Continuous Cerebral Perfusion Research Articles

Espectroscopia no infravermelho próximo (NIRS) em unidade de terapia intensiva neonatal: experiência de um hospital universitário brasileiro

Near-infrared spectroscopy (NIRS) is a non-invasive method to assess regional brain and/or renal oxygenation, and an important tool for a better clinical management. The aim of this study was to describe clinical cases of newborns admitted to the Neonatal Intensive Care Unit of a Brazilian university hospital who were monitored with NIRS, and to evaluate the applicability of NIRS demonstrating its use as a continuous monitoring method for newborns at high risk for brain injury. This study was part of the Conclusion Work of Medical Residency in Neonatology in Neonatology. Case 1: Persistent ductus arteriosus-NIRS guided indication for drug treatment. Case 2: Septic shock-NIRS was helpful identifying the need of inotropes. Case 3: Anemia of prematurity-NIRS showed an increase of cerebral oxygenation after red blood cells transfusions. Case 4: Hypoxic-ischemic encephalopathy-NIRS identified sign of poor neurological prognostic. NIRS is a continuous cerebral and renal perfusion monitoring method that has easy and good applicability and no complications. The cases reflect the importance and potential of NIRS in clinical practice and in helping diagnose for newborns, as well as enabling prognostic assessment. NIRS proved to be a method of good applicability, without short-term complications. Observing brain oxygenation values can help to avoid conditions associated with the development of neurological sequelae.

Abstract 196: Association Between Continuous Carotid Blow Flow And Continuous Cerebral Perfusion Indexes Assessment By NIRS In A Porcine Model Of Ventricular Fibrillation During CPR

[Background]: Maintenance of cerebral blood flow during cardiopulmonary resuscitation (CPR) is a critical factor affecting the neurological outcome of patients after cardiac arrest. However, dynamic indicator of cerebral blood flow during CPR is not established. Near infrared spectroscopy (NIRS) is a non-invasive technique capable of detecting changes in cerebral blood volume continuously. The aim of this study is to compare cerebral perfusion during CPR obtained by continuous measure of carotid blow flow (CBF) using flow sensor with continuous cerebral perfusion indices (CPI) assessment by NIRS in a porcine model of ventricular fibrillation (VF) cardiac arrest. [Methods]: CBF during CPR were measured in 21 swine (25± 3 kg) using extra-vascular flow probes positioned around the common carotid arteries. The optodes of the NIRS were attached to the skull bone. Following baseline measurements, VF was electrically induced. After the interval of untreated VF, CPR was continued for 25 min, during which mechanical and manual CPR was alternated at every 5 min intervals. CBF and CPI were measured continuously during CPR. The mean volume of CBF and CPI was calculated average 10 beats in each phase. Correlations between CBF volume and CPI were analyzed by Spearman's rank correlation. [Results]: The followability of CBF and CPI during CPR was good. The Spearman's rank correlation coefficient between CBF volume and CPI was different by sections and it was suggested that the CBF volume was too small to assess the correlation in many sections. If the sections with CBF volume>0.4 ml were extracted and reanalyzed, the rate of sections correlated between CBF volume and CPI were increased (Spearman’s correlation coefficient≧0.4 was 41.3%, Spearman’s correlation coefficient≧0.7 was 17.5%).(Table) [Conclusions]: It was suggested that CPI by NIRS can reflect the CBF during CPR in the sections where enough CBF is.

Continuous cerebral and myocardial selective perfusion in neonatal aortic arch surgery.

To assess the feasibility and early outcome of continuous cerebral and myocardial selective perfusion (CCMSP) during aortic arch surgery in neonates. We performed a single-center retrospective study between 2008 and 2019 on neonates who underwent aortic arch surgery with or without associated heart lesion repair. CCMSP with moderate hypothermia levels (28°C) was achieved using selective brachiocephalic artery and ascending aorta cannulation. Target rates of cerebral and myocardial perfusion were 25 to 35 mL/kg/min and 150 ml/m2/min. Cardiopulmonary bypass (CPB) variables and clinical outcomes were analyzed. Overall, 69 neonates underwent either isolated aortic arch repair (n = 31) or aortic arch repair with ventricular septal defect (VSD) closure (n = 38). Age and weight medians were 8 [6 to 15] days and 3.4 [2.9-3.5] kg, respectively. Mean CPB and aortic clamping times were 134 ± 47 and 26 ± 5 minutes for isolated aortic arch repair, and 159 ± 47 and 75 ± 30 minutes for aortoplasty accompanied by VSD closure. Mean CCMSP time was 52 ± 21 minutes with cerebral rate of 32.6 ± 10 mL·kg-1 ·min-1 . Overall in hospital survival was 98.5% (68/69). Major complications were: postoperative cardiac failure requiring mechanical support followed by stroke (n = 1; 1.44%) and transient renal failure requiring dialysis (n = 2; 2.89%). Neither myocardial nor digestive complication occurred. CCMSP is a safe and reproducible strategy for cerebral, myocardial and visceral protection in neonatal aortic arch repair, with or without VSD closure, resulting in low complication and mortality.

