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Malliou A, Mitsiou C, Kyritsis AP, Alexiou GA. Therapeutic Hypothermia in Treating Glioblastoma: A Review. Ther Hypothermia Temp Manag 2024; 14:2-9. [PMID: 37184912 DOI: 10.1089/ther.2023.0014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2023] Open
Abstract
Glioblastoma (GBM) is the most commonly occurring of all malignant central nervous system (CNS) tumors in adults. Considering the low median survival of only ∼15 months and poor prognosis in GBM patients, despite surgical resection with adjuvant radiation and chemotherapy, it is vital to seek brand new and innovative treatment in combination with already existing methods. Hypothermia participates in many metabolic pathways, inflammatory responses, and apoptotic processes, while also promoting the integrity of neurons. Following the successful application of therapeutic hypothermia across a spectrum of disorders such as traumatic CNS injury, cardiac arrest, and epilepsy, several clinical trials have set to evaluate the potency of hypothermia in treating a variety of cancers, including breast and ovaries cancer. In regard to primary neoplasms and more specifically, GBM, hypothermia has recently shown promising results as an auxiliary treatment, reinforcing chemotherapy's efficacy. In this review, we discuss the recent advances in utilizing hypothermia as treatment for GBM and other cancers.
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Affiliation(s)
- Athina Malliou
- Neurosurgical Institute, University of Ioannina, Ioannina, Greece
| | | | | | - George A Alexiou
- Neurosurgical Institute, University of Ioannina, Ioannina, Greece
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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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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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Exelmans W, Mufty H, Maleux G, Verbrugghe P, Fourneau I. Anatomical feasibility of an endovascular aortic arch repair with the NEXUS endograft in patients treated with a frozen elephant trunk procedure for aortic arch pathology. CVIR Endovasc 2023; 6:10. [PMID: 36862221 PMCID: PMC9981817 DOI: 10.1186/s42155-023-00355-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Accepted: 02/14/2023] [Indexed: 03/03/2023] Open
Abstract
BACKGROUND The aim of this study was to evaluate the feasibility of an endovascular repair, using the NEXUS™ Aortic Arch Stent Graft System, in a real-world cohort of patients, treated with a Frozen Elephant Trunk (FET) procedure for pathology involving the aortic arch. RESULTS The preoperative computed tomography angiography scans of 37 patients were retrospectively analyzed using a dedicated workstation. In total, seven patients (N = 7/37; 18.9%) were eligible for endovascular repair. This number increased to eleven patients (N = 11/37; 29.7%) if an additional relining of the distal aorta would be performed. Device suitability was 47.1% in patients (N = 8/17; 47.1%) with aortic arch aneurysm, 12.5% (N = 1/8; 12.5%) in patients with an acute Stanford type A dissection and 50% (N = 2/4; 50%) in patients with Crawford type II thoraco-abdominal aneurysm. The stent graft was not suitable for any of the two patients with chronic type B dissection (N = 0/2; 0%). In 22 patients (N = 22/37; 59.5%) an endovascular repair with this type of stent graft was not feasible due to an inadequate proximal sealing zone. There was no suitable brachiocephalic trunk landing zone in 13 patients (N = 13/37; 35.1%). There was no suitable distal landing zone distal in 14 patients (N = 14/37; 36.8%). This number decreased to ten patients (N = 10/37; 27.0%) when considering an additional relining of the distal aorta. CONCLUSIONS Endovascular repair with the NEXUS single branch stent graft is feasible in a minority of this real-world cohort that underwent a Frozen Elephant Trunk procedure. However, the applicability of this device probably improves in cases with isolated aortic arch aneurysms.
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Affiliation(s)
- Ward Exelmans
- grid.410569.f0000 0004 0626 3338Department of Vascular Surgery, University Hospitals Leuven, 3000 Leuven, Belgium
| | - Hozan Mufty
- Department of Vascular Surgery, University Hospitals Leuven, 3000, Leuven, Belgium.
| | - Geert Maleux
- grid.410569.f0000 0004 0626 3338Department of Radiology, University Hospitals Leuven, Leuven, Belgium
| | - Peter Verbrugghe
- grid.410569.f0000 0004 0626 3338Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Inge Fourneau
- grid.410569.f0000 0004 0626 3338Department of Vascular Surgery, University Hospitals Leuven, 3000 Leuven, Belgium
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Tsai MT, Wu HY, Hu YN, Lin TW, Wen JS, Luo CY, Roan JN. Safety Time and Optimal Temperature of Unilateral Antegrade Cerebral Perfusion in Acute Type A Aortic Dissection: A Single-Center 15-Year Experience. ACTA CARDIOLOGICA SINICA 2022; 38:159-168. [PMID: 35273437 PMCID: PMC8888319 DOI: 10.6515/acs.202203_38(2).20211113a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 11/13/2021] [Indexed: 01/24/2023]
Abstract
BACKGROUND The optimal level of hypothermia and safe time of unilateral antegrade cerebral perfusion (uACP) in acute type A aortic dissection (ATAAD) repair remain controversial. OBJECTIVES To analyze the association of uACP time and circulatory arrest temperature with surgical outcomes of ATAAD. METHODS We retrospectively analyzed 263 patients who had undergone ATAAD repair between 2006 and 2020 using uACP. The patients were stratified by three chronologically equivalent periods (period 1, 2006 to 2010; period 2, 2011 to 2015; period 3, 2016 to 2020) to demonstrate the decade-long evolution of surgical strategy and outcomes. RESULTS The mean age of the patients was 59.4 ± 12.5 years, and 68.8% were male. The hospital mortality rates were 15.1%, 12.9%, and 11.0% from period 1 to 3 (p = 0.740). The median circulatory arrest temperatures were 20, 23, and 25 °C (p < 0.001), respectively, and the median uACP times were 72, 59, and 41 minutes (p < 0.001). The incidence rates of postoperative permanent neurologic deficits were 13.2%, 10.9%, and 18.3% (p = 0.312), and those of transient neurologic deficits were 9.4%, 10.9%, and 11.9% (p = 0.936), respectively. Multivariate logistic regression analysis showed that uACP time ≥ 60 minutes was an independent predictor of hospital mortality rather than postoperative stroke. ROC curve analysis estimated an optimal cutoff value of 52 minutes of uACP time when the circulatory arrest temperature was ≥ 25 °C to predict hospital mortality (area under the curve: 0.72). CONCLUSIONS Unilateral antegrade cerebral perfusion time was associated with hospital mortality after ATAAD surgery. A safe threshold of 50 to 60 minutes of uACP should be considered.
