Duration Of Circulatory Arrest Research Articles

Risk factors and prognosis of postoperative spinal cord injury in type A aortic dissection.

To investigate the risk factors and prognosis of spinal cord injury (SCI) after surgical procedure in type A aortic dissection (AAD). Between January 2013 and December 2021, a total of 1647 patients with AAD underwent surgical procedure. Postoperative SCI occurred in 58 patients, including 24 patients with paraplegia and 34 patients with paraparesis. Factors associated with SCI was identified through comparison between patients with and without SCI. The mean age was 48.8 ± 10.8 years for patients with SCI and 50.1 ± 12.1 years for those without SCI (P = 0.43), with a comparable gender distribution. Median numbers of intercostal and lumbar arteries with involvement were significantly higher in the SCI group (both P < 0.001). The highest (P = 0.033) and lowest (P = 0.001) level of intraoperative mean arterial pressure (MAP) were significantly lower in the SCI group. Multivariable analysis revealed number of segmental arteries involved (odds ratio [OR]=1.14, 95% CI 1.08-1.20, P = 0.000) and duration of hypothermic circulatory arrest (HCA) (OR = 1.04, 95% CI 1.01-1.08, P = 0.042) were positively associated with the occurrence of SCI. Conversely, the lowest level of MAP was negatively associated with SCI (OR = 0.98, 95% CI 0.96-0.99, P = 0.031). During the long-term follow-up, 14 patients with paraplegia needed the wheel chair, while only one patient with paraparesis needed one (P < 0.001). The risk of postoperative SCI increases when AAD patients experience segmental arteries involved, longer HCA duration, and decreased intraoperative MAP during operation.

Risk factors and prognosis of postoperative spinal cord injury in type A aortic dissection.

To investigate the risk factors and prognosis of spinal cord injury (SCI) after surgical procedure in type A aortic dissection (AAD). Between January 2013 and December 2021, a total of 1647 patients with AAD underwent surgical procedure. Postoperative SCI occurred in 58 patients, including 24 patients with paraplegia and 34 patients with paraparesis. Factors associated with SCI was identified through comparison between patients with and without SCI. The mean age was 48.8 ± 10.8 years for patients with SCI and 50.1 ± 12.1 years for those without SCI (P = 0.43), with a comparable gender distribution. Median numbers of intercostal and lumbar arteries with involvement were significantly higher in the SCI group (both P < 0.001). The highest (P = 0.033) and lowest (P = 0.001) level of intraoperative mean arterial pressure (MAP) were significantly lower in the SCI group. Multivariable analysis revealed number of segmental arteries involved (odds ratio [OR]=1.14, 95% CI 1.08-1.20, P = 0.000) and duration of hypothermic circulatory arrest (HCA) (OR = 1.04, 95% CI 1.01-1.08, P = 0.042) were positively associated with the occurrence of SCI. Conversely, the lowest level of MAP was negatively associated with SCI (OR = 0.98, 95% CI 0.96-0.99, P = 0.031). During the long-term follow-up, 14 patients with paraplegia needed the wheel chair, while only one patient with paraparesis needed one (P < 0.001). The risk of postoperative SCI increases when AAD patients experience segmental arteries involved, longer HCA duration, and decreased intraoperative MAP during operation.

Meta-regression of sulcal patterns, clinical and environmental factors on neurodevelopmental outcomes in participants with multiple CHD types.

