Selective Antegrade Cerebral Perfusion Group Research Articles

Comparison of cases with and without additional lower body perfusion in newborns undergoing aortic arch reconstruction with antegrade selective cerebral perfusion method.

Background The aim of this study was to analyze the effect of additional lower body perfusion, compared to antegrade selective cerebral perfusion, on early postoperative outcomes after aortic arch repair in neonates with biventricular morphology. Methods Between January 2017 and April 2020, a total of 46 neonates (34 males, 12 females; median age: 10 days; range, 7 to 14 days) with biventricular morphology underwent an aortic arch reconstruction were retrospectively analyzed. The effects of antegrade selective cerebral perfusion and additional lower body perfusion techniques on vital organ preservation and mortality were evaluated in these patients who underwent arch reconstruction. Results In the univariate analysis of the whole cohort, postoperative creatinine level was lower in the additional lower body perfusion group, while there was no significant difference between the other parameters. In the multivariate analysis, intraoperative highest lactate level (odds ratio: 1.7; 95% confidence interval: 1.07-2.68; p=0.02) and postoperative 4th t o 6 th h lactate levels (odds ratio: 2.34; 95% confidence interval: 1.08-5.09; p=0.03) were independent predictors of early mortality. Mortality rate was higher in the antegrade selective cerebral perfusion group (22% vs. 7%), although it did not reach statistical significance. In the receiver operating characteristic curve analysis, the cut-off value for intraoperative lactate was 6.2 mmol/L (sensitivity: 85.7%, specificity: 71.1%) and the cut-off value for the lactate level at the postoperative 4th to 6th h was 4.9 mmol/L (sensitivity: 85.7%, specificity: 73.7%). Above these lactate levels were found to be associated with mortality. Conclusion Additional lower body perfusion may have a role in vital organ protection in aortic arch repair of neonates, compared to antegrade selective cerebral perfusion.

ANALYSIS OF THE VISCERAL PERFUSION STRATEGIES DURING INFANT AORTIC ARCH RECONSTRUCTION

Aim To compare the effects of continuous regional perfusion methods for infant aortic arch repair on the incidence of acute renal dysfunction and mortality in the early postoperative period.Methods A total of 121 infants who underwent aortic arch reconstruction in the period from June 2007 to December 2017 were included in the study. Patients were 1:1 propensity score matched using the nearest-neighbor methodology. Sixty-two patients (median age 14 (interquartile range (IQR) [8; 23]) days) were selected for the retrospective analysis and divided in two groups: those who underwent repair with selective antegrade cerebral perfusion (SACP) (SACP group, 31 patients) at 23–26°C and those who received whole brain perfusion and additional lower body perfusion (double arterial cannulation (DAC) group, 31 patients) at 28–32°C.Results In-hospital mortality was 3.2% in the DAC group (3.2%) and 12.8% in the SACP group, respectively (p = 0.03). More patients from the SACP group required an open chest after operation (p = 0.013). Patients from the DAC group had shorter open chest duration (p = 0.002) and shorter length of stay in the intensive care unit (ICU) (p = 0.035). There were no differences in the need for renal replacement therapy (p = 0.20) and rate of creatinine level progression during the first three postoperative days between the groups (p = 0.53). The body mass of less than 2 kilos predisposes patients to the onset of acute renal dysfunction (p = 0.013), which was found to be a predictor of early mortality (p = 0.038).Conclusion Lower body perfusion reported similar results to SACP in terms of the onset of acute renal dysfunction, but was superior in terms of lower mortality and shorter lengths of stay in the ICU.

Antegrade selective cerebral perfusion reduced in-hospital mortality and permanent focal neurological deficit in patients with elective aortic arch surgery†.