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Affiliation(s)
- Meng-Ta Tsai
- Division of Cardiovascular Surgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University;
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Institue of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan
| | - Hsuan-Yin Wu
- Division of Cardiovascular Surgery, Department of Surgery, E-Da Hospital/I-Shou University, Kaohsiung
| | - Yu-Ning Hu
- Division of Cardiovascular Surgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University
| | - Ting-Wei Lin
- Division of Cardiovascular Surgery, Department of Surgery, E-Da Hospital/I-Shou University, Kaohsiung
| | - Jih-Sheng Wen
- Division of Cardiovascular Surgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University
| | - Chwan-Yau Luo
- Division of Cardiovascular Surgery, Department of Surgery, E-Da Hospital/I-Shou University, Kaohsiung
| | - Jun-Neng Roan
- Division of Cardiovascular Surgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University;
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Institue of Clinical Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
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Effects of circulatory arrest and cardiopulmonary bypass on cerebral autoregulation in neonatal swine. Pediatr Res 2022; 91:1374-1382. [PMID: 33947997 PMCID: PMC8566324 DOI: 10.1038/s41390-021-01525-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 02/02/2021] [Accepted: 03/18/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND Cerebral autoregulation mechanisms help maintain adequate cerebral blood flow (CBF) despite changes in cerebral perfusion pressure. Impairment of cerebral autoregulation, during and after cardiopulmonary bypass (CPB), may increase risk of neurologic injury in neonates undergoing surgery. In this study, alterations of cerebral autoregulation were assessed in a neonatal swine model probing four perfusion strategies. METHODS Neonatal swine (n = 25) were randomized to continuous deep hypothermic cardiopulmonary bypass (DH-CPB, n = 7), deep hypothermic circulatory arrest (DHCA, n = 7), selective cerebral perfusion (SCP, n = 7) at deep hypothermia, or normothermic cardiopulmonary bypass (control, n = 4). The correlation coefficient (LDx) between laser Doppler measurements of CBF and mean arterial blood pressure was computed at initiation and conclusion of CPB. Alterations in cerebral autoregulation were assessed by the change between initial and final LDx measurements. RESULTS Cerebral autoregulation became more impaired (LDx increased) in piglets that underwent DH-CPB (initial LDx: median 0.15, IQR [0.03, 0.26]; final: 0.45, [0.27, 0.74]; p = 0.02). LDx was not altered in those undergoing DHCA (p > 0.99) or SCP (p = 0.13). These differences were not explained by other risk factors. CONCLUSIONS In a validated swine model of cardiac surgery, DH-CPB had a significant effect on cerebral autoregulation, whereas DHCA and SCP did not. IMPACT Approximately half of the patients who survive neonatal heart surgery with cardiopulmonary bypass (CPB) experience neurodevelopmental delays. This preclinical investigation takes steps to elucidate and isolate potential perioperative risk factors of neurologic injury, such as impairment of cerebral autoregulation, associated with cardiac surgical procedures involving CPB. We demonstrate a method to characterize cerebral autoregulation during CPB pump flow changes in a neonatal swine model of cardiac surgery. Cerebral autoregulation was not altered in piglets that underwent deep hypothermic circulatory arrest (DHCA) or selective cerebral perfusion (SCP), but it was altered in piglets that underwent deep hypothermic CBP.
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Sarrafpour S, Bose R. Deep Hypothermic Circulatory Arrest for Emergency Repair of Type A Aortic Dissection in a Patient with Cold Agglutinins. THE JOURNAL OF EXTRA-CORPOREAL TECHNOLOGY 2021; 53:299-301. [PMID: 34992321 PMCID: PMC8717724 DOI: 10.1182/ject-2100024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 08/16/2021] [Indexed: 06/14/2023]
Abstract
Cold agglutinins (CA) are auto-antibodies that adhere to erythrocytes in cold temperatures, and can result in agglutination of red blood cells. This process can cause complement-mediated intravascular hemolysis, which can be catastrophic. We describe a patient who developed CA during initiation of deep hypothermic circulatory arrest for emergent repair of Type A aortic dissection. The patient was found to have anti-I and anti-C antibodies and a positive direct Coombs test. CA resolved with re-warming, and resulted in no adverse events.
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Affiliation(s)
- Syena Sarrafpour
- Beth Israel Deaconess Medical Center, Department of Anesthesia, Critical Care, and Pain Medicine, Harvard Medical School, Boston, Massachusetts
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Usmanov ES, Chubarova MA, Saidov SK. Emerging Trends in the Use of Therapeutic Hypothermia as a Method for Neuroprotection in Brain Damage (Review). Sovrem Tekhnologii Med 2021; 12:94-104. [PMID: 34796010 PMCID: PMC8596265 DOI: 10.17691/stm2020.12.5.11] [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: 12/18/2019] [Indexed: 11/14/2022] Open
Abstract
The review analyzes current clinical studies on the use of therapeutic hypothermia as a neuroprotective method for treatment of brain damage. This method yields good outcomes in patients with acute brain injuries and chronic critical conditions. There has been shown the interest of researchers in studying the preventive potential of therapeutic hypothermia in secondary neuronal damage. There has been described participation of new molecules producing positive effect on tissues and cells of the central nervous system - proteins and hormones of cold stress - in the mechanisms of neuroprotection in the brain. The prospects of using targeted temperature management in treatment of brain damage are considered.
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Affiliation(s)
- E Sh Usmanov
- Researcher, Laboratory of Clinical Neurophysiology; Federal Clinical Research Centre for Intensive Care Medicine and Rehabilitology, 777 Lytkino Village, Solnechnogorsk District, Moscow Region, 141534, Russia
| | - M A Chubarova
- Junior Researcher, Laboratory of Clinical Neurophysiology; Federal Clinical Research Centre for Intensive Care Medicine and Rehabilitology, 777 Lytkino Village, Solnechnogorsk District, Moscow Region, 141534, Russia
| | - Sh Kh Saidov
- Senior Researcher, Laboratory of Clinical Neurophysiology Federal Clinical Research Centre for Intensive Care Medicine and Rehabilitology, 777 Lytkino Village, Solnechnogorsk District, Moscow Region, 141534, Russia
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Role of Transcranial Doppler in Cardiac Surgery Patients. CURRENT ANESTHESIOLOGY REPORTS 2021. [DOI: 10.1007/s40140-021-00483-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Abstract
Purpose of Review
This review discusses applications of transcranial Doppler (TCD) in cardiac surgery, its efficacy in preventing adverse events such as postoperative cognitive decline and stroke, and its impact on clinical outcomes in these patients.
Recent Findings
TCD alone and in combination with other neuromonitoring modalities has attracted attention as a potential monitoring tool in cardiac surgery patients. TCD allows not only the detection of microemboli and measurement of cerebral blood flow velocity in cerebral arteries but also the assessment of cerebral autoregulation.