Congenital heart disease affects 1% of infants and is associated with impaired neurodevelopment. Right- or left-sided sulcal features correlate with executive function among people with Tetralogy of Fallot or single ventricle congenital heart disease. Studies of multiple congenital heart disease types are needed to understand regional differences. Further, sulcal pattern has not been studied in people with d-transposition of the great arteries. Therefore, we assessed the relationship between sulcal pattern and executive function, general memory, and processing speed in a meta-regression of 247 participants with three congenital heart disease types (114 single ventricle, 92 d-transposition of the great arteries, and 41 Tetralogy of Fallot) and 94 participants without congenital heart disease. Higher right hemisphere sulcal pattern similarity was associated with improved executive function (Pearson r = 0.19, false discovery rate-adjusted P = 0.005), general memory (r = 0.15, false discovery rate P = 0.02), and processing speed (r = 0.17, false discovery rate P = 0.01) scores. These positive associations remained significant in for the d-transposition of the great arteries and Tetralogy of Fallot cohorts only in multivariable linear regression (estimated change β = 0.7, false discovery rate P = 0.004; β = 4.1, false discovery rate P = 0.03; and β = 5.4, false discovery rate P = 0.003, respectively). Duration of deep hypothermic circulatory arrest was also associated with outcomes in the multivariate model and regression tree analysis. This suggests that sulcal pattern may provide an early biomarker for prediction of later neurocognitive challenges among people with congenital heart disease.

Comparison of Partial Upper Sternotomy Versus Median Sternotomy for Total Arch Replacement in Patients With Type A Aortic Dissection

Objective: Comparative studies of median sternotomy and partial upper sternotomy in total arch replacement for type A aortic dissection are rare, and the safety and benefits of partial upper sternotomy need further evaluation. This study aimed to explore the effectiveness and prognosis of partial upper sternotomy in total arch replacement among patients with type A aortic dissection. Methods: This is a retrospective study of patients who underwent total arch replacement for type A aortic dissection at the First Medical Center of Chinese People’s Liberation Army General Hospital between January 2016 and December 2019. They were grouped into the median sternotomy and partial upper sternotomy groups according to the different treatment methodologies. The intra-operative and prognostic indicators were compared between both groups. Results: Forty-nine patients were included: 31 in the median sternotomy group and 18 in the partial upper sternotomy group. The partial upper sternotomy group had a shorter incision ((9.0 ± 0.8) cm vs. (25.5 ± 1.3) cm, P = 0.02) and smaller postoperative total drainage volume (885 mL vs. 1,820 mL, P = 0.03) than the median sternotomy group. The differences between the 2 groups with respect to other intra-operative indicators such as operation duration, cardiopulmonary bypass duration, aortic occlusion duration, hypothermic circulatory arrest duration, and intra-operative blood loss, and prognostic indicators such as red blood cell infusion, ventilator aid duration, cardiac intensive care unit stay, postoperative hospital stay, and postoperative complications were not significantly different (all P &gt; 0.05). Conclusions: The utilization of partial upper sternotomy in patients with type A aortic dissection resulted in a smaller incision and more aesthetically pleasing scar, along with reduced drainage volume compared to median sternotomy.

Optimal antegrade cerebral perfusion flow in patients undergoing surgery for acute type A aortic dissection: A retrospective single-center analysis.

Systemic hypothermia with bilateral antegrade selective cerebral perfusion (ASCP) is the preferred cerebral protective strategy for type A aortic dissection surgery. The optimal ASCP flow rate remains uncertain and the target flow cannot always be reached due to pressure limitations. The aim of this study was to assess the correlation between ASCP flow and regional cerebral oxygen saturation (rSO2). A retrospective analysis was performed on 140 patients with acute type A aortic dissection who underwent surgery with moderate hypothermic circulatory arrest and bilateral ASCP between 2015 and 2021. Pearson correlation analysis was performed between ASCP flow and rSO2. The median circulatory arrest duration was 46.5 (IQR:37.0-61.0) minutes. There was no significant correlation between ASCP flow and rSO2 for both the right (r = -.02, p = .851), and the left hemisphere (r = - .04, p = .618). The rSO2 values for ten patients who received > 10mL/kg/min flow did not differ significantly from 130 patients who received 10mL/kg/min or less for both the left hemisphere (p = .135), and the right hemisphere (p = .318). The ASCP flow was 5.1 (IQR:5.0- 6.5) mL/kg/min in five patients with, and 7.2 (IQR:5.8-8.3) mL/kg/min in 135 patients without a watershed infarction (p = .098). There was no correlation between ASCP flow rate and rSO2 in patients with acute type A aortic dissection. Furthermore, ASCP flow below 10mL/kg/min was not associated with a reduction in rSO2. Definitive associations between ASCP flow and neurological outcome after type A aortic dissection surgery need further investigation.