We retrospectively evaluated the outcome after elective aortic arch surgery with circulatory arrest to determine the impact of different brain protection strategies on neurological outcome and early and late survival. A total of 925 patients were included. The patients were assigned to 2 groups based on the type of cerebral protection strategy used during circulatory arrest [hypothermic circulatory arrest (HCA) n = 224; antegrade selective cerebral perfusion (ASCP) n = 701]. The propensity score matching (1:1; 210 vs 210 patients) approach was used to minimize selection bias and to obtain comparable groups. The overall in-hospital mortality and permanent focal neurological deficit rates were 5.6% (n = 52) and 5.4% (n = 50) and were significantly lower in patients who received ASCP (4.4% and 3.4%, respectively) as compared to those who underwent HCA (9.4% and 11.6%, respectively) (P = 0.005 and P < 0.001). The propensity-matched analysis showed significantly lower rates of in-hospital mortality [3.8% vs 9.5% (HCA)] and permanent focal neurological deficit in ASCP group [2.9% vs 11.9% (HCA)]. Multivariable logistic regression analysis revealed left ventricular ejection fraction <30%, age >70 years, coronary artery disease, circulatory arrest time >40 min and mitral valve disease as independent predictors of in-hospital mortality. The use of ASCP was protective for early survival. Cox regression analysis revealed that long-term mortality was independently predicted by age, left ventricular ejection fraction <30%, total arch replacement, prior cardiac surgery, PVD, chronic obstructive pulmonary disease and previous stroke, whereas ASCP was protective for late survival. Elective aortic arch surgery is associated with acceptable early and late outcomes. The ASCP is associated with a significant reduction in-hospital mortality and occurrence of permanent neurological deficits.

Neuroprotective effect of selective antegrade cerebral perfusion during prolonged deep hypothermic circulatory arrest: Cerebral metabolism evidence in a pig model.

Objective:The aim of this study was to elucidate the mechanism of cerebral injury and to evaluate selective antegrade cerebral perfusion (SACP) as a superior neuroprotective strategy for prolonged deep hypothermic circulatory arrest (DHCA).Methods:Twelve pigs (6–8-week old) were randomly assigned to DHCA alone (n=6) and DHCA with SACP (n=6) at 18°C for 80 min groups. Serum S100 was determined using an immunoassay analyzer. The concentrations of cerebral dialysate glucose, lactate, pyruvate, glycerol, and glutamate were measured using a microdialysis analyzer.Results:Compared with a peak at T4 (after 60 min of rewarming) in the DHCA group, the serum S100 in the SACP group was significantly lower throughout the study. The DHCA group was susceptible to significant increases in the levels of lactate, glycerol, and glutamate and the ratio of lactate/pyruvate as well as decreases in the level of glucose. These microdialysis variables showed only minor changes in the SACP group. There was a positive correlation between cerebral lactate and intracranial pressure during reperfusion in the DHCA group. However, the apoptosis index and C-FOS protein levels were lower in the SACP group.Conclusion:Metabolic dysfunction is involved in the mechanism of cerebral injury. SACP is a superior neuroprotective strategy for both mild and prolonged DHCA.

Retrograde Cerebral Perfusion Results in Better Perfusion to the Striatum Than the Cerebral Cortex During Deep Hypothermic Circulatory Arrest: A Microdialysis Study.

It remains controversial whether contemporary cerebral perfusion techniques, utilized during deep hypothermic circulatory arrest (DHCA), establish adequate perfusion to deep structures in the brain. This study aimed to investigate whether selective antegrade cerebral perfusion (SACP) or retrograde cerebral perfusion (RCP) can provide perfusion equally to various anatomical positions in the brain using metabolic evidence obtained from microdialysis. Eighteen piglets were randomly assigned to 40 min of circulatory arrest (CA) at 18°C without cerebral perfusion (DHCA group, n = 6) or with SACP (SACP group, n = 6) or RCP (RCP group, n = 6). Microdialysis parameters (glucose, lactate, pyruvate, and glutamate) were measured every 30 min in cortex and striatum. After 3 h of reperfusion, brain tissue was harvested for Western blot measurement of α-spectrin. After 40 min of CA, the DHCA group showed marked elevations of lactate and glycerol and a reduction in glucose in the microdialysis perfusate (all P < 0.05). The changes in glucose, lactate, and glycerol in the perfusate and α-spectrin expression in brain tissue were similar between cortex and striatum in the SACP group (all P > 0.05). In the RCP group, the cortex exhibited lower glucose, higher lactate, and higher glycerol in the perfusate and higher α-spectrin expression in brain tissue compared with the striatum (all P < 0.05). Glutamate showed no difference between cortex and striatum in all groups (all P > 0.05). In summary, SACP provided uniform and continuous cerebral perfusion to most anatomical sites in the brain, whereas RCP resulted in less sufficient perfusion to the cortex but better perfusion to the striatum.