Summary
Neuromonitoring is critically important in cardiac surgery as surgical and anesthetic interventions as well as several other factors may increase the risk of cerebral embolization (gaseous and particulate) and cerebral perfusion anomalies, which may lead to adverse neurological events. As an experimental tool, TCD has revealed a possible association of poor neurological outcome with intraoperative cerebral emboli and impaired cerebral perfusion. However, to date, there is no evidence that routine use of transcranial Doppler can improve neurological outcome after cardiac surgery.
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Continuous EEG for Diagnosis of Electrographic Seizures in the Pediatric Cardiac Critical Care Unit: Using a Precious Resource Wisely. Neurocrit Care 2021; 36:13-15. [PMID: 34331204 DOI: 10.1007/s12028-021-01314-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 07/01/2021] [Indexed: 10/20/2022]
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Falasa MP, Arnaoutakis GJ, Janelle GM, Beaver TM. Neuromonitoring and neuroprotection advances for aortic arch surgery. JTCVS Tech 2021; 7:11-19. [PMID: 34318192 PMCID: PMC8312079 DOI: 10.1016/j.xjtc.2020.12.045] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 12/30/2020] [Indexed: 11/15/2022] Open
Affiliation(s)
- Matt P. Falasa
- Department of Surgery, University of Florida, Gainesville, Fla
| | - George J. Arnaoutakis
- Department of Surgery, University of Florida, Gainesville, Fla
- Division of Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, Fla
| | - Greg M. Janelle
- Department of Anesthesiology, University of Florida, Gainesville, Fla
| | - Thomas M. Beaver
- Department of Surgery, University of Florida, Gainesville, Fla
- Division of Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, Fla
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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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14
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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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15
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Seilitz J, Edström M, Sköldberg M, Westerling-Andersson K, Kasim A, Renberg A, Jansson K, Friberg Ö, Axelsson B, Nilsson KF. Early Onset of Postoperative Gastrointestinal Dysfunction Is Associated With Unfavorable Outcome in Cardiac Surgery: A Prospective Observational Study. J Intensive Care Med 2020; 36:1264-1271. [PMID: 32772778 PMCID: PMC8494005 DOI: 10.1177/0885066620946006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objective: The distribution of postoperative gastrointestinal (GI) dysfunction and its association with outcome were investigated in cardiac surgery patients. Gastrointestinal function was evaluated using the Acute Gastrointestinal Injury (AGI) grade proposed by the European Society of Intensive Care Medicine. Design: Prospective observational study at a single center. Setting: University hospital. Patients: Consecutive patients presenting for elective cardiac surgery with extracorporeal circulation (ECC). Interventions: None. Results: Daily assessment using the AGI grade was performed on the first 3 postoperative days in addition to standard care. For analysis, 3 groups were formed based on the maximum AGI grade: AGI 0, AGI 1, and AGI ≥2. Five hundred and one patients completed the study; 32.7%, 65.1%, and 2.2% of the patients scored a maximum AGI 0, AGI 1, and AGI ≥2, respectively. Patients with AGI grade ≥2 had more frequently undergone thoracic aortic surgery and had longer surgery duration and time on ECC. Patients with AGI grade ≥2 had statistically significant higher frequency of GI complications within 30 days (63.6% vs 1.2% and 5.5% in patients with AGI 0 and AGI 1) and higher 30-day mortality (9.1% vs 0.0% and 1.8% in patients with AGI 0 and AGI 1). Conclusions: Early GI dysfunction following cardiac surgery was associated with an unfavorable outcome. Increased attention to GI dysfunction in cardiac surgery patients is warranted and the AGI grade could be a helpful adjunct to a structured approach.
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Affiliation(s)
- Jenny Seilitz
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Måns Edström
- Department of Anaesthesiology and Intensive Care, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Martin Sköldberg
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Kristian Westerling-Andersson
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Alhamsa Kasim
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Anja Renberg
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Kjell Jansson
- Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Örjan Friberg
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Birger Axelsson
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Kristofer F Nilsson
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
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Xie L, Xu Y, Huang G, Ye M, Hu X, Shu S, Lynn H. MHCA with SACP versus DHCA in Pediatric Aortic Arch Surgery: A Comparative Study. Sci Rep 2020; 10:4439. [PMID: 32157148 PMCID: PMC7064562 DOI: 10.1038/s41598-020-61428-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Accepted: 02/24/2020] [Indexed: 12/31/2022] Open
Abstract
The safety and efficacy of selective antegrade cerebral perfusion (SACP) in children undergoing aortic arch surgery are unclear. In this retrospective analysis, we compared moderate hypothermic circulatory arrest (MHCA; n = 61) plus SACP vs deep hypothermic circulatory arrest (DHCA; n = 53) in children undergoing aortic arch surgery during a period from January 2008 to December 2017. Demographic characteristics and the underlying anomalies were comparable between the two groups. The MHCA + SACP group had shorter cardiopulmonary bypass (CPB) time (146.9 ± 40.6 vs 189.6 ± 41.2 min for DHCA; p < 0.05) and higher nasopharyngeal temperature (26.0 ± 2.1 vs 18.9 ± 1.6 °C; p < 0.01). The MHCA + SACP group had lower rate of neurologic complications (3/61 vs 10/53 for DHCA; p < 0.05) but not complications in other organ systems. The MHCA + SACP group also had less 24-hour chest drainage (median, interquartile rage: 28.9, 12.6–150.0 vs 47.4, 15.2–145.0 ml/kg for DHCA; p < 0.05), shorter duration of postoperative mechanical ventilation (35.0, 15.4–80.3 vs 94.0, 42.0–144.0 h; p < 0.01), and shorter stay in intensive care unit (3.9, 3.0–7.0 vs 7.7, 5.0–15.0 d; p < 0.05). In regression analysis, in-hospital mortality was associated with longer CPB time. In conclusion, MHCA + SACP is associated with better short-term outcomes in children receiving aortic arch surgery under CPB.
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Affiliation(s)
- Ling Xie
- Department of Anesthesiology, Ministry of Education Key Laboratory of Child Development and Disorders; National Clinical Research Center for Child Health and Disorders; China International Science and Technology Cooperation base of Child development and Critical Disorders; Children's Hospital of Chongqing Medical University, Chongqing, P.R. China
| | - Yan Xu
- Department of Anesthesiology, Ministry of Education Key Laboratory of Child Development and Disorders; National Clinical Research Center for Child Health and Disorders; China International Science and Technology Cooperation base of Child development and Critical Disorders; Children's Hospital of Chongqing Medical University, Chongqing, P.R. China
| | - Guijin Huang
- Department of Anesthesiology, Ministry of Education Key Laboratory of Child Development and Disorders; National Clinical Research Center for Child Health and Disorders; China International Science and Technology Cooperation base of Child development and Critical Disorders; Children's Hospital of Chongqing Medical University, Chongqing, P.R. China
| | - Mao Ye
- Department of Anesthesiology, Ministry of Education Key Laboratory of Child Development and Disorders; National Clinical Research Center for Child Health and Disorders; China International Science and Technology Cooperation base of Child development and Critical Disorders; Children's Hospital of Chongqing Medical University, Chongqing, P.R. China
| | - Xiao Hu
- Department of Anesthesiology, Eye & ENT Hospital of Fudan University, Shanghai, China
| | - Shiyu Shu
- Department of Anesthesiology, Eye & ENT Hospital of Fudan University, Shanghai, China.
