, who would otherwise risk being turned down for surgery. A close collaboration between general and cardiac surgeons and a deep understanding of the surgical procedure steps are fundamental to safely performing these procedures. We advocate centralising adrenal surgery in a small number of units with adequate multidisciplinary support.
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Affiliation(s)
- Renata Greco
- Department of Cardiac Surgery, Heart Centre, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Irene Tsappa
- Department of Cardiac Surgery, Heart Centre, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Radu Mihai
- Department of Endocrine Surgery, Churchill Cancer Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Mario Petrou
- Department of Cardiac Surgery, Heart Centre, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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25
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Open aortic arch surgery: the gold standard method. Indian J Thorac Cardiovasc Surg 2019; 35:130-135. [PMID: 33061078 DOI: 10.1007/s12055-018-0732-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Revised: 08/09/2018] [Accepted: 08/15/2018] [Indexed: 10/28/2022] Open
Abstract
Aortic arch pathologies are complex and treating them requires close team collaboration and technical skills to provide safe outcomes with low morbidity and mortality rates. Such challenges are facing both aortic and vascular surgeons. Open aortic arch repair has been the standard method of practice in all cases of aortic arch pathologies for the last four decades since the very first successful published case series by Griepp et al. during 1975. However, since then, repair of multi-segmented thoracic aortic pathologies has been explored through endovascular techniques; this is with or without open repair as a one-stage procedure especially in high-risk and elderly patients. Although the role of endovascular techniques in thoracoabdominal aorta is well established, its utilization as solo technique in aortic arch pathologies remains debatable. In this review, we highlight current evidences behind using open, endovascular, and hybrid procedures in aortic arch surgery.
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26
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Deep Hypothermic Circulatory Arrest Does Not Show Better Protection for Vital Organs Compared with Moderate Hypothermic Circulatory Arrest in Pig Model. BIOMED RESEARCH INTERNATIONAL 2019; 2019:1420216. [PMID: 31119151 PMCID: PMC6500684 DOI: 10.1155/2019/1420216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/08/2018] [Accepted: 03/19/2019] [Indexed: 11/17/2022]
Abstract
Background Continued debates exist regarding the optimal temperature during hypothermic circulatory arrest in aortic arch repair for patients with type A aortic dissection. This study seeks to examine whether the use of moderate hypothermic circulatory arrest in a pig model provides comparable vital organ protection outcomes to the use of deep hypothermic circulatory arrest. Methods Thirteen pigs were randomly assigned to 30 minutes of hypothermic circulatory arrest without cerebral perfusion at 15°C (n = 5), 25°C (n = 5), and a control group (n = 3). The changes in standard laboratory tests and capacity for protection against apoptosis in different vital organs were monitored with different temperatures of hypothermic circulatory arrest management in pig model to determine which temperature was optimal for hypothermic circulatory arrest. Results There were no significant differences in the capacity for protection against apoptosis in vital organs between 2 groups (p > 0.05, respectively). Compared with the moderate hypothermic circulatory arrest group, the deep hypothermic circulatory arrest group had no significant advantages in terms of the biologic parameters of any other organs (p > 0.05). Conclusions Compared with deep hypothermic circulatory arrest, moderate hypothermic circulatory arrest is a moderate technique that has similar advantages with regard to the levels of biomarkers of injury and capacity for protection against apoptosis in vital organs.
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27
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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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28
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Agarwal S, Kendall J, Quarterman C. Perioperative management of thoracic and thoracoabdominal aneurysms. BJA Educ 2019; 19:119-125. [PMID: 33456880 DOI: 10.1016/j.bjae.2019.01.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/06/2018] [Indexed: 11/24/2022] Open
Affiliation(s)
- S Agarwal
- Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - J Kendall
- Liverpool Heart and Chest NHS Foundation Trust, Liverpool, UK
| | - C Quarterman
- Liverpool Heart and Chest NHS Foundation Trust, Liverpool, UK
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29
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Carlin JL, Jain S, Duroux R, Suresh RR, Xiao C, Auchampach JA, Jacobson KA, Gavrilova O, Reitman ML. Activation of adenosine A 2A or A 2B receptors causes hypothermia in mice. Neuropharmacology 2018; 139:268-278. [PMID: 29548686 PMCID: PMC6067974 DOI: 10.1016/j.neuropharm.2018.02.035] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Revised: 01/26/2018] [Accepted: 02/28/2018] [Indexed: 12/25/2022]
Abstract
Extracellular adenosine is a danger/injury signal that initiates protective physiology, such as hypothermia. Adenosine has been shown to trigger hypothermia via agonism at A1 and A3 adenosine receptors (A1AR, A3AR). Here, we find that adenosine continues to elicit hypothermia in mice null for A1AR and A3AR and investigated the effect of agonism at A2AAR or A2BAR. The poorly brain penetrant A2AAR agonists CGS-21680 and PSB-0777 caused hypothermia, which was not seen in mice lacking A2AAR. MRS7352, a likely non-brain penetrant A2AAR antagonist, inhibited PSB-0777 hypothermia. While vasodilation is probably a contributory mechanism, A2AAR agonism also caused hypometabolism, indicating that vasodilation is not the sole mechanism. The A2BAR agonist BAY60-6583 elicited hypothermia, which was lost in mice null for A2BAR. Low intracerebroventricular doses of BAY60-6583 also caused hypothermia, indicating a brain site of action, with neuronal activation in the preoptic area and paraventricular nucleus of the hypothalamus. Thus, agonism at any one of the canonical adenosine receptors, A1AR, A2AAR, A2BAR, or A3AR, can cause hypothermia. This four-fold redundancy in adenosine-mediated initiation of hypothermia may reflect the centrality of hypothermia as a protective response.