Selective Antegrade Cerebral Perfusion Attenuating the TLR4/NF-κB Pathway during Deep Hypothermia Circulatory Arrest in a Pig Model

Objectives: The alteration of the Toll-like receptor/nuclear factor-kappa B (TLR4/NF-κB) signaling pathway during deep hypothermia circulatory arrest (DHCA) has not yet been defined. The aim of this study was to explore the expression of the TLR4/NF-κB pathway cytokine in cerebral injury resulting from DHCA as well as the effect of selective antegrade cerebral perfusion (SACP) on TLR4/NF-κB pathway expression. Methods: Twelve pigs were randomly assigned to DHCA alone (n = 6) or DHCA with SACP (n = 6) at 18°C for 80 min. Serum interleukin (IL)-6 was assayed by ELISA. Apoptosis and NF-κB proteins were detected by fluorescence TUNEL and Western blot, respectively. The level of TLR4 mRNA and protein were determined through qRT-PCR and Western blot. Results: The serum IL-6 level of the SACP group was significantly lower than that of the DHCA group at the end of circulation arrest and experimentation. Apoptotic index and NF-κB protein were apparently lower in SACP animals (p < 0.05). Compared to the DHCA group, the levels of TLR4 protein and mRNA in the SACP group were lower with significance (p < 0.05). Conclusions: The TLR4/NF-κB signaling pathway plays a critical role in the pathogenesis of DHCA cerebral injury. Attenuation of the TLR4/NF-κB inflammatory cytokines probably contributes to the neuroprotective effect of SACP. The TLR4/NF-κB inflammatory signaling pathway may be a novel therapeutic target for developing a new strategy for neuroprotection in DHCA.

Is Selective Antegrade Cerebral Perfusion Superior to Retrograde Cerebral Perfusion for Brain Protection During Deep Hypothermic Circulatory Arrest? Metabolic Evidence From Microdialysis