Bio-Bentall and hybrid arch frozen elephant trunk repair for acute type A aortic dissection with malperfusion

The extent of repair in patients with acute type A aortic dissection is often determined by factors such as entry tear location, aortic anatomy, malperfusion and team expertise. The hybrid arch frozen elephant trunk, which has become an established technique to extend the distal acute type A aortic dissection repair, is particularly useful in malperfusion; however, it remains technically challenging and is associated with increased duration of circulatory arrest and risks of spinal cord ischaemia. Proximal dissection flap extension often determines repairability versus replacement of the aortic root. We present a case report highlighting the proximal and distal extent of repair in a patient with a known ascending aortic aneurysm presenting with an acute type A aortic dissection, with malperfusion, undergoing a successful bio-Bentall procedure and hybrid arch frozen elephant trunk repair.

Hyperlactatemia in patients undergoing pulmonary endarterectomy with deep hypothermic circulatory arrest: Risk factors and its effects on the outcome.

To determine the risk factors of hyperlactatemia in pulmonary endarterectomy (PEA) surgery and assess whether elevated blood lactate levels are associated with adverse outcomes. In this retrospective observational study, a total of 111 consecutive patients who underwent PEA for chronic thromboembolic pulmonary hypertension at the XXX Hospital between December 2016 and January 2022 were included. We retrospectively evaluated arterial blood samples analyzed intraoperatively. The pre- and intraoperative risk factors for hyperlactatemia and the postoperative outcomes were recorded. Lactate levels gradually increased during surgery. The optimal cut-off lactate level for major postoperative complications, calculated using receiver operating characteristic analysis, was 7.0mmol/L. Deep hypothermic circulatory arrest (DHCA) duration, nadir hematocrit, and preoperative pulmonary vascular resistance were risk factors for lactate levels >7mmol/L. Moreover, the intraoperative peak lactate level during PEA under DHCA was found to be a statistically significant predictor of major complications being associated with longer mechanical ventilation time (r = 0.294; p = .003) and intensive care unit length of stay (r = 0.327; p = .001). Deep hypothermic circulatory arrest duration, nadir hematocrit, and preoperative pulmonary vascular resistance were associated with hyperlactatemia. Increased lactate levels were independent predictors of longer mechanical ventilation time, intensive care unit length of stay, and major complications.

Risk Factors for Acute Kidney Injury after Moderate Hypothermic Circulatory Arrest in Hemiarch Replacement

Background. The aim of this study was to clarify the incidence and risk factors for acute kidney injury (AKI) in patients undergoing hemiarch replacement (HAR) under moderate hypothermic circulatory arrest (MHCA) with retrograde cerebral perfusion (RCP). Methods. We retrospectively analyzed patients who underwent HAR under MHCA with RCP at our institution between April 2015 and July 2022. Exclusion criteria were preoperative dialysis, single kidney, and lack of preoperative plasma creatinine data. The study endpoint was the incidence of postoperative AKI, defined using the Kidney Disease: Improving Global Outcomes criteria. Multivariate logistic regression analysis was performed to identify the risk factors for postoperative AKI. Results. One hundred and seventy-nine patients were included in this study. The most common indications for HAR were thoracic aortic aneurysm (n = 107) and acute aortic dissection (n = 57). Concomitant procedures, most frequently aortic valve surgery, were performed in 104 (60.5%) patients. Median circulatory arrest time and minimum rectal temperature were 15 minutes (interquartile range, 11 to 19) and 27.4°C (interquartile range, 25.9 to 28.1), respectively. Operative mortality was 1.1%. The incidence of postoperative AKI was 37.8%. Multivariate analysis showed that acute aortic dissection (odds ratio, 4.57; 95% confidence interval (CI), 2.13–10.14; P &lt; 0.001) and longer operating time (odds ratio, 1.01; 95% CI, 1.00-1.01; P = 0.001) were independent predictors for postoperative AKI. Conclusions. Acute aortic dissection and longer operating time were risk factors for postoperative AKI in patients undergoing HAR under MHCA with RCP. In contrast, neither circulatory arrest time nor minimum rectal temperature was a risk factor for AKI. This may be due to the short duration of circulatory arrest.