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Affiliation(s)
- Jesse Lea Carlin
- Diabetes, Endocrinology, and Obesity Branch, National Institute of Diabetes and Digestive and Kidney Diseases, NIH, Bethesda, MD 20892, USA
| | - Shalini Jain
- Mouse Metabolism Core, National Institute of Diabetes and Digestive and Kidney Diseases, NIH, Bethesda, MD 20892, USA
| | - Romain Duroux
- Molecular Recognition Section, Laboratory of Bioorganic Chemistry, National Institute of Diabetes and Digestive and Kidney Diseases, NIH, Bethesda, MD 20892, USA
| | - R Rama Suresh
- Molecular Recognition Section, Laboratory of Bioorganic Chemistry, National Institute of Diabetes and Digestive and Kidney Diseases, NIH, Bethesda, MD 20892, USA
| | - Cuiying Xiao
- Diabetes, Endocrinology, and Obesity Branch, National Institute of Diabetes and Digestive and Kidney Diseases, NIH, Bethesda, MD 20892, USA
| | - John A Auchampach
- Department of Pharmacology, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI 53226, USA
| | - Kenneth A Jacobson
- Molecular Recognition Section, Laboratory of Bioorganic Chemistry, National Institute of Diabetes and Digestive and Kidney Diseases, NIH, Bethesda, MD 20892, USA
| | - Oksana Gavrilova
- Mouse Metabolism Core, National Institute of Diabetes and Digestive and Kidney Diseases, NIH, Bethesda, MD 20892, USA.
| | - Marc L Reitman
- Diabetes, Endocrinology, and Obesity Branch, National Institute of Diabetes and Digestive and Kidney Diseases, NIH, Bethesda, MD 20892, USA.
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Abstract
Although antegrade cerebral perfusion (ACP) is the predominant method of protecting the brain in patients undergoing total arch replacement, both deep hypothermic circulatory arrest and ACP provide excellent and comparable clinical outcomes with regard to mortality, stroke, and temporary neurological deficit rates.
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Affiliation(s)
- Yutaka Okita
- Division of Cardiovascular Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
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Electroencephalographic Response to Deep Hypothermic Circulatory Arrest in Neonatal Swine and Humans. Ann Thorac Surg 2018; 106:1841-1846. [PMID: 30071237 DOI: 10.1016/j.athoracsur.2018.06.036] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Revised: 06/14/2018] [Accepted: 06/15/2018] [Indexed: 11/21/2022]
Abstract
BACKGROUND Piglets are used to study neurologic effects of deep hypothermic circulatory arrest (DHCA), but no studies have compared human and swine electroencephalogram (EEG) responses to DHCA. The importance of isoelectricity before circulatory arrest is not fully known in neonates. We compared the EEG response to DHCA in human neonates and piglets. METHODS We recorded 2 channel, left and right centroparietal, subdermal EEG in 10 neonatal patients undergoing operations involving DHCA and 10 neonatal piglets that were placed on cardiopulmonary bypass and underwent a simulated procedure using DHCA. EEG waveforms were analyzed for the presence and extent of burst suppression and isoelectricity by automated moving window analysis. The patients were monitored with 16-channel array EEG for 48 hours postoperatively and underwent postoperative brain magnetic resonance imaging. RESULTS After induction of anesthesia, humans and piglets both displayed slowing or brief suppression, then mild burst suppression, and then severe burst suppression during cooling. All piglets subsequently achieved isoelectricity at 22.4° ± 6.9°C, whereas only 1 human did at 20.2°C. Piglets and humans emerged from severe, mild, and then brief suppression patterns during rewarming. Among the patients, there were no seizures during postoperative monitoring and 1 instance of increased white matter injury on postoperative magnetic resonance imaging. CONCLUSIONS Our data suggest that current cooling strategies may not be sufficient to eliminate all EEG activity before circulatory arrest in humans but are sufficient in swine. This important difference between the swine and human response to DHCA should be considered when using this model.
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Manetta F, Mullan CW, Catalano MA. Neuroprotective Strategies in Repair and Replacement of the Aortic Arch. Int J Angiol 2018; 27:98-109. [PMID: 29896042 PMCID: PMC5995688 DOI: 10.1055/s-0038-1649512] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Aortic arch surgery is a technical challenge, and cerebral protection during distal anastomosis is a continued topic of controversy and discussion. The physiologic effects of hypothermic arrest and adjunctive cerebral perfusion have yet to be fully defined, and the optimal strategies are still undetermined. This review highlights the historical context, physiological rationale, and clinical efficacy of various neuroprotective strategies during arch operations.
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Affiliation(s)
- Frank Manetta
- Department of Cardiovascular and Thoracic Surgery, Barbara and Donald Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York
| | - Clancy W. Mullan
- Department of Cardiovascular and Thoracic Surgery, Barbara and Donald Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York
| | - Michael A. Catalano
- Department of Cardiovascular and Thoracic Surgery, Barbara and Donald Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York
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Rewell SSJ, Jeffreys AL, Sastra SA, Cox SF, Fernandez JA, Aleksoska E, van der Worp HB, Churilov L, Macleod MR, Howells DW. Hypothermia revisited: Impact of ischaemic duration and between experiment variability. J Cereb Blood Flow Metab 2017; 37:3380-3390. [PMID: 28084873 PMCID: PMC5624387 DOI: 10.1177/0271678x16688704] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
To assess the true effect of novel therapies for ischaemic stroke, a positive control that can validate the experimental model and design is vital. Hypothermia may be a good candidate for such a positive control, given the convincing body of evidence from animal models of ischaemic stroke. Taking conditions under which substantial efficacy had been seen in a meta-analysis of hypothermia for focal ischaemia in animal models, we undertook three randomised and blinded studies examining the effect of hypothermia induced immediately following the onset of middle cerebral artery occlusion on infarct volume in rats (n = 15, 23, 264). Hypothermia to a depth of 33℃ and maintained for 130 min significantly reduced infarct volume compared to normothermia treatment (by 27-63%) and depended on ischaemic duration (F(3,244) = 21.242, p < 0.05). However, the protective effect varied across experiments with differences in both the size of the infarct observed in normothermic controls and the time to reach target temperature. Our results highlight the need for sample size and power calculations to take into account variations between individual experiments requiring induction of focal ischaemia.