This study aimed to investigate whether selective antegrade cerebral perfusion or retrograde cerebral perfusion is a better technique for brain protection in deep hypothermic circulatory arrest by obtaining metabolic evidence from microdialysis. Randomized, animal study. Assisted circulation laboratory. Eighteen piglets of either sex (9.8 ± 3.1 kg). Animals were randomly assigned to 40 minutes of circulatory arrest at 18°C without cerebral perfusion (deep hypothermic circulatory arrest group, n = 6) or with selective antegrade cerebral perfusion (selective antegrade cerebral perfusion group, n = 6) or retrograde cerebral perfusion (retrograde cerebral perfusion group, n = 6). Reperfusion was continued for 3 hours. Microdialysis (glucose, lactate, pyruvate, and glycerol) variables in the cortex dialysate were measured every 30 minutes. Intracerebral pressure and serum S-100 levels were also monitored. After 3 hours of reperfusion, cortical tissue was harvested for terminal deoxynucleotidyl transferase dUTP nick-end labeling staining. After 40 minutes of circulatory arrest, the deep hypothermic circulatory arrest group presented marked elevations of intracerebral pressure, and serum S-100 levels were higher in the deep hypothermic circulatory arrest group than in the other two groups (p < 0.001, respectively). The selective antegrade cerebral perfusion group exhibited higher glucose, lower lactate, and lower glycerol levels and a lower lactate-to-pyruvate ratio in comparison to the deep hypothermic circulatory arrest group (p < 0.05, respectively); the retrograde cerebral perfusion group had lower lactate and glycerol levels and a lower lactate-to-pyruvate ratio (p < 0.05, respectively) but similar glucose levels compared to deep hypothermic circulatory arrest alone. Furthermore, selective antegrade cerebral perfusion provided better preservation of energy and cell integrity than retrograde cerebral perfusion with higher glucose and lower glycerol levels (p < 0.05, respectively). After 3 hours of reperfusion, fewer apoptotic neurons were found in selective antegrade cerebral perfusion animals than in the other two groups (p < 0.05, respectively). Both selective antegrade cerebral perfusion and retrograde cerebral perfusion were superior to deep hypothermic circulatory arrest alone during circulatory arrest. Retrograde cerebral perfusion was a moderate technique that had similar advantages with regard to less cerebral edema, better clearance of metabolic waste, and lower levels of biomarkers of injury than selective antegrade cerebral perfusion, but its capacity for energy preservation, maintenance of cellular integrity, and protection against apoptosis was lower than that of selective antegrade cerebral perfusion.

Retraction Note to: Continuous Cerebral and Myocardial Perfusion During One-Stage Repair for Aortic Coarctation With Ventricular Septal Defect

Controversy still exists concerning the use of deep hypothermic circulatory arrest (DHCA) and selective antegrade cerebral perfusion (SACP) for repair of aortic coarctation (CoA) with ventricular septal defect (VSD). This report therefore describes outcomes of patients undergoing continuous cerebral and myocardial perfusion (CCMP) under mild hypothermia compared with DHCA and SACP. Retrospective analysis was performed for 110 consecutive patients undergoing anatomic reconstruction of CoA with VSD closure between 1999 and 2011. Patients repaired under CCMP with mild hypothermia (32 °C) (group A, n = 60) were compared with those repaired under DHCA (18 °C) and SACP (group B, n = 50). In group A, the single arterial cannula perfusion technique was used for 15 patients (25 %), and the dual arterial cannula perfusion technique was used for 45 patients (75 %). The preoperative data were similar in the two groups. Group A had no hospital mortalities, compared with two mortalities (4 %) in group B. Group A had shorter myocardial ischemic and cardiopulmonary times, fewer delayed sternal closures, a shorter time to extubation, lower postoperative lactate levels, and fewer patients with low cardiac output requiring extracorporeal membrane oxygenation or with multiorgan failure than group B. During the postoperative course, no clinical or electrical neurologic events occurred in either group. The mean follow-up period was 5.2 ± 3.2 years for group A and 7.5 ± 3.1 years for group B (P = 0.048). One late death occurred in group B and no late deaths in group A. The actuarial survival for the two groups was similar (100 % for group A vs 96 % for group B; P = 0.264). The freedom from all types of cardiac reintervention was 96.7 % in group A and 89.6 % in group B (P = 0.688). All the patients were free of neurologic symptoms. The authors’ perfusion strategy using CCMP with mild hypothermia for repair of CoA with VSD is feasible, safe, and associated with improved postoperative recovery and should be the method of choice.

RETRACTED ARTICLE: Continuous Cerebral and Myocardial Perfusion During One-Stage Repair for Aortic Coarctation With Ventricular Septal Defect