Predictors of the inability to achieve full oral feeding in postoperative infants with CHD.

Poor oral feeding is a known contributor to growth challenges in neonates with complex CHD who require early surgery. Almost 60% of these infants do not achieve full oral feeding by hospital discharge. This study's objective was to identify predictors of the inability to achieve full oral feeding by discharge in neonates with complex CHD following surgical intervention with cardiopulmonary bypass. A retrospective analysis of a prospective study of 192 full-term neonates with complex CHD was performed. A stepwise selection logistic regression model was developed to predict oral feeding status at hospital discharge. Univariate subgroup analysis was performed with groups determined based on a CHD classification system. 58% of neonates (112/192) failed to achieve full oral feeding by hospital discharge. A logistic regression model identified duration of deep hypothermic circulatory arrest and reintubation as predictors of the inability to achieve full oral feeding. Among neonates who achieved full oral feeding by discharge (42%), only 7.5% did so after postoperative day 10. Brain maturation, brain injury, and preoperative oral feeding were not predictors of full postoperative oral feeding. Many infants with CHD fail to achieve full oral feeding by time of hospital discharge. Longer duration of deep hypothermic circulatory arrest and increased number of intubations were predictive of poor feeding after surgery. Prolonging hospitalisation solely to achieve full oral feeding after postoperative day ten is of limited utility; earlier discharge should be promoted to avoid negative impacts on neonatal neurodevelopment as unintended consequences of lengthy hospitalisations.

Association between Bilateral Selective Antegrade Cerebral Perfusion and Postoperative Ischemic Stroke in Patients with Emergency Surgery for Acute Type A Aortic Dissection-Single Centre Experience.

Acute type A aortic dissection (ATAAD) is a surgical emergency with a mortality of 1-2% per hour. Since its discovery over 200 years ago, surgical techniques for repairing a dissected aorta have evolved, and with the introduction of hypothermic circulatory arrest and cerebral perfusion, complex techniques for replacing the entire aortic arch were possible. However, postoperative neurological complications contribute significantly to mortality in this group of patients. The aim of this study was to determine the association between different bilateral selective antegrade cerebral perfusion (ACP) times and the incidence of postoperative ischemic stroke in patients with emergency surgery for ATAAD. Patients with documented hemorrhagic or ischemic stroke, clinical signs of stroke or neurological dysfunction prior to surgery, that died on the operating table or within 48 h after surgery, from whom the postoperative neurological status could not be assessed, and with incomplete medical records were excluded from this study. The diagnosis of postoperative stroke was made using head computed tomography imaging (CT) when clinical suspicion was raised by a neurologist in the immediate postoperative period. For selective bilateral antegrade cerebral perfusion, we used two balloon-tipped cannulas inserted under direct vision into the innominate artery and the left common carotid artery. Each cannula is connected to a separate pump with an independent pressure line. Near-infrared spectroscopy was used in all cases for cerebral oxygenation monitoring. The circulatory arrest was initiated after reaching a target core temperature of 25-28 °C. In total, 129 patients were included in this study. The incidence of postoperative ischemic stroke documented on a head CT was 24.8% (31 patients), and postoperative death was 20.9% (27 patients). The most common surgical technique performed was supravalvular ascending aorta and Hemiarch replacement with a Dacron graft in 69.8% (90 patients). The mean cardiopulmonary bypass time was 210 +/- 56.874 min, the mean aortic cross-clamp time was 114.775 +/- 34.602 min, and the mean cerebral perfusion time was 37.837 +/- 18.243 min. Using logistic regression, selective ACP of more than 40 min was independently associated with postoperative ischemic stroke (OR = 3.589; 95%CI = 1.418-9.085; p = 0.007). Considering the high incidence of postoperative stroke in our study population, we concluded that bilateral selective ACP should be used with caution, especially in patients with severely calcified ascending aorta and/or aortic arch and supra-aortic vessels. All efforts should be made to minimize the duration of circulatory arrest when using bilateral selective ACP with a target of less than 30 min, in hypothermia, at a body temperature of 25-28 °C.