Abstract 483: Out of Hospital Cardiac Arrest Outcomes After Transitioning to Pit Crew Model

Introduction: One of the leading causes of untimely death as per the Resuscitation Outcomes Consortium Epistry for cardiac arrest is out of hospital cardiac arrest (OHCA). Adoption of the choreographed approach of the pit crew model resuscitation improved outcomes after OHCA in some previous studies. Hypothesis: Compare outcomes post OHCA before and after adopting a pit crew model approach in one of the largest counties in Kansas. Methods: The data was collected before (2010 – 2012) and after the pit crew (2013-2016) approach from 2010 to 2016. The patient demographics and resuscitation variables were similar and comparable including the emergency and fire department personnel. The primary outcome was the proportion of patients having sustained return of spontaneous circulation (ROSC). Secondary outcomes were average number of pauses >10 seconds, cerebral performance post return of spontaneous circulation, and average cardio-pulmonary resuscitation (CPR) cycles to ROSC. Results: The patients who had sustained ROSC post pit crew approach was 67.9% vs 32.1% (p=< 0.001). Average number of CPR pause time > 10 seconds post pit crew model was 1 vs 5 (p=0.01). Cerebral performance post return of spontaneous circulation using pit crew approach with good cerebral performance was 47% vs 56% (p=0.2), moderate cerebral disability was 17% vs 23% (p=0.19), severe cerebral disability was 8% vs 11% (p=0.44) and in coma/vegetative state was 8% vs 16% (p=0.001). Average CPR cycles to ROSC was 6.63. Conclusion: This focused model of high-quality CPR performance with individualized assigned tasks with minimal interruptions has shown increased numbers of sustained ROSC. The pit crew model approach also has showed decline in the rates of cerebral performance especially with moderate and severe cerebral performance including the patients in coma or vegetative state which is mainly through continuous cerebral perfusion pressures. More studies with better follow-up care in coordination with hospital outcomes will be key for the pit crew approach to be adopted.

Early outcome of aortic balloon occlusion during total aortic arch replacement with the frozen elephant trunk technique for aortic dissection.

The aim of this study was to propose and evaluate the new operative technique of aortic balloon occlusion in total aortic arch replacement (TAR) with the frozen elephant trunk that can significantly decrease the time of circulatory arrest and increase the hypothermic cardiopulmonary bypass (CPB) temperature. Between 2010 and 2018, 1335 patients with aortic dissection who underwent TAR with the frozen elephant trunk were included in the study. The newest 80 cases were treated with aortic balloon occlusion. To illustrate the difference with the new procedure, 1255 conventional TAR cases served as the historical control. Femoral and right axillary artery cannulations were used for CPB and antegrade selective cerebral perfusion. Circulatory arrest was implemented at the nasopharyngeal temperature of 28°C with continuous antegrade selective cerebral perfusion. After the stent graft was inserted into the true lumen of the descending aorta, the aortic balloon in a sheath was deployed into the stent graft and positioned at the metal part of the stent graft. When the balloon was inflated with enough saline to compress the stent graft, the sheath was simultaneously pressed by hand to properly fix the balloon and avoid displacement. Then femoral perfusion could be resumed. The aortic balloon occlusion technique was successful in all patients, with the median duration of circulatory arrest being 5 (interquartile range 3-7) min. The 30-day mortality rate was 6.25% (5/80), whereas with the conventional method it was 9.40% (118/1255). The postoperative conscious revival (8.67 vs 11.40 h, P < 0.001) and mechanical ventilation times (19.70 vs 24.45 h, P = 0.02) were significantly shorter. Decreases in postoperative acute kidney injuries (13.75% vs 32.11%, P = 0.001) and liver injuries (8.75% vs 37.61%, P < 0.001) were also observed. The patients were transfused with lesser quantities of red blood cells, plasma and platelets. The aortic balloon occlusion technique is a feasible way to shorten circulatory arrest significantly, to obviate the need for deep hypothermia in TAR with the frozen elephant trunk and to provide favourable protective effects on the central nervous, haematological and visceral systems. With these satisfactory results, this technique deserves further investigation.