Controversy still exists concerning the use of deep hypothermic circulatory arrest (DHCA) and selective antegrade cerebral perfusion (SACP) for repair of aortic coarctation (CoA) with ventricular septal defect (VSD). This report therefore describes outcomes of patients undergoing continuous cerebral and myocardial perfusion (CCMP) under mild hypothermia compared with DHCA and SACP. Retrospective analysis was performed for 110 consecutive patients undergoing anatomic reconstruction of CoA with VSD closure between 1999 and 2011. Patients repaired under CCMP with mild hypothermia (32 °C) (group A, n = 60) were compared with those repaired under DHCA (18 °C) and SACP (group B, n = 50). In group A, the single arterial cannula perfusion technique was used for 15 patients (25 %), and the dual arterial cannula perfusion technique was used for 45 patients (75 %). The preoperative data were similar in the two groups. Group A had no hospital mortalities, compared with two mortalities (4 %) in group B. Group A had shorter myocardial ischemic and cardiopulmonary times, fewer delayed sternal closures, a shorter time to extubation, lower postoperative lactate levels, and fewer patients with low cardiac output requiring extracorporeal membrane oxygenation or with multiorgan failure than group B. During the postoperative course, no clinical or electrical neurologic events occurred in either group. The mean follow-up period was 5.2 ± 3.2 years for group A and 7.5 ± 3.1 years for group B (P = 0.048). One late death occurred in group B and no late deaths in group A. The actuarial survival for the two groups was similar (100 % for group A vs 96 % for group B; P = 0.264). The freedom from all types of cardiac reintervention was 96.7 % in group A and 89.6 % in group B (P = 0.688). All the patients were free of neurologic symptoms. The authors' perfusion strategy using CCMP with mild hypothermia for repair of CoA with VSD is feasible, safe, and associated with improved postoperative recovery and should be the method of choice.

Comparative study of brain protection in ascending aorta replacement for acute type A aortic dissection: retrograde cerebral perfusion versus selective antegrade cerebral perfusion

Postoperative disorders of the central nervous system remain a major problem in thoracic aortic surgery. Both retrograde cerebral perfusion and selective antegrade cerebral perfusion have become established techniques for cerebral circulatory management. In this study, we compared neurologic outcomes and mortality between retrograde cerebral perfusion and antegrade selective cerebral perfusion in patients with acute type A aortic dissection who underwent emergency ascending aorta replacement. Between January 2003 and April 2011, a total of 203 patients with acute type A aortic dissection underwent emergency ascending aorta replacement in our hospital. We performed retrograde cerebral perfusion in 109 patients before 2006, and then mainly performed antegrade selective cerebral perfusion in 94 patients from 2006 onward. Cardiopulmonary bypass time and systemic circulatory arrest time were significantly longer in the antegrade selective cerebral perfusion group (p = 0.04, p < 0.001, respectively). The incidences of transient brain dysfunction and permanent brain dysfunction after surgery did not differ significantly between the groups. There were also no differences between the groups in other intraoperative variables, such as aortic cross-clamp time and the lowest rectal temperature, or in operative outcomes, including postoperative intensive-care-unit stay, mean peak amylase, and lipase levels until postoperative day 7, and 30-day mortality. Both retrograde cerebral perfusion and antegrade selective cerebral perfusion were associated with acceptable levels of postoperative neurologic deficits, mortality, and morbidity. Either of these techniques for brain protection can be used selectively, based on a comprehensive assessment of general condition, in patients undergoing surgery for acute type A aortic dissection.

Hyperoxia Management During Deep Hypothermia for Cerebral Protection in Circulatory Arrest Rabbit Model

As a brain protection strategy, antegrade selective cerebral perfusion (ASCP) is widely used in thoracic aorta surgery with deep hypothermic circulatory arrest (DHCA), yet the oxygen management for ASCP has never been standardized. The aim of this study was to investigate the possible neuroprotective effects of hyperoxia management during deep hyperthermia for ASCP combined with DHCA in a rabbit model. Rabbits were assigned into four groups: sham group, without cardiopulmonary bypass (CPB); DHCA group, DHCA for 80 minutes; ASCP group, ASCP combined with DHCA; and SH group, hyperoxia management combined with ASCP and DHCA. Hyperoxia management was performed when the nasopharyngeal temperature was below 22°C. Deep hypothermic circulatory arrest was initiated when nasopharyngeal temperature reached 16-18°C. Blood samples were withdrawn to determine blood gas indexes and neurobiochemical markers of damage, and brain tissues were stored for biochemical analysis. Cerebral oxygen balance was performed better in the SH group compared with the DHCA group and the ASCP group. Hyperoxia management did not increase lipid peroxidation with lower malondialdehyde levels in the SH group compared with the DHCA group and the ASCP group (p < 0.05). S100 calcium binding protein B in the SH group was lower compared with the DHCA group and the ASCP group (p < 0.05). There was no significant difference of neuron-specific enolase in the SH group compared with the sham group. Hyperoxia management during deep hypothermia provided substantial dissolved oxygen and demonstrated better cerebral protection over normoxia management.