| | - Harness Lynn
- Division of Cardiac Surgery, Johns Hopkins Hospital, School of Medicine, Baltimore, Maryland, USA
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17
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KUBAT E, ÇALIŞKAN A, ÜNAL EU, USANMAZ SE, SORAN TÜRKCAN B, SARITAŞ A, DEMİREL YILMAZ E, İREZ AKSÖYEK A. Antegrad Serebral Perfüzyon ve Distal Ilımlı Hipotermik Sirkülatuar Arrest Tekniğinin Endotel Fonksiyonuna İlişkin Biyobelirteçler Üzerine Etkisi. ACTA MEDICA ALANYA 2020. [DOI: 10.30565/medalanya.642337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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18
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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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19
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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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20
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Neurological Complications in Cardiac Surgery. CURRENT ANESTHESIOLOGY REPORTS 2019. [DOI: 10.1007/s40140-019-00344-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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21
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Kondo N, Tamura K, Hiraoka A, Totsugawa T, Chikazawa G, Sakaguchi T, Yoshitaka H. Treatment outcomes for acute type A aortic dissection with patent false lumen in patients over the age of 80. Gen Thorac Cardiovasc Surg 2019; 67:765-772. [PMID: 30888589 DOI: 10.1007/s11748-019-01111-9] [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: 03/28/2018] [Accepted: 03/04/2019] [Indexed: 11/27/2022]
Abstract
OBJECTIVES While reports which focus on the outcomes of conservative treatments for acute type A aortic dissection in patients over the age of 80 are worth considering, recently many studies have reported improved outcomes of surgical treatment. Accordingly, we analyzed the outcomes of surgical and conservative treatments for acute type A aortic dissection with patent false lumen in patients over the age of 80. METHODS We retrospectively investigated 70 patients over 80 years in age out of 248 consecutive patients with acute type A aortic dissection between January, 2010, and May, 2015. Of the 70 patients, 44 underwent surgical treatments (ascending replacement in 33 and total arch replacement in 11) and 23 patients underwent conservative medical treatments. RESULTS In the surgical treatment, the 30-day mortality rate was 14% (6/44) and the rate of morbidity was 34%. And 17 patients (39%) were discharged home without ambulatory assistance. The actuarial survival rates in the surgical treatment group were 83% and 60% at 1 and 3 years, respectively. The in-hospital death rate of conservative medical treatment was 43% (10/23). Only 26% of the patients having had conservative treatment were discharged home without ambulatory assistance. The actuarial survival rate in the conservative medical group was 8.7% at 1 year. CONCLUSION Surgical outcomes of acute type A aortic dissection with patent false lumen were satisfactory in patients aged over 80 in this study by meticulously determining operative indications, depending on the background of each patient.
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Affiliation(s)
- Nobuo Kondo
- Department of Cardiovascular Surgery, The Sakakibara Heart Institute of Okayama, 2-5-1, Nakai-cho, Kita-Ku, Okayama, 700-0804, Japan.
| | - Kentaro Tamura
- Department of Cardiovascular Surgery, The Sakakibara Heart Institute of Okayama, 2-5-1, Nakai-cho, Kita-Ku, Okayama, 700-0804, Japan
| | - Arudo Hiraoka
- Department of Cardiovascular Surgery, The Sakakibara Heart Institute of Okayama, 2-5-1, Nakai-cho, Kita-Ku, Okayama, 700-0804, Japan
| | - Toshinori Totsugawa
- Department of Cardiovascular Surgery, The Sakakibara Heart Institute of Okayama, 2-5-1, Nakai-cho, Kita-Ku, Okayama, 700-0804, Japan
| | - Genta Chikazawa
- Department of Cardiovascular Surgery, The Sakakibara Heart Institute of Okayama, 2-5-1, Nakai-cho, Kita-Ku, Okayama, 700-0804, Japan
| | - Taichi Sakaguchi
- Department of Cardiovascular Surgery, The Sakakibara Heart Institute of Okayama, 2-5-1, Nakai-cho, Kita-Ku, Okayama, 700-0804, Japan
| | - Hidenori Yoshitaka
- Department of Cardiovascular Surgery, The Sakakibara Heart Institute of Okayama, 2-5-1, Nakai-cho, Kita-Ku, Okayama, 700-0804, Japan
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22
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Jackson TC, Kochanek PM. A New Vision for Therapeutic Hypothermia in the Era of Targeted Temperature Management: A Speculative Synthesis. Ther Hypothermia Temp Manag 2019; 9:13-47. [PMID: 30802174 PMCID: PMC6434603 DOI: 10.1089/ther.2019.0001] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Three decades of animal studies have reproducibly shown that hypothermia is profoundly cerebroprotective during or after a central nervous system (CNS) insult. The success of hypothermia in preclinical acute brain injury has not only fostered continued interest in research on the classic secondary injury mechanisms that are prevented or blunted by hypothermia but has also sparked a surge of new interest in elucidating beneficial signaling molecules that are increased by cooling. Ironically, while research into cold-induced neuroprotection is enjoying newfound interest in chronic neurodegenerative disease, conversely, the scope of the utility of therapeutic hypothermia (TH) across the field of acute brain injury is somewhat controversial and remains to be fully defined. This has led to the era of Targeted Temperature Management, which emphasizes a wider range of temperatures (33–36°C) showing benefit in acute brain injury. In this comprehensive review, we focus on our current understandings of the novel neuroprotective mechanisms activated by TH, and discuss the critical importance of developmental age germane to its clinical efficacy. We review emerging data on four cold stress hormones and three cold shock proteins that have generated new interest in hypothermia in the field of CNS injury, to create a framework for new frontiers in TH research. We make the case that further elucidation of novel cold responsive pathways might lead to major breakthroughs in the treatment of acute brain injury, chronic neurological diseases, and have broad potential implications for medicines of the distant future, including scenarios such as the prevention of adverse effects of long-duration spaceflight, among others. Finally, we introduce several new phrases that readily summarize the essence of the major concepts outlined by this review—namely, Ultramild Hypothermia, the “Responsivity of Cold Stress Pathways,” and “Hypothermia in a Syringe.”