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Affiliation(s)
- Sarah SJ Rewell
- Florey Institute of Neuroscience and Mental Health, Melbourne Brain Centre, Heidelberg, Australia
- Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Amy L Jeffreys
- Florey Institute of Neuroscience and Mental Health, Melbourne Brain Centre, Heidelberg, Australia
- Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Steven A Sastra
- Florey Institute of Neuroscience and Mental Health, Melbourne Brain Centre, Heidelberg, Australia
- Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Susan F Cox
- Florey Institute of Neuroscience and Mental Health, Melbourne Brain Centre, Heidelberg, Australia
- Department of Medicine, University of Melbourne, Melbourne, Australia
| | - John A Fernandez
- Florey Institute of Neuroscience and Mental Health, Melbourne Brain Centre, Heidelberg, Australia
- Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Elena Aleksoska
- Florey Institute of Neuroscience and Mental Health, Melbourne Brain Centre, Heidelberg, Australia
- Department of Medicine, University of Melbourne, Melbourne, Australia
| | - H Bart van der Worp
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magus, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Leonid Churilov
- Florey Institute of Neuroscience and Mental Health, Melbourne Brain Centre, Heidelberg, Australia
- Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Malcolm R Macleod
- Department of Clinical Neurosciences, University of Edinburgh, Edinburgh, UK
| | - David W Howells
- Florey Institute of Neuroscience and Mental Health, Melbourne Brain Centre, Heidelberg, Australia
- School of Medicine, Faculty of Health, University of Tasmania, Hobart, Tasmania
- David W Howells, School of Medicine, Faculty of Health, University of Tasmania, Medical Science Precinct, 17 Liverpool Street, Hobart, Tasmania, Australia.
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Remodeling pathway control of mitochondrial respiratory capacity by temperature in mouse heart: electron flow through the Q-junction in permeabilized fibers. Sci Rep 2017; 7:2840. [PMID: 28588260 PMCID: PMC5460290 DOI: 10.1038/s41598-017-02789-8] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Accepted: 04/18/2017] [Indexed: 12/16/2022] Open
Abstract
Fuel substrate supply and oxidative phosphorylation are key determinants of muscle performance. Numerous studies of mammalian mitochondria are carried out (i) with substrate supply that limits electron flow, and (ii) far below physiological temperature. To analyze potentially implicated biases, we studied mitochondrial respiratory control in permeabilized mouse myocardial fibers using high-resolution respirometry. The capacity of oxidative phosphorylation at 37 °C was nearly two-fold higher when fueled by physiological substrate combinations reconstituting tricarboxylic acid cycle function, compared with electron flow measured separately through NADH to Complex I or succinate to Complex II. The relative contribution of the NADH pathway to physiological respiratory capacity increased with a decrease in temperature from 37 to 25 °C. The apparent excess capacity of cytochrome c oxidase above physiological pathway capacity increased sharply under hypothermia due to limitation by NADH-linked dehydrogenases. This mechanism of mitochondrial respiratory control in the hypothermic mammalian heart is comparable to the pattern in ectotherm species, pointing towards NADH-linked mt-matrix dehydrogenases and the phosphorylation system rather than electron transfer complexes as the primary drivers of thermal sensitivity at low temperature. Delineating the link between stress and remodeling of oxidative phosphorylation is important for understanding metabolic perturbations in disease evolution and cardiac protection.
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Fernández Suárez FE, Fernández Del Valle D, González Alvarez A, Pérez-Lozano B. Intraoperative care for aortic surgery using circulatory arrest. J Thorac Dis 2017; 9:S508-S520. [PMID: 28616347 PMCID: PMC5462730 DOI: 10.21037/jtd.2017.04.67] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Accepted: 04/06/2017] [Indexed: 11/06/2022]
Abstract
The total circulatory arrest (CA) is necessary to achieve optimal surgical conditions in certain aortic pathologies, especially in those affecting the ascending aorta and aortic arch. During this procedure it is necessary to protect all the organs of ischemia, especially those of the central nervous system and for this purpose several strategies have been developed. The first and most important protective method is systemic hypothermia. The degree of hypothermia and the route of application have been evolving and currently tend to use moderate hypothermia (MH) (20.1-28 °C) associated with unilateral or bilateral selective cerebral perfusion methods. In this way the neurological results are better, the interval of security is greater and the times of extracorporeal circulation are smaller. Even so, it is necessary to take into account that there is the possibility of ischemia in the lower part of the body, especially of the abdominal viscera and the spinal cord, therefore the time of circulatory stop should be limited and not to exceed 80 minutes. Evidence of possible neurological drug protection is very weak and only mannitol, magnesium, and statins can produce some benefit. Inhalational anesthetics and some intravenous seem to have advantages, but more studies would be needed to test their long-term benefit. Other important parameters to be monitored during these procedures are blood glucose, anemia and coagulation disorders and acid-base balance. The recommended monitoring is common in complex cardiovascular procedures and it is of special importance the neurological monitoring that can be performed with several techniques, although currently the most used are Bispectral Index (BIS) and Near-Infrared Spectroscopy (NIRS). It is also essential to monitor the temperature routinely at the nasopharyngeal and bladder level and it is important to control coagulation with rotational thromboelastometry (ROTEM).