Radiological properties of neurological injury following acute type A aortic dissection repair

ObjectiveThe study objective was to assess the radiological properties of acute type A aortic dissection–related neurological injuries and identify predictors of neurological injury. MethodsOur single-center, retrospective, observational study included all patients who underwent acute type A aortic dissection repair between January 1998 and December 2021. Multivariable analyses and Cox regression were performed to identify predictors of embolic lesions, watershed lesions, neurological injury, 30-day mortality, and late mortality. ResultsA total of 538 patients were included. Of these, 120 patients (22.3%) experienced postoperative neurological injury; 74 patients (13.8%) had postoperative stroke, and 36 patients (6.8%) had postoperative coma. The 30-day mortality was 22.7% in the neurological injury group versus 5.8% in the no neurological injury group (P < .001). We identified several independent predictors of neurological injury. Cerebral malperfusion (odds ratio, 2.77; 95% confidence interval, 1.53-5.00), systemic hypotensive shock (odds ratio, 1.97; 95% confidence interval, 1.13-3.43), and aortic arch replacement (odds ratio, 3.08; 95% confidence interval, 1.17-8.08) predicted embolic lesions. Diabetes mellitus (odds ratio, 5.35; 95% confidence interval, 1.85-15.42), previous cardiac surgery (odds ratio, 8.62; 95% confidence interval, 1.47-50.43), duration of hypothermic circulatory arrest (odds ratio, 1.05; 95% confidence interval, 1.01-1.08), cardiopulmonary bypass time (odds ratio, 1.01; 95% confidence interval, 1.00-1.01), ascending aortic/arch cannulation (odds ratio, 5.68; 95% confidence interval, 1.88-17.12), and left ventricular cannulation (odds ratio, 17.81; 95% confidence interval, 1.69-188.01) predicted watershed lesions. Retrograde cerebral perfusion (odds ratio, 0.28; 95% confidence interval, 0.01-0.84) had a protective effect against watershed lesions. ConclusionsIn this study, we demonstrated that the radiological features of neurological injury may be as important as clinical characteristics in understanding the pathophysiology and causality behind neurological injury related to acute type A aortic dissection repair.

The Association of the Cerebral Protection Strategy with Early Mortality and Postoperative Stroke in Acute Type A Aortic Dissection: A Systematic Review and Meta-Analysis

Objective. The optimal cerebral protection strategy in acute type A aortic dissection (ATAAD) is still without a clear consensus. The purpose of this meta-analysis was to compare the outcome of different cerebral protection strategies on ATAAD patients. Materials and Methods. We conducted a systematic review including all studies concerning surgically managed ATAAD patients between 1.1.2010 and 28.2.2022 and reporting the use of cerebral protection strategies in three large databases (Pubmed, Cochrane library, and Scopus). The main outcome events were 30-day mortality and a postoperative stroke rate. The pooled event rates adjusted by age, gender, CPB duration, circulatory arrest duration, and total arch reconstruction rate were calculated. Results. Overall, 39 articles were included covering a total of 16, 876 ATAAD patients. The estimated adjusted pooled early mortality rate was 10.1% (95% confidence interval [CI] 9.1–11.3%) in the ACP group, 15.9% (13.3–18.9%) in the RCP group, and 11.6% (9.2–14.5%) in the HCA group. Compared to the RCP group, ACP and HCA demonstrated lower early mortality (RCP vs. ACP odds-ratio 1.66 [1.28–2.15],p &lt; 0.001; RCP vs. HCA odds-ratio 1.45 [1.02–2.07],p = 0.039). The adjusted pooled stroke rate was 9.0% (8.3–9.8%) in the ACP group, 10.5% (9.3–11.7%) in the RCP group, and 9.1% (8.1–10.2%) in the HCA group. Conclusion. Early mortality might be more common in ATAAD patients treated with RCP compared to ACP and HCA. With regards to postoperative stroke, the results were inconclusive despite the trending inferiority of RCP compared to the other strategies.