Direct Arterial Cannulation Allows Easy and Safe Continuous Selective Cerebral Perfusion During Repair of Interrupted Aortic Arch Even for Low Birth Weight Neonates.

To review the outcomes of direct innominate artery cannulation for continuous cerebral perfusion used for repair of interrupted aortic arch (IAA) in a consecutive cohort of neonates regardless of weight. Between September 1999 and April 2016, forty-four children with IAA (18 type A and 26 type B) underwent repair using continuous, hypothermic (18°C) low-flow cerebral perfusion via direct innominate artery cannulation. Associated cardiac lesions were truncus arteriosus (TA; 5), ventricular septal defect (VSD; 30), transposition of the great arteries (TGA; 1), unbalanced atrioventricular septal defect (1), double-inlet left ventricle (1), double-outlet right ventricle (3), and aortopulmonary window (APW; 5). Truncus arteriosus, single VSD, TGA, and APW were corrected while the other patients were palliated. Age at the time of surgery was 7 days (4-120 days) and weight 3.1 kg (2.1-5.8 kg). Selective cerebral perfusion was maintained in all patients. During the selective cerebral perfusion, perfusion flow rate was maintained at 30 mL/kg/min. Aortic cross-clamp time, low-flow, and total cardiopulmonary bypass time were 63 (40-116), 28 (17-41), and 108 (80-217) minutes, respectively. There were no deaths nor clinical evidence of neurological injury. Postoperative ventilation time, length of intensive care unit, and hospital stay were 3 (2-14), 5 (3-21), and 13 (6-27) days, respectively. Follow-up, complete at 84 months (24-221), revealed no late clinically evident neurologic sequelae nor innominate artery complications. Direct innominate arterial cannulation with continuous selective cerebral perfusion can be safely applied for repair of IAA even in low birth weight neonates. It is technically simple and associated with excellent clinical outcomes.

Abstract 270: Non-Invasive Cerebral Perfusion and Autoregulation Monitoring Post-Cardiac Arrest

Objective: The primary aim of this study was to test the feasibility of non-invasive cerebral perfusion monitoring post-arrest. We secondarily tested the association between measured autoregulation, the presence of cerebral edema, and neurological recovery. Methods: This was a prospective, pilot study inclusive of patients successfully resuscitated from cardiac arrest in the Emergency Department (ED). After return of spontaneous circulation, an investigator placed non-invasive, bifrontal monitoring to measure cerebral perfusion. The device uses an acousto-optic sensor to measure continuous cerebral perfusion and measurements are arbitrary units between 0-100, where 0 represents no flow (Ornim, Tel Aviv). Subjects had invasive, continuous arterial monitoring to assess mean arterial pressure (MAP). Multimodal measurements continued for 60 minutes. We calculated a Pearson coefficient between the perfusion measurements and MAP as an assessment of cerebral autoregulation, where a correlation coefficient &gt; 0.3 indicates poor autoregulation, and a coefficient of 1 indicates completely passive cerebral perfusion to changes in MAP. Head computed tomography defined the presence of cerebral edema in the ED. Results: We enrolled 14 patients post-arrest with sustained return of circulation. The mean age was 55 ± 14 years, 7 were female, and 10 were African American. Six patients had pulseless electrical activity, 5 asystole, and 2 ventricular fibrillation. Bystander CPR rates were low (4 of 14, 31%). Two patients (14%) survived to hospital discharge. Cerebral perfusion was comparable between patients that survived and those that died (difference 3.1, 95% CI -14 to 8). Cerebral perfusion measurement was higher in patients with cerebral edema (difference 6.1, 95% CI 0.2 - 11.9). Autoregulation was worse in the presence of edema (0.30) compared to no edema (0.14), though this difference did not reach statistical significance (95% CI -0.7 to 0.4). Conclusions: In a pilot study, non-invasive post-arrest perfusion measurements plus coupling with MAP for autoregulation was feasible. Perfusion measurements were increased in the presence of cerebral edema but whether such measurements have prognostic value requires further study.