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Affiliation(s)
| | | | - Adrián González Alvarez
- Department of Anesthesiology, Central University Hospital of Asturias, Oviedo, Asturias, Spain
| | - Blanca Pérez-Lozano
- Department of Anesthesiology, Central University Hospital of Asturias, Oviedo, Asturias, Spain
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36
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Does moderate hypothermia really carry less bleeding risk than deep hypothermia for circulatory arrest? A propensity-matched comparison in hemiarch replacement. J Thorac Cardiovasc Surg 2016; 152:1559-1569.e2. [PMID: 27692949 DOI: 10.1016/j.jtcvs.2016.08.014] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Revised: 07/27/2016] [Accepted: 08/11/2016] [Indexed: 01/12/2023]
Abstract
BACKGROUND Moderate (MHCA) versus deep (DHCA) hypothermia for circulatory arrest in aortic arch surgery has been purported to reduce coagulopathy and bleeding complications, although there are limited data supporting this claim. This study aimed to compare bleeding-related events after aortic hemiarch replacement with MHCA versus DHCA. METHODS Patients who underwent hemiarch replacement at a single institution from July 2005 to August 2014 were stratified into DHCA and MHCA groups (minimum systemic temperature ≤20°C and >20°C, respectively) and compared. Then, 1:1 propensity matching was performed to adjust for baseline differences. RESULTS During the study period, 571 patients underwent hemiarch replacement: 401 (70.2%) with DHCA and 170 (29.8%) with MHCA. After propensity matching, 155 patients remained in each group. There were no significant differences between matched groups with regard to the proportion transfused with red blood cells, plasma, platelet concentrates, or cryoprecipitate on the operative day, the rate of reoperation for bleeding, or postoperative hematologic laboratory values. Among patients who received plasma, the median transfusion volume was statistically greater in the DHCA group (6 vs 5 units, P = .01). MHCA also resulted in a slight reduction in median volume of blood returned via cell saver (500 vs 472 mL, P < .01) and 12-hour postoperative chest tube output (440 vs 350, P < .01). Thirty-day mortality and morbidity did not differ significantly between groups. CONCLUSIONS MHCA compared with DHCA during hermiarch replacement may slightly reduce perioperative blood-loss and plasma transfusion requirement, although these differences do not translate into reduced reoperation for bleeding or postoperative mortality and morbidity.
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37
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Kayatta MO, Chen EP. Optimal temperature management in aortic arch operations. Gen Thorac Cardiovasc Surg 2016; 64:639-650. [PMID: 27501694 DOI: 10.1007/s11748-016-0699-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2016] [Accepted: 07/26/2016] [Indexed: 01/26/2023]
Abstract
Hypothermic circulatory arrest is a critical component of aortic arch procedures, without which these operations could not be safely performed. Despite the use of hypothermia as a protective adjunct for organ preservation, aortic arch surgery remains complex and is associated with numerous complications despite years of surgical advancement. Deep hypothermic circulatory arrest affords the surgeon a safe period of time to perform the arch reconstruction, but this interruption of perfusion comes at a high clinical cost: stroke, paraplegia, and organ dysfunction are all potential-associated complications. Retrograde cerebral perfusion was subsequently developed as a technique to improve upon the rates of neurologic dysfunction, but was done with only modest success. Selective antegrade cerebral perfusion, on the other hand, has consistently been shown to be an effective form of cerebral protection over deep hypothermia alone, even during extended periods of circulatory arrest. A primary disadvantage of using deep hypothermic circulatory arrest is the prolonged bypass times required for cooling and rewarming which adds significantly to the morbidity associated with these procedures, especially coagulopathic bleeding and organ dysfunction. In an effort to mitigate this problem, the degree of hypothermia at the time of the initial circulatory arrest has more recently been reduced in multiple centers across the globe. This technique of moderate hypothermic circulatory arrest in combination with adjunctive brain perfusion techniques has been shown to be safe when performing aortic arch operations. In this review, we will discuss the evolution of these protection strategies as well as their relative strengths and weaknesses.
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Affiliation(s)
- Michael O Kayatta
- 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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Gupta B, Dodge-Khatami A, Tucker J, Taylor MB, Maposa D, Urencio M, Salazar JD. Antegrade cerebral perfusion at 25 °C for arch reconstruction in newborns and children preserves perioperative cerebral oxygenation and serum creatinine. Transl Pediatr 2016; 5:114-124. [PMID: 27709092 PMCID: PMC5035759 DOI: 10.21037/tp.2016.06.03] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Antegrade cerebral perfusion (ACP) typically is used with deep hypothermia for cerebral protection during aortic arch reconstructions. The impact of ACP on cerebral oxygenation and serum creatinine at a more tepid 25 °C was studied in newborns and children. METHODS Between 2010 and 2014, 61 newborns and children (<5 years old) underwent aortic arch reconstruction using moderate hypothermia (25.0±0.9 °C) with ACP and a pH-stat blood gas management strategy. These included 44% Norwood-type operations, 30% isolated arch reconstructions, and 26% arch reconstructions with other major procedures. Median patient age at surgery was 9 days (range, 3 days-4.7 years). Cerebral oxygenation (NIRS) was monitored continuously perioperatively for 120 hours. Serum creatinine was monitored daily. RESULTS Median cardiopulmonary bypass (CPB) and cross clamp times were 181 minutes (range, 82-652 minutes) and 72 minutes (range, 10-364 minutes), respectively. ACP was performed at a mean flow rate of 46±6 mL/min/kg for a median of 48 minutes (range, 10-123 minutes). Cerebral and somatic NIRS were preserved intraoperatively and remained at baseline postoperatively during the first 120 hours. Peak postoperative serum creatinine levels averaged 0.7±0.3 mg/dL for all patients. There were 4 (6.6%) discharge mortalities. Six patients (9.8%) required ECMO support. Median postoperative length of hospital and intensive care unit (ICU) stay were 16 days(range, 4-104 days) and 9 days (range, 1-104 days), respectively. Two patients (3.3%) received short-term peritoneal dialysis for fluid removal, and none required hemodialysis. Three patients (4.9%) had an isolated seizure which resolved with medical therapy, and none had a neurologic deficit or stroke. CONCLUSIONS ACP at 25 °C preserved perioperative cerebral oxygenation and serum creatinine for newborns and children undergoing arch reconstruction. Early outcomes are encouraging, and additional study is warranted to assess the impact on late outcomes.
