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Montagner M, Kofler M, Pitts L, Heck R, Buz S, Kurz S, Falk V, Kempfert J. Matched comparison of 3 cerebral perfusion strategies in open zone-0 anastomosis for acute type A aortic dissection. Eur J Cardiothorac Surg 2022; 62:6565841. [PMID: 35396839 DOI: 10.1093/ejcts/ezac214] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 02/24/2022] [Accepted: 03/23/2022] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES The present study aims to investigate outcomes after the surgical treatment of acute type A aortic dissection in regard to three available selective cerebral perfusion strategies. METHODS From 2000 to 2019, patients were selected based on the employment of either retrograde cerebral perfusion (RCP), unilateral antegrade cerebral perfusion (uACP) or bilateral antegrade cerebral perfusion (bACP) during open zone-0 anastomosis. Propensity score TriMatch analysis considering several preoperative and intraoperative variables was used to identify well-balanced triplets. The primary end point of the study was a new cerebral operation-related neurologic deficit. RESULTS Operative times (operation time, cardiopulmonary bypass time, reperfusion time) were significantly longer in the RCP group, in which deeper hypothermia was applied (27.5 [24-28], 28 [26-28] and 16 [16-17]°C for uACP, bACP and RCP, respectively, P-value <0.001). The RCP group showed higher red blood cell concentrates and fresh frozen plasma transfusion rates. No significant difference of new cerebral operation-related neurologic deficit was observed between the 3 groups (12.9% vs 12.9% vs 11.3% for RCP, uACP and bACP, P-value = 0.86). In addition, 30-day mortality showed similar distribution independently of the cerebral perfusion strategy adopted (17.7% vs 14.5% vs 17.7% for RCP, uACP and bACP, P-value = 0.86). CONCLUSIONS However, based on a small sample size, the comparison showed no relevant differences in terms of neurologic outcome and 30-day mortality, confirming RCP, uACP and bACP as safe and reproducible selective cerebral perfusion strategies in surgery for acute type A aortic dissection.
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Affiliation(s)
- Matteo Montagner
- Department of Cardiothoracic and Vascular Surgery, German Heart Center, Berlin, Germany
| | - Markus Kofler
- Department of Cardiothoracic and Vascular Surgery, German Heart Center, Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site, Berlin, Germany
| | - Leonard Pitts
- Department of Cardiothoracic and Vascular Surgery, German Heart Center, Berlin, Germany
| | - Roland Heck
- Department of Cardiothoracic and Vascular Surgery, German Heart Center, Berlin, Germany
| | - Semih Buz
- Department of Cardiothoracic and Vascular Surgery, German Heart Center, Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site, Berlin, Germany
| | - Stephan Kurz
- Department of Cardiovascular Surgery, Charité-Berlin Medical School, Berlin, Germany
| | - Volkmar Falk
- Department of Cardiothoracic and Vascular Surgery, German Heart Center, Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site, Berlin, Germany.,Department of Cardiovascular Surgery, Charité-Berlin Medical School, Berlin, Germany.,Translational Cardiovascular Technologies, Institute of Translational Medicine, Department of Health Sciences and Technology, Swiss Federal Institute of Technology (ETH) Zurich, Zurich, Switzerland
| | - Jörg Kempfert
- Department of Cardiothoracic and Vascular Surgery, German Heart Center, Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site, Berlin, Germany
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Honkanen HP, Mustonen C, Tuominen H, Kiviluoma K, Anttila V, Juvonen T. Spinal cord injury during selective cerebral perfusion and segmental artery occlusion: an experimental study. Interact Cardiovasc Thorac Surg 2022; 34:145-152. [PMID: 34999799 PMCID: PMC8923407 DOI: 10.1093/icvts/ivab219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Accepted: 06/14/2021] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES Since selective cerebral perfusion (SCP) has been used in aortic arch surgical procedures, the core temperature during lower body circulatory arrest (LBCA) has been steadily rising. Simultaneously, the use of a frozen elephant trunk (FET) graft has been increasing. The safe period of LBCA in relation to spinal