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Affiliation(s)
- Travis C Jackson
- 1 John G. Rangos Research Center, UPMC Children's Hospital of Pittsburgh, Safar Center for Resuscitation Research, University of Pittsburgh, School of Medicine, Pittsburgh, Pennsylvania.,2 Department of Critical Care Medicine, University of Pittsburgh, School of Medicine, Pittsburgh, Pennsylvania
| | - Patrick M Kochanek
- 1 John G. Rangos Research Center, UPMC Children's Hospital of Pittsburgh, Safar Center for Resuscitation Research, University of Pittsburgh, School of Medicine, Pittsburgh, Pennsylvania.,2 Department of Critical Care Medicine, University of Pittsburgh, School of Medicine, Pittsburgh, Pennsylvania
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23
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Fan S, Wang D, Wu C, Pan Z, Li Y, An Y, Li H, Wang G, Dai J, Wang Q. Effects of 4 major brain protection strategies during aortic arch surgery: A protocol for a systematic review and network meta-analysis using Stata. Medicine (Baltimore) 2018; 97:e11448. [PMID: 29979447 PMCID: PMC6076180 DOI: 10.1097/md.0000000000011448] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Reliable brain protection during aortic arch surgery remains a formidable surgical challenge. Various cerebral protection techniques have been used in the clinic; however, there is no consensus regarding which strategy is best. We will perform a network meta-analysis (NMA) focusing on the permanent neurological deficits (PND) and perioperative mortality associated with 4 major brain protection strategies used during aortic arch surgery. METHODS We will perform a literature search of MEDLINE, EMBASE, Cochrane Library, and PubMed databases. The primary outcomes of interest in this analysis will be PND and perioperative mortality. Inconsistencies in the NMA will be evaluated with global and local approaches. Network rank and surface under the cumulative ranking curve (SUCRA) analyses will be performed to evaluate and identify the superiority of different brain protection techniques. RESULTS This study is ongoing and will be submitted to a peer-reviewed journal for consideration of publication. CONCLUSIONS Our study will increase understanding of 4 major brain protection strategies during aortic arch surgery and be helpful to clinicians using NMA in their studies.
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Affiliation(s)
- Shulei Fan
- Chongqing Medical University
- Department of Respiratory Medicine, Second Affiliated Hospital of Chongqing Medical University
| | - Daoxing Wang
- Chongqing Medical University
- Department of Respiratory Medicine, Second Affiliated Hospital of Chongqing Medical University
| | - Chun Wu
- Chongqing Medical University
- Department of Cardiothoracic Surgery, Children's Hospital of Chongqing Medical University, Ministry of Education Key Laboratory of Child Development and Disorders
- China International Science and Technology Cooperation Base of Child Development and Critical Disorders
- Chongqing Key Laboratory of Pediatrics, Chongqing Medical University, Chongqing, China
| | - Zhengxia Pan
- Chongqing Medical University
- Department of Cardiothoracic Surgery, Children's Hospital of Chongqing Medical University, Ministry of Education Key Laboratory of Child Development and Disorders
- China International Science and Technology Cooperation Base of Child Development and Critical Disorders
- Chongqing Key Laboratory of Pediatrics, Chongqing Medical University, Chongqing, China
| | - Yonggang Li
- Chongqing Medical University
- Department of Cardiothoracic Surgery, Children's Hospital of Chongqing Medical University, Ministry of Education Key Laboratory of Child Development and Disorders
- China International Science and Technology Cooperation Base of Child Development and Critical Disorders
- Chongqing Key Laboratory of Pediatrics, Chongqing Medical University, Chongqing, China
| | - Yong An
- Chongqing Medical University
- Department of Cardiothoracic Surgery, Children's Hospital of Chongqing Medical University, Ministry of Education Key Laboratory of Child Development and Disorders
- China International Science and Technology Cooperation Base of Child Development and Critical Disorders
- Chongqing Key Laboratory of Pediatrics, Chongqing Medical University, Chongqing, China
| | - Hongbo Li
- Chongqing Medical University
- Department of Cardiothoracic Surgery, Children's Hospital of Chongqing Medical University, Ministry of Education Key Laboratory of Child Development and Disorders
- China International Science and Technology Cooperation Base of Child Development and Critical Disorders
- Chongqing Key Laboratory of Pediatrics, Chongqing Medical University, Chongqing, China
| | - Gang Wang
- Chongqing Medical University
- Department of Cardiothoracic Surgery, Children's Hospital of Chongqing Medical University, Ministry of Education Key Laboratory of Child Development and Disorders
- China International Science and Technology Cooperation Base of Child Development and Critical Disorders
- Chongqing Key Laboratory of Pediatrics, Chongqing Medical University, Chongqing, China
| | - Jiangtao Dai
- Chongqing Medical University
- Department of Cardiothoracic Surgery, Children's Hospital of Chongqing Medical University, Ministry of Education Key Laboratory of Child Development and Disorders
- China International Science and Technology Cooperation Base of Child Development and Critical Disorders
- Chongqing Key Laboratory of Pediatrics, Chongqing Medical University, Chongqing, China
| | - Quan Wang
- Chongqing Medical University
- Department of Cardiothoracic Surgery, Children's Hospital of Chongqing Medical University, Ministry of Education Key Laboratory of Child Development and Disorders
- China International Science and Technology Cooperation Base of Child Development and Critical Disorders
- Chongqing Key Laboratory of Pediatrics, Chongqing Medical University, Chongqing, China
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Di Marco L, Murana G, Leone A, Pacini D. Con-debate: short circulatory arrest times in arch reconstructive surgery: is simple retrograde cerebral perfusion or hypothermic circulatory arrest as good or better than complex antegrade cerebral perfusion for open distal involvement or hemi-arch? J Vis Surg 2018; 4:46. [PMID: 29682456 DOI: 10.21037/jovs.2018.01.18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Accepted: 01/25/2018] [Indexed: 11/06/2022]
Affiliation(s)
- Luca Di Marco
- Cardiac Surgery Unit, Cardio-Thoracic-Vascular Department, S. Orsola Hospital, University of Bologna, Bologna, Italy
| | - Giacomo Murana
- Cardiac Surgery Unit, Cardio-Thoracic-Vascular Department, S. Orsola Hospital, University of Bologna, Bologna, Italy
| | - Alessandro Leone
- Cardiac Surgery Unit, Cardio-Thoracic-Vascular Department, S. Orsola Hospital, University of Bologna, Bologna, Italy
| | - Davide Pacini
- Cardiac Surgery Unit, Cardio-Thoracic-Vascular Department, S. Orsola Hospital, University of Bologna, Bologna, Italy
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Stein LH, Rubinfeld G, Balsam LB, Ursomanno P, DeAnda A. Too Cold to Clot? Does Intraoperative Hypothermia Contribute to Bleeding After Aortic Surgery? AORTA : OFFICIAL JOURNAL OF THE AORTIC INSTITUTE AT YALE-NEW HAVEN HOSPITAL 2018; 5:106-116. [PMID: 29657946 DOI: 10.12945/j.aorta.2017.16.049] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Accepted: 03/12/2017] [Indexed: 11/18/2022]
Abstract
Background We determined the impact of intraoperative hypothermia on postoperative bleeding after thoracic aortic surgery. Methods We retrospectively analyzed 98 consecutive patients who underwent aortic surgery with deep hypothermic circulatory arrest between 2010 and 2014. We evaluated lowest temperature, absolute decrease in temperature, and rewarming rate. Univariate and multivariate regression were used to determine relationships between temperature, clinical characteristics, and measures of postoperative bleeding. Results The mean age of patients was 60.5 ± 15.1 years, with 64.3% male and 60% Caucasian. The lowest temperatures recorded were 13.5 ± 4.6°C at the bypass circuit. Change in hematocrit was associated with ethnicity, preoperative hematocrit, and rewarming rate. Chest tube output was associated with body mass index, preoperative platelet count, prior cardiac surgery, cardiopulmonary bypass (CPB) duration, intraoperative blood product transfusion, lowest surface temperature, and change in surface temperature. Postoperative packed red blood cell transfusion was associated with ejection fraction, chronic obstructive pulmonary disease (COPD), platelet count, partial thromboplastin time, CPB duration, and lowest blood temperature. Fresh frozen plasma transfusion correlated with COPD, CPB duration, and final blood temperature. Platelet transfusion correlated with body mass index and preoperative platelet count. Unplanned reoperation for bleeding was associated with final temperature and change in temperature. Conclusion We found no consistent associations between intraoperative temperature and indicators of bleeding. Intraoperative cooling strategies should be based on optimal end-organ protection rather than fear of postoperative bleeding; rewarming strategies may ameliorate the risk of coagulopathy.