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Affiliation(s)
- Bhawna Gupta
- Division of Cardiothoracic Surgery, The Children's Heart Center, The University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Ali Dodge-Khatami
- Division of Cardiothoracic Surgery, The Children's Heart Center, The University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Juan Tucker
- Division of Cardiothoracic Surgery, The Children's Heart Center, The University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Mary B Taylor
- Divisions of Pediatric Critical Care and Pediatric Cardiology, The Children's Heart Center, The University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Douglas Maposa
- Division of Pediatric Anesthesiology, The Children's Heart Center, The University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Miguel Urencio
- Division of Cardiothoracic Surgery, The Children's Heart Center, The University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Jorge D Salazar
- Division of Cardiothoracic Surgery, The Children's Heart Center, The University of Mississippi Medical Center, Jackson, Mississippi, USA
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Gong M, Ma WG, Guan XL, Wang LF, Li JC, Lan F, Sun LZ, Zhang HJ. Moderate hypothermic circulatory arrest in total arch repair for acute type A aortic dissection: clinical safety and efficacy. J Thorac Dis 2016; 8:925-33. [PMID: 27162668 DOI: 10.21037/jtd.2016.02.75] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Continued debates exist regarding the optimal temperature during hypothermic circulatory arrest (HCA) in aortic arch repair for patients with type A aortic dissection (TAAD). This study seeks to examine whether the use of moderate HCA in emergency aortic arch surgery provides comparable operative outcomes to deep HCA for patients with acute TAAD. METHODS We prospectively enrolled 74 consecutive patients (mean age 47.7±9.8 years, 54 males) with acute TAAD, who underwent emergency total arch replacement and frozen elephant trunk implantation under HCA (18-28 °C) with unilateral selective antegrade cerebral perfusion (uSACP). Patients were divided into two groups based on the nasopharyngeal temperature at the initiation of HCA: deep HCA (DHCA, <20 °C) in 35 (47.3%) and moderate HCA (MHCA, 20-28 °C) in 39 (52.7%). Operative outcomes including mortality, morbidity and visceral organ functions were compared between the two groups. RESULTS The mean times of cardiopulmonary bypass (CPB) and aortic cross-clamp were 211±54 and 238±62 minutes (P=0.053) and 118±27 and 142±45 minutes (P=0.005) in the MHCA and DHCA groups, respectively. Operative mortality did not differ between two groups (10.2% in MHCA vs. 14.3% in DHCA groups, P=0.862). Nor did the incidence of morbidities differ between the two groups (P>0.05). The temporal trend in the changes of postoperative levels of creatinine, aspartate aminotransferase, total bilirubin and lactate did not differ between two groups (P>0.05). Multivariate analysis found that the temperature during HCA (MHCA vs. DHCA) did not affect operative mortality, morbidities and neurologic complications. Instead, CPB time (in minutes) was the risk factor for operative mortality (odds ratio, 1.032; 95% confidence interval, 1.004-1.061; P=0.023). CONCLUSIONS Moderate HCA is associated with equivalent operative mortality and morbidity and visceral organ functions compared to deep HCA in patients with acute TAAD undergoing total arch replacement under uSACP. This study implies the clinical safety and efficacy of moderate HCA in emergency aortic arch repair for such patients, which provides equivalent cerebral and visceral organ protection while decreasing CPB and cross-clamp times without increasing the risk of operative mortality and morbidity.
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Affiliation(s)
- Ming Gong
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, and Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing 100029, China
| | - Wei-Guo Ma
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, and Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing 100029, China
| | - Xin-Liang Guan
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, and Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing 100029, China
| | - Long-Fei Wang
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, and Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing 100029, China
| | - Jia-Chen Li
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, and Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing 100029, China
| | - Feng Lan
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, and Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing 100029, China
| | - Li-Zhong Sun
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, and Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing 100029, China
| | - Hong-Jia Zhang
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, and Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing 100029, China
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40
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Yan TD. Mini-Bentall procedure and hemi-arch replacement. Ann Cardiothorac Surg 2015; 4:208-9. [PMID: 25870824 DOI: 10.3978/j.issn.2225-319x.2015.03.04] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2015] [Accepted: 03/14/2015] [Indexed: 11/14/2022]
Affiliation(s)
- Tristan D Yan
- 1 The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia ; 2 Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital and Sydney Adventist Hospital, University of Sydney, Sydney, Australia
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41
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The human burst suppression electroencephalogram of deep hypothermia. Clin Neurophysiol 2015; 126:1901-1914. [PMID: 25649968 DOI: 10.1016/j.clinph.2014.12.022] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2014] [Revised: 11/27/2014] [Accepted: 12/27/2014] [Indexed: 12/30/2022]
Abstract
OBJECTIVE Deep hypothermia induces 'burst suppression' (BS), an electroencephalogram pattern with low-voltage 'suppressions' alternating with high-voltage 'bursts'. Current understanding of BS comes mainly from anesthesia studies, while hypothermia-induced BS has received little study. We set out to investigate the electroencephalogram changes induced by cooling the human brain through increasing depths of BS through isoelectricity. METHODS We recorded scalp electroencephalograms from eleven patients undergoing deep hypothermia during cardiac surgery with complete circulatory arrest, and analyzed these using methods of spectral analysis. RESULTS Within patients, the depth of BS systematically depends on the depth of hypothermia, though responses vary between patients except at temperature extremes. With decreasing temperature, burst lengths increase, and burst amplitudes and lengths decrease, while the spectral content of bursts remains constant. CONCLUSIONS These findings support an existing theoretical model in which the common mechanism of burst suppression across diverse etiologies is the cyclical diffuse depletion of metabolic resources, and suggest the new hypothesis of local micro-network dropout to explain decreasing burst amplitudes at lower temperatures. SIGNIFICANCE These results pave the way for accurate noninvasive tracking of brain metabolic state during surgical procedures under deep hypothermia, and suggest new testable predictions about the network mechanisms underlying burst suppression.