cord ischaemic tolerance in combination with segmental artery occlusion by the FET procedure has not been defined. METHODS Sixteen pigs were assigned to undergo 65 (n = 10) or 90 min (n = 6) of SCP at 28°C with LBCA in combination with occlusion of the 8 uppermost segmental arteries in the thoracic (Th) aorta (15-20 cm FET, Th8-level). The follow-up period consisted of a 6-h intensive period and a 5-day observation period. Near-infrared spectroscopy of the collateral network was used to determine spinal cord oxygenation. The neurological status of the patients was evaluated daily, and the brain and the spinal cord were harvested for a histopathological analysis. RESULTS Five out of 6 pigs after 90 min and 1 out of 10 pigs after 65 min of LBCA died within 48 h of multiorgan failure. Of the survivors in the 65-min group, 6 out of 9 had paraparesis/paraplegia; the remaining 3 reached normal function. The lone survivor after 90 min of LBCA was paraplegic. Nadir near-infrared spectroscopy of the collateral network values at Th8 and Th10 were 34 (±5) and 39 (±4), and they were reached within 35 min of SCP in both groups. CONCLUSIONS An extended FET graft with LBCA and SCP durations >65 min at 28°C results in a poor outcome.
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Affiliation(s)
- Hannu-Pekka Honkanen
- Department of Surgery, Research Unit of Surgery, Anaesthesia and Intensive Care, University of Oulu, Medical Research Center, Oulu, Finland
| | - Caius Mustonen
- Department of Surgery, Research Unit of Surgery, Anaesthesia and Intensive Care, University of Oulu, Medical Research Center, Oulu, Finland
| | - Hannu Tuominen
- Department of Pathology, Oulu University Hospital, Oulu, Finland
| | - Kai Kiviluoma
- Department of Surgery, Research Unit of Surgery, Anaesthesia and Intensive Care, University of Oulu, Medical Research Center, Oulu, Finland
| | - Vesa Anttila
- Department of Surgery, Heart Center, University of Turku and Turku University Hospital, Turku, Finland
| | - Tatu Juvonen
- Department of Surgery, Research Unit of Surgery, Anaesthesia and Intensive Care, University of Oulu, Medical Research Center, Oulu, Finland
- Department of Cardiac Surgery, Heart and Lung Center, Helsinki University Central Hospital, Helsinki, Finland
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Sánchez Pérez R, Tirado Requero P, Polo López L, Rey Lois J, Ramchandani Ramchandani B, García-Guereta Silva L, González Rocafort Á, Aroca Peinado Á. [Neurological changes and outcomes of paediatric surgery of the aortic arch using selective cerebral perfusion]. An Pediatr (Barc) 2020; 93:305-312. [PMID: 32513600 DOI: 10.1016/j.anpedi.2020.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Revised: 02/21/2020] [Accepted: 03/09/2020] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION The aims of this article are to analyse the neuropsychological changes in the medium-term in children subjected to aortic arch surgery using selective cerebral perfusion (SCP), as well as to detect any modifiable factors in the surgical technique that may contribute to minimising the subsequent neurological involvement. MATERIAL AND METHODS Inclusion criteria were established as: aortic arch disease operated on using SCP during the first year of life, between 10 August 2004 and 24 May 2016, biventricular physiology, and gestational age greater than 31 weeks. In the absence of a chromosomal disease, they were classified, from a neurological point of view, using the Rankin score. Children over 4-years of age were subjected to intelligence studies, including attention level, development, and psycho-lingual skills. RESULTS The study included a total of 82 patients with a mean age of 1.8 months. The mean SCP flow was 32ml/kg/min. The mean time of SCP was 31minutes. The overall mortality of the series was 14.8%. Neurological dysfunction was observed in 35.9% of patients, and the following were detected as risk factors: surgery in patients less than 10-days-old, duration of SCP greater than 40minutes, and the time required for the cooling down and/or warming-up. Attention deficit was diagnosed in 35.2% of patients greater than 5-years-old. CONCLUSIONS Patients operated on using SCP in in the first year of life required a neuropsychological follow-up, and there are modifiable surgical factors that may have an influence on neurological development.