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Affiliation(s)
- Louis H Stein
- Division of Cardiothoracic Surgery, SUNY Downstate Medical Center, Brooklyn, New York, USA
| | - Gregory Rubinfeld
- Department of Cardiothoracic Surgery, NYU Langone Medical Center, New York, New York, USA
| | - Leora B Balsam
- Department of Cardiothoracic Surgery, NYU Langone Medical Center, New York, New York, USA
| | - Patricia Ursomanno
- Maimonides Heart and Vascular Center, Maimonides Medical Center, Brooklyn, New York, USA
| | - Abe DeAnda
- Division of Cardiothoracic Surgery, University of Texas Medical Branch-Galveston, Galveston, Texas, USA
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Park SJ, Jeon BB, Kim HJ, Kim JB. Aortic arch repair under moderate hypothermic circulatory arrest with or without antegrade cerebral perfusion based on the extent of repair. J Thorac Dis 2018; 10:1875-1883. [PMID: 29707342 DOI: 10.21037/jtd.2018.03.51] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background For aortic-arch repair, moderate hypothermic circulatory arrest (HCA) have shown favorable outcomes over conventional deep HCA when coupled with antegrade cerebral perfusion (ACP); however, recent studies have shown that ACP may not be essential when circulatory arrest time is less than 30 minutes. This study aims to evaluate the stratified arch repair strategy of moderate HCA with or without ACP based on the extent of procedure. Methods Consecutive 138 patients (63 female; mean age, 60.2±15.7 years) undergoing open arch repair due to acute aortic syndrome (n=69) or chronic aneurysm (n=69) from January 2012 through April 2017 were enrolled in this study. Stratified neuroprotective strategy was employed according to the extent of repair: hemi-arch repair (n=93) was performed under moderated HCA alone and total-arch repair (n=45) under moderate HCA combined with unilateral ACP. Results Median total circulatory arrest and total procedural times were 8.0 minutes [interquartile range (IQR), 6.0-10.0] and 233.0 minutes (IQR, 196.0-290.0 minutes), respectively in the hemi-arch group, and 25.0 minutes (IQR, 12.0-33.0 minutes) and 349.0 minutes (IQR, 276.0-406.0 minutes), respectively in the total-arch group. Early mortality occurred in 2 patients (1.4%) who underwent hemi-arch repair for acute aortic dissection. There was no permanent neurological injury, but 2 cases (1.4%) of temporary neurologic deficit in the hemi-arch group. Other complications included re-exploration for bleeding in 6 (4.3%), postoperative extracorporeal life support in 5 (3.6%) and new-dialysis in 6 (4.3%). Conclusions Stratified cerebral perfusion strategy using moderate hypothermia for aortic-arch surgery based on the extent of arch repair showed satisfactory safety and reasonable efficiency.
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Affiliation(s)
- Sung Jun Park
- Department of Thoracic and Cardiovascular Surgery, The Armed Forces Daegu Hospital, Daegu, South Korea
| | - Bo Bae Jeon
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Hee Jung Kim
- Department of Thoracic and Cardiovascular Surgery, Sejong General Hospital, Bucheon, South Korea
| | - Joon Bum Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
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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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Kamenskaya OV, Klinkova AS, Chernyavsky AM, Lomivorotov VV, Meshkov IO, Karaskov AM. Deep Hypothermic Circulatory Arrest vs. Antegrade Cerebral Perfusion in Cerebral Protection during the Surgical Treatment of Chronic Dissection of the Ascending and Arch Aorta. THE JOURNAL OF EXTRA-CORPOREAL TECHNOLOGY 2017; 49:16-25. [PMID: 28298661 PMCID: PMC5347214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Accepted: 10/18/2016] [Indexed: 06/06/2023]
Abstract
Circulatory arrest during aortic surgery presents a risk of neurological complications. The present study aimed to investigate the effectiveness of deep hypothermic circulatory arrest (DHCA) vs. antegrade cerebral perfusion (ACP) in cerebral protection during the surgical treatment of chronic dissection of the ascending and arch aorta and to assess the quality-of-life (QoL) in the long-term postoperative period with respect to the used cerebral protection method. In a prospective, randomized study, 58 patients with chronic type I aortic dissection who underwent ascending aorta and aortic arch replacement surgery were included. Patients were allocated in two groups: 29 patients who underwent surgery under moderate hypothermia (24°C) combined with ACP and 29 patients who underwent surgery under DHCA (18°C) with craniocerebral hypothermia. The regional hemoglobin oxygen saturation (rSO2, %) were compared during surgery, neurological complications were analyzed during the early postoperative period, QoL was compared in the long-term postoperative period (1-year follow-up). During the early postoperative period, 37.9% of patients in the DHCA group exhibited neurological complications, compared with 13.8% of those in the ACP group (p < .05). The risk of neurological complications in the early postoperative period was dependent on the extent of rSO2 decrease during circulatory arrest. In the ACP group, rSO2 decreased by ≤17% from baseline during circulatory arrest. In the DHCA group, a more profound decrease in rSO2 (>30%) was recorded (p < .05). QoL in the long-term period after surgery improved, but it was not dependent on the cerebral protection method used during surgery. ACP during aortic replacement demonstrated the most advanced properties of cerebral protection that can be evidenced by a lesser degree of neurological complications, compared with patients who underwent surgery under conditions of DHCA. QoL after surgery was not dependent on the cerebral protection method used during surgery.