Safe Reentry for False Aneurysm Operations in High-Risk Patients

In the absence of a standardized safe surgical reentry strategy for high-risk patients with large or anterior postoperative aortic false aneurysm (PAFA), we aimed to describe an effective and safe approach for such patients. We prospectively analyzed patients treated for PAFA between 2006 and 2015. According to the preoperative computed tomography scan examination, patients were divided into two groups according to the anatomy and extension of PAFA: in group A, high-risk PAFA (diameter ≥3 cm) developed in the anterior mediastinum; in group B, low-risk PAFA (diameter <3 cm) was situated posteriorly. For group A, a safe surgical strategy, including continuous cerebral, visceral, and coronary perfusion was adopted before resternotomy; group B patients underwent conventional surgery. We treated 27 patients (safe reentry, n= 13; standard approach, n= 14). Mean age was 60 years (range, 29 to 80); 17 patients were male. Mean interval between the first operation and the last procedure was 4.3 years. Overall 30-day mortality rate was 7.4% (1 patient in each group). No aorta-related mortality was observed at 1 and 5 years in either group. The Kaplan-Meier overall survival estimates at 1 and 5 years were, respectively, 92.3% ± 7.4% and 73.4% ± 13.4% in group A, and 92.9% ± 6.9% and 72.2% ± 13.9% in group B (log rank test, p= 0.830). Freedom from reoperation for recurrent aortic disease was 100% at 1 year and 88% at 5 years. The safe reentry technique with continuous cerebral, visceral, and coronary perfusion for high-risk patients resulted in early and midterm outcomes similar to those observed for low-risk patients undergoing conventional surgery.

Cerebral Vasoreactivity, Apolipoprotein E, and the Risk of Dementia: A Population-Based Study.

Cerebral vasoreactivity (CVR) is a key factor in maintenance of continuous cerebral perfusion and a marker of (micro)vascular damage. We aimed to determine the longitudinal relation between CVR and the risk of dementia in the general population. We determined CVR in nondemented participants who underwent transcranial Doppler with induced hypercapnia from 1997 to 1999, as part of the ongoing population-based Rotterdam Study. We used a Cox model to determine the risk of dementia in relation to CVR, adjusted for age, sex, cardiovascular risk factors, and carotid intima-media thickness. We furthermore determined decline on a cognitive test battery in relation to CVR, using linear mixed models. Among 1629 participants (mean ± SD age 70.6 ± 6.2 years, 46.2% female) with a mean follow-up of 11.5 years, 209 were diagnosed with dementia, of whom 171 had Alzheimer disease. Higher CVR at baseline was associated with lower risk of dementia (adjusted hazard ratio, 95% confidence interval, per SD increase: 0.87, 0.75-1.00) and Alzheimer disease (adjusted hazard ratio, 0.84; 0.71-0.99). This association was more profound in APOEε4 carriers than in noncarriers (adjusted hazard ratio for all dementia: 0.77, 0.60-0.98 versus 0.89, 0.73-1.07). Performance on cognitive tests at baseline was better with higher CVR (g-factor: P=0.02), but during 3 cognitive assessments over 11 years of follow-up, higher CVR at baseline was associated with less decline in test scores on the Stroop reading and interference tasks in APOEε4 carriers only (P=0.01 and 0.02, respectively). Impaired CVR is associated with an increased risk of dementia in the general population.

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.

Combination of Flow Reversal and Distal Filter for Cerebral Protection during Carotid Artery Stenting

Carotid artery stenting (CAS) with distal filter protection allows continuous cerebral perfusion, although it is associated with a greater risk of cerebral ischemic complications than other protection systems. To reduce cerebral ischemic complications, CAS was performed under combined cerebral protection using both flow reversal (FR) and a distal filter. Fifty-six stenoses of 52 patients were treated with CAS using the combined protection of FR and a distal filter, with intermittent occlusion of both the common carotid artery (CCA) and the external carotid artery. The blood flow was reversed into the guiding catheter to the central venous system via an external filter, which collected the debris. Clinical outcomes, the rates of capturing visible debris, and new ischemic signals on diffusion-weighted magnetic resonance imaging (DWI-MRI) were evaluated. The overall technical success rate was 92.9% (52/56). Successful stent deployment was achieved in 100% (56/56) of the cases. No procedural-related emboli causing a neurologic deficit were observed. In 38.5% (20/52) of the cases, visible debris were captured by only the external filter, and in 17.3% (9/52), visible debris were captured by both external and distal filters. In no case was visible debris noted in only the distal filter. New ischemic signals on DWI-MRI were detected in 9.6% (5/52). The 30-day myocardial infarction, stroke, and death rates were 0%. The additional use of a distal filter captures emboli in 17.3% of cases, and because the occlusion is only intermittent, the procedure is potentially applicable even in those who cannot tolerate prolonged balloon occlusion of the CCA.