Proximal and extended aortic arch replacement in acute DeBakey type I aortic dissection.

This study aimed to compare the short- and long-term outcomes of proximal repair vs. extensive arch surgery for acute DeBakey type I aortic dissection. From April 2014 to September 2020, 121 consecutive patients with acute type A dissection were surgically treated at our institute. Of these patients, 92 had dissections extending beyond the ascending aorta. Of the 92 patients, 58 underwent proximal repair, including aortic root and/or hemiarch replacement, and 34 underwent extended repair, including partial and total arch replacement. Perioperative variables and early and late postoperative results were statistically analyzed. The duration of surgery, cardiopulmonary bypass, and circulatory arrest was significantly shorter in the proximal repair group (p < 0.01). The overall operative mortality rate was 10.3% in the proximal repair group and 14.7% in the extended repair group (p = 0.379). The mean follow-up period was 31.1 ± 26.7 months in the proximal repair group and 35.3 ± 26.8 months in the extended repair group. During follow-up, the cumulative survival and freedom from reintervention rates at 5 years were 66.4% and 92.9% in the proximal repair group, and 76.1% and 72.6% in the extended repair group, respectively (p = 0.515 and p = 0.134). No significant differences were found in the rates of long-term cumulative survival and freedom from aortic reintervention between the two surgical strategies. These findings suggest limited aortic resection achieves acceptable patient outcomes.

Visceral protection in total arch replacement for aortic dissection: Effect of lower body hypothermia.

Optimal hypothermia strategy for total arch replacement in acute type A aortic dissection (ATAAD) is unclear. A higher temperature during circulatory arrest might reduce tolerance to ischemia for visceral organs. We sought to investigate the effect of hypothermia on visceral protection. From January 2010 to December 2019, 1138 consecutive patients underwent total arch replacement combined with frozen elephant trunk for acute type A aortic dissection. The data were retrospectively collected and analyzed. Visceral organ injury and visceral-related adverse outcomes were defined as acute renal failure or spinal cord injury or both. Multivariate logistic regression analysis and multivariate linear regression model were used. The mean age of patient was 46.9 ± 10.0 years, with a male preponderance (79.6%). Operative mortality was 6.1% (69 patients). Spinal cord injury occurred in 55 (4.8%) patients and 133 (11.7%) patients had acute renal failure. In the multivariate logistic regression model, neither bladder temperature (odds ratio [OR] 0.971, 95% confidence interval [CI] 0.922-1.024, p = .278) nor circulatory arrest duration (OR 1.017, 95% CI 0.987-1.047, p = .267) significantly associated with visceral-related adverse outcomes. Female, lower limb malperfusion, age, cardiopulmonary bypass(CPB) duration and preoperative serum creatinine level were independent risk factors of visceral-related outcomes. There was a significant negative correlation between bladder temperature and CPB duration in multiple linear regression model (β = -3.67, p < .0001). Bladder temperature had no effect on outcomes related to visceral protection under the premise of short circulatory arrest duration, but female gender, lower limb malperfusion, age, CPB duration, and preoperative serum creatinine level were independent risk factors. Bladder temperature negatively correlated to CPB duration.