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Affiliation(s)
- Oksana Vasilyevna Kamenskaya
- Clinical Physiology Group, Center of Anesthesiology and Critical Care Medicine, Novosibirsk Research Institute of Circulation Pathology, Novosibirsk, 630055, Russia
| | - Asya Stanislavovna Klinkova
- Clinical Physiology Group, Center of Anesthesiology and Critical Care Medicine, Novosibirsk Research Institute of Circulation Pathology, Novosibirsk, 630055, Russia
| | - Alexander Mikhailovich Chernyavsky
- Center of Surgery, Aorta, Coronary and Peripheral Arteries, Novosibirsk Research Institute of Circulation Pathology, Novosibirsk, 630055, Russia
| | - Vladimir Vladimirovich Lomivorotov
- Center of Anesthesiology and Critical Care Medicine, Novosibirsk Research Institute of Circulation Pathology, Novosibirsk, 630055, Russia
| | - Ivan Olegovich Meshkov
- Clinical Physiology Group, Center of Anesthesiology and Critical Care Medicine, Novosibirsk Research Institute of Circulation Pathology, Novosibirsk, 630055, Russia
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Salameh A, Dhein S, Dähnert I, Klein N. Neuroprotective Strategies during Cardiac Surgery with Cardiopulmonary Bypass. Int J Mol Sci 2016; 17:ijms17111945. [PMID: 27879647 PMCID: PMC5133939 DOI: 10.3390/ijms17111945] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Revised: 11/02/2016] [Accepted: 11/15/2016] [Indexed: 12/27/2022] Open
Abstract
Aortocoronary bypass or valve surgery usually require cardiac arrest using cardioplegic solutions. Although, in principle, in a number of cases beating heart surgery (so-called off-pump technique) is possible, aortic or valve surgery or correction of congenital heart diseases mostly require cardiopulmonary arrest. During this condition, the heart-lung machine also named cardiopulmonary bypass (CPB) has to take over the circulation. It is noteworthy that the invention of a machine bypassing the heart and lungs enabled complex cardiac operations, but possible negative effects of the CPB on other organs, especially the brain, cannot be neglected. Thus, neuroprotection during CPB is still a matter of great interest. In this review, we will describe the impact of CPB on the brain and focus on pharmacological and non-pharmacological strategies to protect the brain.
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Affiliation(s)
- Aida Salameh
- Clinic for Paediatric Cardiology Heart Centre, University of Leipzig, 04289 Leipzig, Germany.
| | - Stefan Dhein
- Rudolf-Boehm-Institute for Pharmacology and Toxicology, University of Leipzig, 04107 Leipzig, Germany.
| | - Ingo Dähnert
- Clinic for Paediatric Cardiology Heart Centre, University of Leipzig, 04289 Leipzig, Germany.
| | - Norbert Klein
- Department of Cardiology, Angiology and Internal Intensive Care Medicine, St. Georg Hospital, Academic Medical Centre, University of Leipzig, 04129 Leipzig, Germany.
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30
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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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31
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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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Bhalala US, Appachi E, Mumtaz MA. Neurologic Injury Associated with Rewarming from Hypothermia: Is Mild Hypothermia on Bypass Better than Deep Hypothermic Circulatory Arrest? Front Pediatr 2016; 4:104. [PMID: 27734011 PMCID: PMC5039167 DOI: 10.3389/fped.2016.00104] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Accepted: 09/07/2016] [Indexed: 11/13/2022] Open
Abstract
Many known risk factors for adverse cardiovascular and neurological outcomes in children with congenital heart defects (CHD) are not modifiable; however, the temperature and blood flow during cardiopulmonary bypass (CPB), are two risk factors, which may be altered in an attempt to improve long-term neurological outcomes. Deep hypothermic circulatory arrest, traditionally used for aortic arch repair, has been associated with short-term and long-term neurologic sequelae. Therefore, there is a rising interest in using moderate hypothermia with selective antegrade cerebral blood flow on CPB during aortic arch repair. Rewarming from moderate-to-deep hypothermia has been shown to be associated with neuronal injury, neuroinflammation, and loss of cerebrovascular autoregulation. A significantly lesser degree of rewarming is required following mild (33-35°C) hypothermia as compared with moderate (28-32°C), deep (21-27°C), and profound (less than 20°C) hypothermia. Therefore, we believe that mild hypothermia is associated with a lower risk of rewarming-induced neurologic injury. We hypothesize that mild hypothermia with selective antegrade cerebral perfusion during CPB for neonatal aortic arch repair would be associated with improved neurologic outcome.
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Affiliation(s)
- Utpal S Bhalala
- Children's Hospital of San Antonio, Baylor College of Medicine , San Antonio, TX , USA
| | - Elumalai Appachi
- Children's Hospital of San Antonio, Baylor College of Medicine , San Antonio, TX , USA
| | - Muhammad Ali Mumtaz
- Children's Hospital of San Antonio, Baylor College of Medicine , San Antonio, TX , USA
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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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35
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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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Current status of cerebral protection for aortic arch surgery. J Thorac Cardiovasc Surg 2014; 148:2466-2467. [PMID: 25451498 DOI: 10.1016/j.jtcvs.2014.09.085] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2014] [Accepted: 09/24/2014] [Indexed: 11/21/2022]
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Billeter AT, Hellmann J, Roberts H, Druen D, Gardner SA, Sarojini H, Galandiuk S, Chien S, Bhatnagar A, Spite M, Polk HC. MicroRNA-155 potentiates the inflammatory response in hypothermia by suppressing IL-10 production. FASEB J 2014; 28:5322-36. [PMID: 25231976 DOI: 10.1096/fj.14-258335] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Therapeutic hypothermia is commonly used to improve neurological outcomes in patients after cardiac arrest. However, therapeutic hypothermia increases sepsis risk and unintentional hypothermia in surgical patients increases infectious complications. Nonetheless, the molecular mechanisms by which hypothermia dysregulates innate immunity are incompletely understood. We found that exposure of human monocytes to cold (32°C) potentiated LPS-induced production of TNF and IL-6, while blunting IL-10 production. This dysregulation was associated with increased expression of microRNA-155 (miR-155), which potentiates Toll-like receptor (TLR) signaling by negatively regulating Ship1 and Socs1. Indeed, Ship1 and Socs1 were suppressed at 32°C and miR-155 antagomirs increased Ship1 and Socs1 and reversed the alterations in cytokine production in cold-exposed monocytes. In contrast, miR-155 mimics phenocopied the effects of cold exposure, reducing Ship1 and Socs1 and altering TNF and IL-10 production. In a murine model of LPS-induced peritonitis, cold exposure potentiated hypothermia and decreased survival (10 vs. 50%; P < 0.05), effects that were associated with increased miR-155, suppression of Ship1 and Socs1, and alterations in TNF and IL-10. Importantly, miR-155-deficiency reduced hypothermia and improved survival (78 vs. 32%, P < 0.05), which was associated with increased Ship1, Socs1, and IL-10. These results establish a causal role of miR-155 in the dysregulation of the inflammatory response to hypothermia.