Innominate Artery Cannulation and Antegrade Cerebral Perfusion for Aortic Arch Reconstruction in Infants and Children

Innominate artery cannulation has been widely adopted as a means to perform aortic arch reconstruction with continuous cerebral perfusion in the newborn. Although this technique has been subsequently utilized in infants and children, there is currently no data regarding the safety or efficacy in these older children. The purpose of this study was to review our experience with innominate artery cannulation for aortic arch reconstruction in patients beyond the neonatal period. This was a retrospective review of 42 infants and children who underwent aortic arch reconstruction using the technique of innominate artery cannulation with continuous cerebral perfusion. Of these procedures, 29 (69%) were primary arch reconstructions, while 13 (31%) were aortic arch reoperations. The median age at surgery was 8 months, and 22 patients underwent concomitant intracardiac repairs. There was no operative mortality in this cohort of 42 patients undergoing aortic arch reconstruction. There was also no overt evidence of neurologic injury. Specifically, none of the patients demonstrated a neurologic deficit, clinical seizure, or unexpected delay in regaining a normal state of consciousness. The median duration of antegrade cerebral perfusion was 34 minutes. The median duration of hospital stay was 11 days. No patient required reoperation on the aortic arch with a median of 45-month follow-up. Innominate artery cannulation is a safe and effective technique for aortic arch reconstruction in nonneonates. We conclude that antegrade cerebral perfusion is a useful technique for aortic arch reconstruction in this patient population.

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.

Outcome of Continuous Cerebral and Myocardial Perfusion Under Mild Hypothermia for Aortic Coarctation with Ventricular Septal Defect Repair

Controversy still exists on the use of the optimal cardiopulmonary bypass (CPB) management in aortic coarctation (CoA) with ventricular septal defect (VSD) repair. We report the outcome of patients undergoing continuous cerebral and myocardial perfusion (CCMP) under mild hypothermia. This is a retrospective analysis of 60 consecutive patients undergoing anatomic reconstruction of CoA with VSD closure between 1999 and 2011. Single arterial cannula perfusion technique was used in 15 (25%) patients, and a dual arterial cannula perfusion technique was used in 45 (75%) patients. There were no hospital or late mortalities. Average CPB time was 105 ± 28 minutes, aortic clamp 27 ± 7 minutes, and descending aortic cross-clamp time 24 ± 5 minutes. Average continuous cerebral perfusion flow was 64 ± 8 mL/kg per minute. No patient needed delayed sternal closure. Average duration of ventilation was 38 ± 20 hours, ICU stay 7 ± 3 days, and hospital stay 14 ± 6 days. No patient required revision for bleeding and/or extracorporeal membrane oxygenation support. No neurologic complications were noted. A perfusion strategy using CCMP with mild hypothermia for CoA and VSD repair is feasible and safe.

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.

Retracted: Selective Cerebro‐Myocardial Perfusion Under Mild Hypothermia During Primary Repair for Aortic Coarctation With Ventricular Septal Defect

The following article from Artificial Organs, "Selective Cerebro-Myocardial Perfusion Under Mild Hypothermia During Primary Repair for Aortic Coarctation With Ventricular Septal Defect" by Huiwen Chen, Haifa Hong, Zhongqun Zhu and Jinfen Liu, published online on 2 November 2012 in Wiley Online Library (wileyonlinelibrary.com), has been retracted by agreement between the authors, the journal Editor-in-Chief, Paul S. Malchesky, the International Center for Artificial Organs and Transplantation and Wiley Periodicals, Inc. The retraction has been agreed due to simultaneous publication of a substantially similar article, "Continuous Cerebral and Myocardial Perfusion During One-Stage Repair for Aortic Coarctation With Ventricular Septal Defect", by Huiwen Chen, Haifa Hong, Zhongqun Zhu and Jinfen Liu, in Pediatric Cardiology 7 November 2012 [Epub ahead of print].