Brain Protection in Patients with Aortic Dissection and Coronary Artery Disease

The aim. To compare the effectiveness of methods of protecting the brain and visceral organs during operations for aortic aneurysms combined with coronary artery lesions.&#x0D; Materials and methods. In the period from 2012 to 2020, 23 patients with Stanford type A and non-A non-B aortic dissection with damage to the coronary arteries were operated at the National Amosov Institute of Cardiovascular Surgery of the NAMS of Ukraine using the brain protection techniques. Out of 23 surgical interventions, 16 were performed for Stanford type A acute aortic dissection, 3 for Stanford type A chronic aortic dissection, 1 for Stanford type A subacute aortic dissection, and 3 for Stanford non-A non-B aortic dissection. The main causes of aortic dissection were hypertension (16 patients), Marfan syndrome (3 patients), bicuspid aortic valve (4 patients).&#x0D; Results. The most threatening postoperative complication in this group of patients is neurological damage, which was observed in 4 (17%) patients after surgery, with gradual recovery of brain function. Also, the complications observed were respiratory failure in 3 (13%) patients, which required long-term artificial ventilation (more than 72 hours), and multiple organ failure in 1 (4.3%) patient, which caused a fatal outcome.Complications such as kidney and liver failure were not observed (most likely due to the small sample size). Heart failure was not noted as well. Hospital mortality was 4.3% (1 fatal case). In our study, among the entire group of operated patients, symptoms of neurological damage occurred in 4 (17.4%) patients, hemorrhagic stroke was present in 1 (4.3%) patient with a complicated medical history, 2 (8.6%) patients had hemiparesis and in 1 case (4.3%) there were cognitive disorders.&#x0D; Conclusions. Comparing brain protection techniques, taking into account the prolongation of aortic clamping time due to coronary artery shunting compared to isolated aortic dissection, it can be concluded that longer duration of selective brain perfusion (retrograde or antegrade) or duration of circulatory arrest more often lead to postoperative complications, namely neurological lesions.&#x0D; On the other hand, the small number of observations does not make it possible to fully assess the impact of each of the techniques. Further follow-up with a larger sample will provide opportunities for a more complete evaluation of brain protection techniques in operations for dissecting aortic aneurysms and coronary artery lesions.

Machine Learning to Predict Executive Function in Adolescents with Repaired d-Transposition of the Great Arteries, Tetralogy of Fallot, and Fontan Palliation

To identify predictors of impaired executive function in adolescents after surgical repair of critical congenital heart disease (CHD). We analyzed patient factors, medical and surgical history, and family social class from 3 single-center studies of adolescents with d-transposition of the great arteries (d-TGA), tetralogy of Fallot (TOF), and Fontan repair. Machine learning models were developed using recursive partitioning to predict an executive function composite score based on five subtests (population mean 10, SD 3) of the Delis-Kaplan Executive Function System. The sample included 386 patients (139 d-TGA, 91 TOF, 156 Fontan) of age 15.1±2.1 (mean±SD) years and an executive function composite score of 8.6±2.4. Family social class emerged as the most important predictive factor. The lowest (worst) mean executive function score (5.3) occurred in patients with low to medium social class (Hollingshead index <56) with one or more neurologic events and a diagnosis of TOF. The highest (best) mean score (9.7) occurred in subjects with high social class (Hollingshead index ≥56) and shorter duration of deep hypothermic circulatory arrest. Other factors predicting lower executive function scores included low birth weight and a greater number of catheterizations. In regression tree modeling, family social class was the strongest predictor of executive function in adolescents with critical CHD, even in the presence of medical risk factors. Additional predictors included CHD diagnosis, birth weight, neurologic events, and number of procedures. These data highlight the importance of social class in mitigating risks of executive dysfunction in CHD.

Duration of deep hypothermic circulatory arrest for aortic arch surgery: is it a myth, fiction, or scientific leap?