Cerebral functions and metabolism after antegrade selective cerebral perfusion in aortic arch surgery

Antegrade selective cerebral perfusion (ASCP) represents the best method of cerebral protection during surgery of the thoracic aorta. However, brain integrity and metabolism after antegrade cerebral perfusion have not yet been investigated. We assessed cerebral positron emission tomography (PET), diffusion-weighted imaging, proton magnetic resonance spectroscopy and cognitive functions in patients undergoing either ASCP or coronary artery bypass grafting (CABG) to elucidate whether cerebral perfusion was associated with postoperative neuronal alterations, metabolic deficit or cognitive decline. Seventeen patients undergoing aortic arch surgery using ASCP with moderate hypothermia (26 degrees C) (ASCP group) and 15 patients undergoing elective on-pump CABG (CABG group) were prospectively enrolled in the study. Brain PET, diffusion-weighted imaging, proton magnetic resonance spectroscopy and neuropsychometric testing were performed preoperatively, and at 1 week and 6 months postoperatively (T1, T2 and T3, respectively). Patient data were compared for statistic analysis with a normal database made up of healthy subjects. One patient in each group was excluded because they refused postoperative evaluation. There were neither strokes nor hospital deaths. Two patients suffered from temporary neurological dysfunction (one in each group). Proton magnetic resonance spectroscopy did not reveal significant alterations in cortical N-acetyl-aspartate (NAA) content within and between the groups at T2 and T3. In the ASCP group, brain diffusion-weighted magnetic resonance showed a significant increase of the apparent diffusion coefficient values, reflecting vasogenic cerebral oedema, at T2, that disappeared at T3. Magnetic resonance detected new focal brain lesions in two CABG group patients. In seven ASCP group patients, PET scan showed glucose hypometabolism in the occipital lobes at T2, which disappeared in five patients at successive examination (T3). Significant cognitive decline was not observed in any patient. Test score changes between and within groups were not significant. There was no evidence of ischaemic brain injury after ASCP even if some degree of reversible brain oedema secondary to cardiopulmonary bypass (CPB) was present. The cognitive outcomes in patients undergoing ASCP were comparable to patients undergoing coronary artery bypass. The lack of left subclavian artery perfusion during cerebral perfusion leads to temporary glucose hypometabolism in the occipital lobes without neuronal injury.

Clinical application of cerebral oxygenation monitoring during aortic aneurysm operation