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42
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Rodrigues DB, Maccarini PF, Salahi S, Oliveira TR, Pereira PJS, Limao-Vieira P, Snow BW, Reudink D, Stauffer PR. Design and optimization of an ultra wideband and compact microwave antenna for radiometric monitoring of brain temperature. IEEE Trans Biomed Eng 2014; 61:2154-60. [PMID: 24759979 DOI: 10.1109/tbme.2014.2317484] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
We present the modeling efforts on antenna design and frequency selection to monitor brain temperature during prolonged surgery using noninvasive microwave radiometry. A tapered log-spiral antenna design is chosen for its wideband characteristics that allow higher power collection from deep brain. Parametric analysis with the software HFSS is used to optimize antenna performance for deep brain temperature sensing. Radiometric antenna efficiency (η) is evaluated in terms of the ratio of power collected from brain to total power received by the antenna. Anatomical information extracted from several adult computed tomography scans is used to establish design parameters for constructing an accurate layered 3-D tissue phantom. This head phantom includes separate brain and scalp regions, with tissue equivalent liquids circulating at independent temperatures on either side of an intact skull. The optimized frequency band is 1.1-1.6 GHz producing an average antenna efficiency of 50.3% from a two turn log-spiral antenna. The entire sensor package is contained in a lightweight and low-profile 2.8 cm diameter by 1.5 cm high assembly that can be held in place over the skin with an electromagnetic interference shielding adhesive patch. The calculated radiometric equivalent brain temperature tracks within 0.4 °C of the measured brain phantom temperature when the brain phantom is lowered 10 °C and then returned to the original temperature (37 °C) over a 4.6-h experiment. The numerical and experimental results demonstrate that the optimized 2.5-cm log-spiral antenna is well suited for the noninvasive radiometric sensing of deep brain temperature.
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Ganapathi AM, Hanna JM, Schechter MA, Englum BR, Castleberry AW, Gaca JG, Hughes GC. Antegrade versus retrograde cerebral perfusion for hemiarch replacement with deep hypothermic circulatory arrest: does it matter? A propensity-matched analysis. J Thorac Cardiovasc Surg 2014; 148:2896-902. [PMID: 24908350 DOI: 10.1016/j.jtcvs.2014.04.014] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2014] [Revised: 03/17/2014] [Accepted: 04/08/2014] [Indexed: 11/17/2022]
Abstract
OBJECTIVE The choice of cerebral perfusion strategy for aortic arch surgery has been debated, and the superiority of antegrade (ACP) or retrograde (RCP) cerebral perfusion has not been shown. We examined the early and late outcomes for ACP versus RCP in proximal (hemi-) arch replacement using deep hypothermic circulatory arrest (DHCA). METHODS A retrospective analysis of a prospectively maintained database was performed for all patients undergoing elective and nonelective hemiarch replacement at a single referral institution from June 2005 to February 2013. Total arch cases were excluded to limit the analysis to shorter DHCA times and a more uniform patient population for whom clinical equipoise regarding ACP versus RCP exists. A total of 440 procedures were identified, with 360 (82%) using ACP and 80 (18%) using RCP. The endpoints included 30-day/in-hospital and late outcomes. A propensity score with 1:1 matching of 40 pre- and intraoperative variables was used to adjust for differences between the 2 groups. RESULTS All 80 RCP patients were propensity matched to a cohort of 80 similar ACP patients. The pre- and intraoperative characteristics were not significantly different between the 2 groups after matching. No differences were found in 30-day/in-hospital mortality or morbidity outcomes. The only significant difference between the 2 groups was a shorter mean operative time in the RCP cohort (P = .01). No significant differences were noted in late survival (P = .90). CONCLUSIONS In proximal arch operations using DHCA, equivalent early and late outcomes can be achieved with RCP and ACP, although the mean operative time is significantly less with RCP, likely owing to avoidance of axillary cannulation. Questions remain regarding comparative outcomes with straight DHCA and lesser degrees of hypothermia.
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Affiliation(s)
- Asvin M Ganapathi
- Duke Center for Aortic Disease, Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Jennifer M Hanna
- Duke Center for Aortic Disease, Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Matthew A Schechter
- Duke Center for Aortic Disease, Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Brian R Englum
- Duke Center for Aortic Disease, Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Anthony W Castleberry
- Duke Center for Aortic Disease, Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Jeffrey G Gaca
- Duke Center for Aortic Disease, Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - G Chad Hughes
- Duke Center for Aortic Disease, Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC.
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Bashir M, Field M, Shaw M, Fok M, Harrington D, Kuduvalli M, Oo A. Influences on Early and Medium-Term Survival Following Surgical Repair of the Aortic Arch. AORTA : OFFICIAL JOURNAL OF THE AORTIC INSTITUTE AT YALE-NEW HAVEN HOSPITAL 2014; 2:56-73. [PMID: 26798716 DOI: 10.12945/j.aorta.2014.13-040] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/12/2013] [Accepted: 03/12/2014] [Indexed: 11/18/2022]
Abstract
OBJECTIVES It is now well established by many groups that surgery on the aortic arch may be achieved with consistently low morbidity and mortality along with relatively good survival compared to estimated natural history for a number of aortic arch pathologies. The objectives of this study were to: 1) report, compare, and analyze our morbidity and mortality outcomes for hemiarch and total aortic arch surgery; 2) examine the survival benefit of hemiarch and total aortic arch surgery compared to age- and sex-matched controls; and 3) define factors which influence survival in these two groups and, in particular, identify those that are modifiable and potentially actionable. METHODS Outcomes from patients undergoing surgical resection of both hemiarch and total aortic arch at the Liverpool Heart and Chest Hospital between June 1999 and December 2012 were examined in a retrospective analysis of data collected for The Society for Cardiothoracic Surgeons (UK). RESULTS Over the period studied, a total of 1240 patients underwent aortic surgery, from which 287 were identified as having undergone hemi to total aortic arch surgery under deep or moderate hypothermic circulatory arrest. Twenty three percent of patients' surgeries were nonelective. The median age at the time of patients undergoing elective hemiarch was 64.3 years and total arch was 65.3 years (P = 0.25), with 40.1% being female in the entire group. A total of 140 patients underwent elective hemiarch replacement, while 81 underwent elective total arch replacement. Etiology of the aortic pathology was degenerative in 51.2% of the two groups, with 87.1% requiring aortic valve repair in the elective hemiarch group and 64.2% in the elective total arch group (P < 0.001). Elective in-hospital mortality was 2.1% in the hemiarch group and 6.2% (P = 0.15) in the total arch group with corresponding rates of stroke (2.9% versus 4.9%, P = 0.47), renal failure (4.3% versus 6.2%, P = 0.54), reexploration for bleeding (4.3% versus 4.9%, P > 0.99), and prolonged ventilation (8.6% versus 16.1%, P = 0.09). Overall mortality was 20.9% at 5 years, while it was 15.7% in the elective hemiarch and 25.9% in the total arch group (P = 0.065). Process control charts demonstrated stability of annualized mortality outcomes over the study period. Survival curve was flat and parallel compared to age- and sex-matched controls beyond 2 years. Multivariate analysis demonstrated the following independent factors associated with survival: renal dysfunction [hazard ratio (HR) = 3.11; 95% confidence interval (CI) = 1.44-6.73], New York Heart Association (NYHA) class ≥ III (HR = 2.25; 95% CI = 1.38-3.67), circulatory arrest time > 100 minutes (HR = 2.92; 95% CI = 1.57-5.43), peripheral vascular disease (HR = 2.44; 95% CI = 1.25-4.74), and concomitant coronary artery bypass graft operation (HR = 2.14; 95% CI = 1.20-3.80). CONCLUSIONS Morbidity, mortality, and medium-term survival were not statistically different for patients undergoing elective hemi-aortic arch and total aortic arch surgery. The survival curve in this group of patients is flat and parallel to sex- and age-matched controls beyond 2 years. Multivariate analysis identified independent influences on survival as renal dysfunction, NYHA class ≥ III, circulatory arrest time (> 100 min), peripheral vascular disease, and concomitant coronary artery bypass grafting. Focus on preoperative optimization of some of these variables may positively influence long-term survival.