Significance of Combining Distal Filter Protection and a Guiding Catheter With Temporary Balloon Occlusion for Carotid Artery Stenting: Clinical Results and Evaluation of Debris Capture

Carotid artery stenting (CAS) with distal filter protection allows for continuous cerebral perfusion. However, this procedure has been reported to be associated with a greater risk of debris migrating into the cerebral arteries. To improve the extent of debris capture, we used a guiding catheter with temporary balloon occlusion and temporary aspiration from the common carotid artery. Eighty-one stenoses were treated with CAS using distal filter protection; simple distal filter protection (conventional group, n = 50) or distal filter protection with temporary proximal flow control and blood aspiration was performed using a 9-F guiding catheter with a temporary balloon occlusion positioned at the common carotid artery (proximal occlusion group, n = 31). Clinical outcomes, rates of capturing visible debris, and new ischemic signals on diffusion-weighted magnetic resonance imaging (DWI) were evaluated. Events involving procedure-related emboli causing neurological deficits occurred in 6.0% (3/50) and 3.2% (1/31) of patients in the conventional and proximal occlusion groups, respectively (P = 1.0). The rates of visible debris capture by using the distal filter were 64.0% (32/50) and 29.0% (9/31) in the convention and proximal occlusion groups, respectively, being significantly lower in the proximal occlusion group (P < 0.01). New ischemic signals on DWI were detected in 44.0% (22/50) and 12.9% (4/31) of cases in the conventional and proximal occlusion groups, respectively, being significantly lower in the proximal occlusion group (P < 0.01). Combining distal filter protection and a guiding catheter with temporary balloon occlusion in CAS significantly reduced visible debris captured by the distal filter and occurrence of small postprocedural cerebral infarctions detected by DWI.

Simplified Technique of Total Aortic Arch Replacement With Minimal Circulatory and Myocardial Ischemia

This manuscript describes the initial experience of 15 patients undergoing aortic arch replacement using a modification of the trifurcate arch technique described by Spielvogel and coworkers [1]. This technique provides continuous antegrade cerebral perfusion and minimal myocardial ischemia with mild hypothermia.

Clinical and biochemical outcomes for additive mesenteric and lower body perfusion during hypothermic circulatory arrest for complex total aortic arch replacement surgery

Surgical repair of transverse aortic arch aneurysms frequently employ hypothermia and antegrade cerebral perfusion as protective strategies during circulatory arrest. However, prolonged mesenteric and lower limb ischemia can lead to significant lactic acidosis and end organ dysfunction, which remains a significant cause of post-operative morbidity and mortality. We report our experience with additive warm mesenteric and lower body perfusion (1-3 L/min, 30°C) in addition to continuous cerebral and myocardial perfusion in 5 patients who underwent total aortic arch replacement with trifurcated head vessel re-implantation and distal elephant trunk reconstruction. Concomitant surgical procedures included re-operations (2), aortic root operations (2), coronary artery bypass (2) and descending thoracic aortic replacement (1). Serum lactate levels demonstrated a rapid decline from a peak 9.9 ± 2.6 post circulatory arrest to 3.4 ± 2.0 in the intensive care unit (ICU). The lowest serum bicarbonate levels were 19.3 ± 3.5 mmol/L, intra-operatively, which normalized to 28.4 ± 2.4 mmol/L on return to the ICU. The lowest pH levels were 7.25 ± 0.10, corrected to 7.43 ± 0.04 on return to the ICU. Mean cardiopulmonary bypass and aortic cross-clamp times were 361 ± 104 and 253 ± 85 minutes, respectively. Mean cerebral and lower body circulatory arrest times were 0 (0) and 50 ± 35 minutes, respectively. The mean time required for systemic rewarming was 95 ± 66 minutes. There were no in-hospital mortalities and no patient experienced any neurological, mesenteric, renal or lower limb ischemic complications. Two patients required mechanical ventilation >24 hours, and one patient returned for reoperation for bleeding. Median intensive care unit and total hospital lengths of stay were 5 and 16 days, respectively. Our results suggest early serum lactate clearance, normalization of acidosis, and metabolic recovery when utilizing a simultaneous cerebral perfusion and warm body protection strategy for complex aortic arch surgery. This additive perfusion strategy may attenuate visceral and lower body ischemia that normally develops during periods of deep hypothermic circulatory arrest.

Three-Region Perfusion Strategy for Aortic Arch Reconstruction in the Norwood

We describe a new method of selective regional perfusion during arch reconstruction in the Norwood procedure. The strategy involves direct sequential perfusion of the coronary and splanchnic circulations coupled with continuous cerebral perfusion, while repairing the arch in a distal to proximal fashion. This technique provides the potential for decreased coronary and splanchnic ischemic times, which in combination with continuous selective cerebral perfusion may further allow for warmer operating temperatures and decreased overall bypass times.