Cerebral and visceral organ protection during aortic arch surgery. Intraoperative tactics and monitoring details

Abstract

Aim. The study is aimed at presenting the protocol of intraoperative organ protection, analyzing its effectiveness during aortic arch surgery and evaluating the rate of postoperative complications in this group of patients. Methods. The study included 141 patients. In the first group (n=70) patients underwent aortic arch surgery with hypothermic circulatory arrest (target core temperature 26 °C) and antegrade cerebral perfusion. Patients of the second group (n=71) underwent ascending aortic replacement using cardiopulmonary bypass with moderate hypothermia (target core temperature 32 °C). Cerebral and tissue oxygenation monitoring was performed in all the cases. In the first group transcranial Doppler monitoring was also performed. 33 patients in the first group and 34 patients in the second group underwent testing before and after surgery in order to evaluate cognitive function. Patients’ condition was evaluated during the in-hospital period that was about 15.97±20.54 days. Results. In-hospital mortality rate was 4,2 % in the first group and 0% in the second one (p=0.12). Stroke was observed in 1.4 and 0 % of cases respectively. The rate of encephalopathy (as the leading symptom) was 7.1 and 5.6 % in 1st and 2nd groups respectively. Multimodal monitoring enabled to dynamically adjust the flow rate of antegrade cerebral perfusion. As a result, cerebral SctO2 and linear velocity were maintained within the acceptable range.Conclusion. The presented protocol proved to be effective, it allows to perform aortic arch surgery with the same postoperative neurological complications’ rate as after ascending aortic replacement. We recommend performing reconstructive aortic arch surgery by using moderate hypothermic circulatory arrest (26-28 °С) and selective antegrade cerebral perfusion. In this modality, it is important to perform the distal anastomosis quickly and start patient’s rewarming (this will significantly shorten the duration of cardiopulmonary bypass and, as a result, decrease the rate of postoperative complications) and to carry out both precise intraoperative monitoring of the brain condition (by using cerebral oxymetry and transcranial Doppler) and central core temperature.Received 21 June 2016. Accepted 21 October 2016.Funding: The study had no sponsorship.Conflict of interest: The authors declare no conflict of interest.Author contributionsConceptualization and study design: Belov Yu.V., Charchyan E.R., Akselrod B.A.Material acquisition and analysis: Khachatryan Z.R., Oystrakh A.S., Medvedeva L.A., Guskov D.A., Fedulova S.V.Statistical data processing: Khachatryan Z.R., Guskov D.A., Skvortsov A.A.Article writing: Akselrod B.A., Khachatryan Z.R., Skvortsov A.A. Review & editing: Charchyan E.R., Akselrod B.A., Eremenko A.A., Belov Yu.V.