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Affiliation(s)
- Mohamad Bashir
- Thoracic Aortic Aneurysm Service, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Mark Field
- Thoracic Aortic Aneurysm Service, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Matthew Shaw
- Thoracic Aortic Aneurysm Service, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Matthew Fok
- Thoracic Aortic Aneurysm Service, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Deborah Harrington
- Thoracic Aortic Aneurysm Service, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Manoj Kuduvalli
- Thoracic Aortic Aneurysm Service, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Aung Oo
- Thoracic Aortic Aneurysm Service, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
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Al Kindi AH, Al Kimyani N, Alameddine T, Al Abri Q, Balan B, Al Sabti H. "Open" approach to aortic arch aneurysm repair. J Saudi Heart Assoc 2014; 26:152-61. [PMID: 24954988 DOI: 10.1016/j.jsha.2014.02.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2013] [Revised: 01/04/2014] [Accepted: 02/18/2014] [Indexed: 11/30/2022] Open
Abstract
Aortic arch aneurysm is a relatively rare entity in cardiac surgery. Repair of such aneurysms, either in isolation or combined with other cardiac procedures, remains a challenging task. The need to produce a relatively bloodless surgical field with circulatory arrest, while at the same time protecting the brain, is the hallmark of this challenge. However, a clear understanding of the topic allows a better and less morbid approach to such a complex surgery. Literature has shown the advantage of selective cerebral perfusion techniques in comparison with only circulatory arrest. Ability to perfuse the brain has allowed circulatory arrest temperatures at moderate hypothermia without the need for deep hypothermia. Even though cannulation site selection appears to be a minor issue, literature has shown that the subclavian/axillary route has the best outcomes and that femoral cannulation should only be reserved for no access patients. Although different techniques for arch anastomosis have been described, we routinely perform the distal first technique as we find it to be less cumbersome and easiest to reproduce. In this review our aim is to outline a systematic approach to aortic arch surgery. Starting with indications for intervention and proceeding with approaches on site of cannulation, approaches to brain protection with hypothermia and selective cerebral perfusion and finally surgical steps in performing the distal and arch vessels anastomosis.
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Affiliation(s)
- Adil H Al Kindi
- Division of Cardiothoracic Surgery, Department of Surgery, Sultan Qaboos University Hospital, Muscat
| | - Nasser Al Kimyani
- Division of Cardiac Anesthesia, Department of Anesthesia, Sultan Qaboos University Hospital, Muscat
| | - Tarek Alameddine
- Division of Cardiothoracic Surgery, Department of Surgery, Sultan Qaboos University Hospital, Muscat
| | - Qasim Al Abri
- Division of Cardiothoracic Surgery, Department of Surgery, Sultan Qaboos University Hospital, Muscat
| | - Baskaran Balan
- Division of Cardiothoracic Surgery, Department of Surgery, Sultan Qaboos University Hospital, Muscat
| | - Hilal Al Sabti
- Division of Cardiothoracic Surgery, Department of Surgery, Sultan Qaboos University Hospital, Muscat
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Stauffer PR, Snow BW, Rodrigues DB, Salahi S, Oliveira TR, Reudink D, Maccarini PF. Non-invasive measurement of brain temperature with microwave radiometry: demonstration in a head phantom and clinical case. Neuroradiol J 2014; 27:3-12. [PMID: 24571829 DOI: 10.15274/nrj-2014-10001] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2013] [Accepted: 12/14/2013] [Indexed: 12/27/2022] Open
Abstract
This study characterizes the sensitivity and accuracy of a non-invasive microwave radiometric thermometer intended for monitoring body core temperature directly in brain to assist rapid recovery from hypothermia such as occurs during surgical procedures. To study this approach, a human head model was constructed with separate brain and scalp regions consisting of tissue equivalent liquids circulating at independent temperatures on either side of intact skull. This test setup provided differential surface/deep tissue temperatures for quantifying sensitivity to change in brain temperature independent of scalp and surrounding environment. A single band radiometer was calibrated and tested in a multilayer model of the human head with differential scalp and brain temperature. Following calibration of a 500MHz bandwidth microwave radiometer in the head model, feasibility of clinical monitoring was assessed in a pediatric patient during a 2-hour surgery. The results of phantom testing showed that calculated radiometric equivalent brain temperature agreed within 0.4°C of measured temperature when the brain phantom was lowered 10°C and returned to original temperature (37°C), while scalp was maintained constant over a 4.6-hour experiment. The intended clinical use of this system was demonstrated by monitoring brain temperature during surgery of a pediatric patient. Over the 2-hour surgery, the radiometrically measured brain temperature tracked within 1-2°C of rectal and nasopharynx temperatures, except during rapid cooldown and heatup periods when brain temperature deviated 2-4°C from slower responding core temperature surrogates. In summary, the radiometer demonstrated long term stability, accuracy and sensitivity sufficient for clinical monitoring of deep brain temperature during surgery.