To analyze the correlation between cerebral oxygenation and cerebral complications after aortic aneurysm operation and to evaluate the protective effects of DHCA and/or ASCP during aortic aneurysm operation. Thirty patients with aortic aneurysm, 24 with Stanford type A dissection, 4 with Stanford type B dissection, 1 with degenerative aneurysm in ascending and arch aorta, and 1 with false aneurysm in thoraco-abdominal aorta, 23 males and 7 females, aged 44 +/- 12, underwent aorta operation with circulatory arrest were alternatively allocated to two groups: 22 patients underwent aortic arch replacement under deep hypothermic circulatory arrest (DHCA) plus antegrade selective cerebral perfusion (ASCP), and 8 patients underwent descending thoracic aorta replacement under DHCA only. There was no significant difference in the lowest core temperature, hematocrit at lowest core temperature, and velocity of rewarming between these 2 groups. Near-infrared spectroscopy (NIRS) was used to continuously monitor the cerebral tissue oxygenation index (TOI) percutaneously. The mean circulatory arrest time in the DHCA + ASCP group was 23.25 min, significantly longer than that of the DHCA group (16.67 min, P = 0.022). Cerebral complication occurred in 8 patients after aortic operation (complication group). The baseline TOI of the complication group was 70% +/- 5%, and the maximum decrease in TOI was 58% +/- 8%; and the baseline TOI of the non-complication group was 69% +/- 8%, and the maximum decrease in TOI was 55% +/- 8%; however, there were no significant differences between these 2 groups (both P > 0.05). The TOI decrease was more significant in the DHCA group than in the DHCA + ASCP group. During circulatory arrest, the levels of TOI were higher than the baseline level all along in the ASCP group and were lower than the baseline level 3 to 10 minutes after arrest in the DHCA group. The duration of TOI less than the baseline level in the DHCA group was significantly longer than that in the ASCP group. Mild decrease of TOI is not significantly correlated to the occurrence of complication. DHCA + ASCP is more effective in brain protection compared with only DHCA.

Retrograde cerebral perfusion with intermittent pressure augmentation provides adequate neuroprotection: Diffusion- and perfusion-weighted magnetic resonance imaging study in an experimental canine model

Diffusion- and perfusion-weighted magnetic resonance imaging can identify ischemic brain injury in the hyperacute stage. For neuroprotection during thoracic aortic surgery, we developed a novel retrograde cerebral perfusion with intermittent pressure augmentation. The purpose of this study was to assess the efficiency of this novel method for neuroprotection in real time by using diffusion- and perfusion-weighted magnetic resonance imaging. Sixteen beagle dogs were randomly divided into 4 groups: the antegrade selective cerebral perfusion group (n = 4; antegrade selective cerebral perfusion at a flow rate of 10 mL x kg(-1) x min(-1)); the intermittent retrograde cerebral perfusion group (n = 4; retrograde cerebral perfusion at a baseline pressure of 15 mm Hg with intermittent pressure augmentation to 45 mm Hg every 30 seconds); the conventional retrograde cerebral perfusion group (n = 4; conventional retrograde cerebral perfusion at a fixed pressure of 25 mm Hg); and the circulatory arrest group (n = 4; only circulatory arrest). Diffusion- and perfusion-weighted magnetic resonance images were acquired during each session of cerebral perfusion. Regions of interest were defined, and the apparent diffusion coefficient and relative regional cerebral blood volume were calculated in these regions of interest. Finally, the brain was evaluated for its histopathologic damage score. The best apparent diffusion coefficient values were observed in the intermittent retrograde cerebral perfusion group in all the regions of interest, although the relative regional cerebral blood volume values were mostly lower than those in the antegrade selective cerebral perfusion group. The total Histopathologic Damage Score (0, normal; 32, worst) in the intermittent retrograde cerebral perfusion group (8.0 +/- 0.6) was significantly lower than that in the conventional retrograde cerebral perfusion (17.5 +/- 1.7; P < .01) and circulatory arrest (25 +/- 1.0; P < 0.01) groups and was equivalent to that in the antegrade selective cerebral perfusion group (7.8 +/- 0.8; P = .9). Intermittent retrograde cerebral perfusion provides adequate neuroprotection by allowing high apparent diffusion coefficient values to be maintained.

Hypothermic circulatory arrest with and without cold selective antegrade cerebral perfusion: impact on neurological recovery and tissue metabolism in an acute porcine model.