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Affiliation(s)
- Adrian T Billeter
- Price Institute of Surgical Research, Hiram C. Polk, Jr., M.D. Department of Surgery, and
| | - Jason Hellmann
- Diabetes and Obesity Center, Institute of Molecular Cardiology, University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Henry Roberts
- Price Institute of Surgical Research, Hiram C. Polk, Jr., M.D. Department of Surgery, and
| | - Devin Druen
- Price Institute of Surgical Research, Hiram C. Polk, Jr., M.D. Department of Surgery, and
| | - Sarah A Gardner
- Price Institute of Surgical Research, Hiram C. Polk, Jr., M.D. Department of Surgery, and
| | - Harshini Sarojini
- Price Institute of Surgical Research, Hiram C. Polk, Jr., M.D. Department of Surgery, and
| | - Susan Galandiuk
- Price Institute of Surgical Research, Hiram C. Polk, Jr., M.D. Department of Surgery, and
| | - Sufan Chien
- Price Institute of Surgical Research, Hiram C. Polk, Jr., M.D. Department of Surgery, and
| | - Aruni Bhatnagar
- Diabetes and Obesity Center, Institute of Molecular Cardiology, University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Matthew Spite
- Diabetes and Obesity Center, Institute of Molecular Cardiology, University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Hiram C Polk
- Price Institute of Surgical Research, Hiram C. Polk, Jr., M.D. Department of Surgery, and
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Quinones QJ, Ma Q, Zhang Z, Barnes BM, Podgoreanu MV. Organ protective mechanisms common to extremes of physiology: a window through hibernation biology. Integr Comp Biol 2014; 54:497-515. [PMID: 24848803 DOI: 10.1093/icb/icu047] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Supply and demand relationships govern survival of animals in the wild and are also key determinants of clinical outcomes in critically ill patients. Most animals' survival strategies focus on the supply side of the equation by pursuing territory and resources, but hibernators are able to anticipate declining availability of nutrients by reducing their energetic needs through the seasonal use of torpor, a reversible state of suppressed metabolic demand and decreased body temperature. Similarly, in clinical medicine the majority of therapeutic interventions to care for critically ill or trauma patients remain focused on elevating physiologic supply above critical thresholds by increasing the main determinants of delivery of oxygen to the tissues (cardiac output, perfusion pressure, hemoglobin concentrations, and oxygen saturation), as well as increasing nutritional support, maintaining euthermia, and other general supportive measures. Techniques, such as induced hypothermia and preconditioning, aimed at diminishing a patient's physiologic requirements as a short-term strategy to match reduced supply and to stabilize their condition, are few and underutilized in clinical settings. Consequently, comparative approaches to understand the mechanistic adaptations that suppress metabolic demand and alter metabolic use of fuel as well as the application of concepts gleaned from studies of hibernation, to the care of critically ill and injured patients could create novel opportunities to improve outcomes in intensive care and perioperative medicine.
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Affiliation(s)
- Quintin J Quinones
- *Department of Anesthesiology, Systems Modeling of Perioperative Organ Injury Laboratory, Duke University, Box 3094, Durham, NC 27710, USA; Institute for Arctic Biology, University of Alaska, Fairbanks, AK, USA
| | - Qing Ma
- *Department of Anesthesiology, Systems Modeling of Perioperative Organ Injury Laboratory, Duke University, Box 3094, Durham, NC 27710, USA; Institute for Arctic Biology, University of Alaska, Fairbanks, AK, USA
| | - Zhiquan Zhang
- *Department of Anesthesiology, Systems Modeling of Perioperative Organ Injury Laboratory, Duke University, Box 3094, Durham, NC 27710, USA; Institute for Arctic Biology, University of Alaska, Fairbanks, AK, USA
| | - Brian M Barnes
- *Department of Anesthesiology, Systems Modeling of Perioperative Organ Injury Laboratory, Duke University, Box 3094, Durham, NC 27710, USA; Institute for Arctic Biology, University of Alaska, Fairbanks, AK, USA
| | - Mihai V Podgoreanu
- *Department of Anesthesiology, Systems Modeling of Perioperative Organ Injury Laboratory, Duke University, Box 3094, Durham, NC 27710, USA; Institute for Arctic Biology, University of Alaska, Fairbanks, AK, USA*Department of Anesthesiology, Systems Modeling of Perioperative Organ Injury Laboratory, Duke University, Box 3094, Durham, NC 27710, USA; Institute for Arctic Biology, University of Alaska, Fairbanks, AK, USA
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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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40
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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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Damberg A, Schälte G, Autschbach R, Hoffman A. Safety and pitfalls in frozen elephant trunk implantation. Ann Cardiothorac Surg 2013; 2:669-76. [PMID: 24109583 DOI: 10.3978/j.issn.2225-319x.2013.09.16] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2013] [Accepted: 09/23/2013] [Indexed: 11/14/2022]
Abstract
The frozen elephant trunk (FET) procedure, or open stent grafting, is a tool for the combined open and endovascular treatment via a median sternotomy of extensive aortic disease involving both aortic arch and descending thoracic aorta. The technique aims to stabilize the maximum extent of the thoracic aorta in one step, with the goal of either rendering a secondary intervention to the downstream aorta unnecessary or producing an easy landing zone for secondary thoracic endovascular aortic repair (TEVAR) or open surgery. Even though large case series have reported good results, we still have no conclusive evidence as to which patients and what kind of pathologies benefit from this technique. The surgical sequences described for total arch replacement with the FET procedure are just as varied as the associated devices and indications. This article focuses on important perioperative and surgical aspects, as well as potential complications during FET procedures.
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Affiliation(s)
- Anneke Damberg
- Department of Cardiothoracic and Cardiovascular Surgery, University Hospital RWTH Aachen, Pauwelsstr. 30, 52074 Aachen, Germany
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42
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Tang GHL, Spielvogel D, Lansman SL. Hypothermia alone might not be enough for cerebral protection in aortic arch surgery. Tex Heart Inst J 2013; 40:566-567. [PMID: 24391323 PMCID: PMC3853809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Affiliation(s)
- Gilbert H L Tang
- Section of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, New York 10595
| | - David Spielvogel
- Section of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, New York 10595
| | - Steven L Lansman
- Section of Cardiothoracic Surgery, Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, New York 10595
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