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Affiliation(s)
- Raúl Sánchez Pérez
- Servicio de Cirugía Cardiaca Infantil y Cardiopatías Congénitas del Adulto, Hospital Universitario La Paz, Madrid, España.
| | | | - Luz Polo López
- Servicio de Cirugía Cardiaca Infantil y Cardiopatías Congénitas del Adulto, Hospital Universitario La Paz, Madrid, España
| | - Juvenal Rey Lois
- Servicio de Cirugía Cardiaca Infantil y Cardiopatías Congénitas del Adulto, Hospital Universitario La Paz, Madrid, España
| | - Bunty Ramchandani Ramchandani
- Servicio de Cirugía Cardiaca Infantil y Cardiopatías Congénitas del Adulto, Hospital Universitario La Paz, Madrid, España
| | | | - Álvaro González Rocafort
- Servicio de Cirugía Cardiaca Infantil y Cardiopatías Congénitas del Adulto, Hospital Universitario La Paz, Madrid, España
| | - Ángel Aroca Peinado
- Servicio de Cirugía Cardiaca Infantil y Cardiopatías Congénitas del Adulto, Hospital Universitario La Paz, Madrid, España
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Wu Y, Jiang R, Li Z, Pan Y, Yang L, Wang T, Yu R, Yang S. Application of a Modified Extracorporeal Circulation Perfusion Method During Surgery for Acute Stanford Type A Aortic Dissection. Heart Lung Circ 2020; 29:1203-9. [PMID: 32059950 DOI: 10.1016/j.hlc.2019.11.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 10/10/2019] [Accepted: 11/23/2019] [Indexed: 11/20/2022]
Abstract
AIM The aim of this study was to investigate the effect of the modified extracorporeal circulation perfusion method during surgery for acute Stanford type A aortic dissection in patients who underwent stented elephant trunk implantation and arch replacement. METHOD A total of 69 patients with acute Stanford type A aortic dissection who underwent stented elephant trunk implantation and arch replacement were retrospectively analysed from 2017 to 2018. According to the perfusion method of extracorporeal circulation, patients were divided into a routine perfusion (RP) group and a modified perfusion (MP) group. Clinical data were collected, including the time of extracorporeal circulation and deep hypothermic circulatory arrest, incidence of acute kidney injury and neurological complications, and comparisons between the two groups were conducted by using independent sample t-tests for normally distributed qualitative data, the Mann-Whitney U-test for skewed qualitative data, and the chi square test or Fisher's exact test for categorical data. RESULTS There were 55 (80%) males and 14 (20%) females in the entire cohort, and the mean ± standard deviation age was 50.4±9.0 years. A total of 53 (77%) patients were included in the RP group, and 16 (23%) were included in the MP group. Patients in the MP group were older (55.5±7.8 vs 48.8±8.9 years), and the difference was significant (p=0.008). Compared with the RP group, the time of extracorporeal circulation (218.0 [44.7] vs 246.0 [58.0] min; p=0.005) and deep hypothermic circulatory arrest (4.0 [2.0] vs 25.0 [10.0] min; p<0.001) was shorter, and the incidence of postoperative acute kidney injury (n=6 [37.5%] vs n=36 [67.9%]; p=0.029) was lower in the MP group; the differences were significant. Six (6) patients died in the RP group; no patients died in the MP group. The total in-hospital mortality rate was 8.7%. CONCLUSIONS The modified extracorporeal circulation perfusion method is feasible, with satisfactory results.
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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