Clinically, selective antegrade cerebral perfusion (SACP) seems to be associated with a better neurological outcome compared to hypothermic circulatory arrest (HCA) alone, but the pathophysiological mechanisms are not well understood. Therefore, this study was undertaken to assess the effects of HCA with and without SACP on the cerebral integrity using multimodal neurophysiological monitoring. 12 pigs were randomly assigned to 100 min HCA at 20 degrees C brain temperature with (n = 6) and without (n = 6) SACP. Haemodynamics, metabolics and neurophysiology (EEG, SSEP, ICP, spectroscopy, cerebral tissue monitoring) were monitored. Animals were sacrified 4 h after reperfusion and the brains perfused for histopathological assessment. There were no clinically relevant differences in hemodynamics between groups. During reperfusion, EEG and SSEP recovery was significantly faster in the SACP group (P < 0.05). The rise in ICP during reperfusion was markedly reduced in the SACP group (P < 0.01) for the trend). Three hours after reperfusion, median ICP was 130% compared to baseline in the SACP group and 225% in the HCA group (P < 0.01). Invasive as well as noninvasive cerebral monitoring indirectly indicates the occurrence of tissue acidosis in the HCA group even 4 h after HCA. Cold SACP is associated with better neurophysiological recovery and less cerebral edema, indicated by lower intracranial pressures during reperfusion. Neurophysiological recovery correlated well with the rise in ICP. HCA alone causes prolonged acidosis in the brain tissue during reperfusion. From these data, SACP appears to be superior to HCA alone, but further studies have to elucidate the optimal regimes for SACP.

Deep hypothermic circulatory arrest and antegrade selective cerebral perfusion during ascending aorta-hemiarch replacement: A retrospective comparative study

Objective: We sought to compare the results of ascending aorta-hemiarch replacement by using 2 different methods of cerebral protection in terms of hospital mortality, neurologic outcome, and systemic morbidity and to determine predictive risk factors associated with hospital mortality and neurologic outcome after ascending aorta-hemiarch replacement. Methods: Between January 1995 and September 2001, 289 patients (mean age, 62.2 ± 13.2 years; urgent status, 122/289 [42.2%]) underwent ascending aorta-hemiarch replacement with the aid of antegrade selective cerebral perfusion (161 patients) or deep hypothermic circulatory arrest (128 patients). Results: Overall hospital mortality was 11.4% (deep hypothermic circulatory arrest group, 13.3%; antegrade selective cerebral perfusion group, 9.9%; P =.375). A logistic regression analysis revealed acute type A dissection (P =.001; odds ratio, 4.3) and age of greater than 70 years (P =.019; odds ratio, 2.5) to be independent predictors of hospital mortality. The permanent neurologic dysfunction rate was 9.3% (deep hypothermic circulatory arrest group, 12.5%; antegrade selective cerebral perfusion group, 7.6%; P =.075). Logistic regression analysis revealed acute type A dissection (P =.001; odds ratio, 6.7) and history of cerebral infarction-transient ischemic attack (P =.038; odds ratio, 3.4) to be independent predictors of permanent neurologic dysfunction. The transient neurologic dysfunction rate was 8.0% (deep hypothermic circulatory arrest group, 7.1%; antegrade selective cerebral perfusion group, 8.7%; P =.530). Acute type A dissection (P =.001; odds ratio, 5.1) was indicated as an independent predictor of transient neurologic dysfunction by means of logistic regression. Renal dysfunction (postoperative creatinine level of >250 μmol/L; deep hypothermic circulatory arrest, 10 [7.8%]; antegrade selective cerebral perfusion, 6 [3.7%]; P =.030), as well as prolonged intubation time (deep hypothermic circulatory arrest, 3.8 ± 6.3 days; antegrade selective cerebral perfusion, 2.2 ± 2.5 days; P =.005) were more common in the deep hypothermic circulatory arrest group. Conclusion: The use of antegrade selective cerebral perfusion and deep hypothermic circulatory arrest during ascending aorta-hemiarch replacement resulted in acceptable hospital mortality and neurologic outcome. Reduced postoperative intubation time and better renal function preservation were observed in the antegrade selective cerebral perfusion group.J Thorac Cardiovasc Surg 2003;125:849-54