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Affiliation(s)
- Paul R Stauffer
- Departments of Radiation Oncology and Biomedical Engineering, Duke University; Durham, NC, USA - Department of Radiation Oncology, Thomas Jefferson University; Philadelphia PA, USA -
| | - Brent W Snow
- Department of Surgery and Urology, University of Utah; Salt Lake City, UT, USA - Thermimage Inc.; Salt Lake City, UT, USA
| | - Dario B Rodrigues
- Departments of Radiation Oncology and Biomedical Engineering, Duke University; Durham, NC, USA - CEFITEC, FCT, New University of Lisbon; Caparica, Portugal
| | - Sara Salahi
- Departments of Radiation Oncology and Biomedical Engineering, Duke University; Durham, NC, USA - ANSYS, Inc.; Irvine, CA, USA
| | - Tiago R Oliveira
- Departments of Radiation Oncology and Biomedical Engineering, Duke University; Durham, NC, USA - Institute of Physics, University of São Paulo; São Paulo, Brazil
| | | | - Paolo F Maccarini
- Departments of Radiation Oncology and Biomedical Engineering, Duke University; Durham, NC, USA
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Tian DH, Wan B, Bannon PG, Misfeld M, LeMaire SA, Kazui T, Kouchoukos NT, Elefteriades JA, Bavaria J, Coselli JS, Griepp RB, Mohr FW, Oo A, Svensson LG, Hughes GC, Yan TD. A meta-analysis of deep hypothermic circulatory arrest versus moderate hypothermic circulatory arrest with selective antegrade cerebral perfusion. Ann Cardiothorac Surg 2013; 2:148-58. [PMID: 23977575 DOI: 10.3978/j.issn.2225-319x.2013.03.13] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2013] [Accepted: 03/22/2013] [Indexed: 11/14/2022]
Abstract
INTRODUCTION A recent concern of deep hypothermic circulatory arrest (DHCA) in aortic arch surgery has been its potential association with increased risk of coagulopathy, elevated inflammatory response and end-organ dysfunction. Recently, moderate hypothermic circulatory arrest (MHCA) with selective antegrade circulatory arrest (SACP) seeks to negate potential hypothermia-related morbidities, while maintaining adequate neuroprotection. The present meta-analysis aims to compare postoperative outcomes in arch surgery using DHCA or MHCA+SACP as neuroprotective strategies. METHODS Electronic searches were performed using six databases from their inception to January 2013. Two reviewers independently identified all relevant studies comparing DHCA with MHCA+SACP, as defined by a recent hypothermia temperature consensus. Data were extracted and meta-analyzed according to pre-defined clinical endpoints. RESULTS Nine comparative studies were identified for inclusion in the present meta-analysis. Stroke rates were significantly lower in patients undergoing MHCA+SACP (P=0.0007, I(2)=0%), while comparable results were observed with temporary neurological deficit, mortality, renal failure or bleeding. Infrequent and inconsistent reporting of systemic outcomes precluded analysis of other systemic outcomes. CONCLUSIONS The present meta-analysis indicated the superiority of MHCA+SACP in terms of stroke risk.
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Affiliation(s)
- David H Tian
- The Systematic Review Unit, The Collaborative Research (CORE) Group, Sydney, Australia
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Tian DH, Wan B, Bannon PG, Misfeld M, LeMaire SA, Kazui T, Kouchoukos NT, Elefteriades JA, Bavaria JE, Coselli JS, Griepp RB, Mohr FW, Oo A, Svensson LG, Hughes GC, Underwood MJ, Chen EP, Sundt TM, Yan TD. A meta-analysis of deep hypothermic circulatory arrest alone versus with adjunctive selective antegrade cerebral perfusion. Ann Cardiothorac Surg 2013; 2:261-70. [PMID: 23977593 DOI: 10.3978/j.issn.2225-319x.2013.05.11] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2013] [Accepted: 05/20/2013] [Indexed: 11/14/2022]
Abstract
INTRODUCTION Recognizing the importance of neuroprotection in aortic arch surgery, deep hypothermic circulatory arrest (DHCA) now underpins operative practice as it minimizes cerebral metabolic activity. When prolonged periods of circulatory arrest are required, selective antegrade cerebral perfusion (SACP) is supplemented as an adjunct. However, concerns exist over the risks of SACP in introducing embolism and hypo- and hyper-perfusing the brain. The present meta-analysis aims to compare postoperative outcomes in arch surgery using DHCA alone or DHCA + SACP as neuroprotection strategies. METHODS Electronic searches were performed using six databases from their inception to January 2013. Two reviewers independently identified all relevant studies comparing DHCA alone with DHCA + SACP. Data were extracted and meta-analyzed according to pre-defined clinical endpoints. RESULTS Nine comparative studies were identified in the present meta-analysis, with 648 patients employing DHCA alone and 370 utilizing DHCA + SACP. No significant differences in temporary or permanent neurological outcomes were identified. DHCA + SACP was associated with significantly better survival outcomes (P=0.008, I(2)=0%), despite longer cardiopulmonary bypass time. Infrequent and inconsistent reporting of other clinical results precluded analysis of systemic outcomes. CONCLUSIONS The present meta-analysis indicate the superiority of DHCA + SACP in terms of mortality outcomes.
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Affiliation(s)
- David H Tian
- Collaborative Research (CORE) Group, Sydney, Australia
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