The use of deep hypothermic circulatory arrest (DHCA) to provide aortic surgeons with a bloodless operative field while simultaneously protecting the brain and peripheries from ischemic damage revolutionized cardiac and aortic surgery, and is currently used in specialist centers across the globe. However, it is associated with manifold adverse outcomes, including neurocognitive dysfunction and mortality. This review seeks to analyze the relationship between DHCA duration and clinical outcome, and evaluate the controversies and limitations surrounding its use. We performed a review of available literature with statistical analysis to evaluate the relationship between DHCA duration (<40 min and >40 min) and key clinical outcomes, including mortality, permanent and temporary neurological deficit, renal damage, admission length, and reintervention rate. The controversies surrounding DHCA use and future directions for care are also explored. Statistical analysis revealed no significant association (P>0.05) between DHCA duration and clinical outcomes (early and late mortality rates, neurological deficit, admission length, and reintervention rate), both with and without adjunctive perfusion techniques. Available literature suggests that the relationships between DHCA duration (with and without adjunctive perfusion) and clinical outcomes are unclear, and at present not statistically significant. Alternative surgical and endovascular techniques have been identified as promising novel approaches not requiring DHCA, as have the use of biomarkers to enable early diagnosis and intervention for aortic pathologies.

Partial aortic arch replacement without circulatory arrest: A case study.

Hypothermic circulatory arrest is commonly used during aortic arch surgery. However, it is associated with high risk of visceral organ and lower limb ischemia. There may be advantages to reduction duration of hypothermic circulatory arrest to prevent ischemic complications. We present a case of partial aortic arch replacement without use of hypothermic circulatory arrest.

Association between Duration of Deep Hypothermic Circulatory Arrest and Surgical Outcome in Patients with Acute Type A Aortic Dissection: A Large Retrospective Cohort Study

(1) Background: Deep hypothermic circulatory arrest (DHCA) with selective antegrade cerebral perfusion (ACP) is an established cerebral protection technique for the conduction of complex surgical procedures involving the aortic arch. It is controversial whether the duration of DHCA is associated with adverse outcome in patients with acute type A aortic dissection (AAAD). Our goal was to investigate whether DHCA time was associated with surgical outcome in patients undergoing a surgical treatment of AAAD. (2) Methods: A total of 410 patients were divided into two groups based on the DHCA time less than 60 min and equal to or longer than 60 min. (3) Results: Patients with longer DHCA times were significantly younger (p = 0.001). Intraoperatively, complex procedures with aortic arch surgery were more common in patients with longer DHCA times (p < 0.001). Accordingly, cardiopulmonary bypass (p < 0.001), cross-clamping (p < 0.001) and DHCA times (p < 0.001) were significantly longer in this group. Postoperatively, only the duration of mechanical ventilation (p < 0.001) and the rate of tracheotomy were significantly higher in these patients. Thirty-day mortality was satisfactory for both groups (p = 0.746). (4) Conclusions: Our results showed that improvements in perioperative management including ACP allow for the successful performance of surgical treatment of AAAD under DHCA with a duration of even longer than 60 min.

Anaesthetic implications of right atrial myxoma in a premature infant.

Sir, Cardiac myxoma is a benign tumour and the most common primary cardiac tumour in adults; however, it is unusual in paediatric patients, with only 20% constituting right atrial myxomas (RAMs).[1] A 3-month-old male baby, weighing 1.7 kg, presented to our hospital with tachypnoea while feeding and failure to thrive. The baby was born prematurely after 29 weeks of gestation. On examination, the baby looked emaciated [Figure 1]. A pansystolic murmur was present at the left lower sternal border on auscultation. Transthoracic echocardiography (TTE) revealed a large, homogenous, pedunculated mass (19 mm × 10 mm) attached to the interatrial septum (IAS) and protruding into the tricuspid valve (TV) causing tricuspid regurgitation (TR) [Figure 2]. Blood investigations revealed haemoglobin of 9.8 g/dL and platelet count of 78000/mm3. Surgical removal of the RAM was planned because of the inability to gain weight.Figure 1: Intraoperative image showing an emaciated look of the child. Fr: FrenchFigure 2: Apical four-chamber view on TTE showing RA myxoma. RA: right atrium, RV: right ventricle, LA: left atrium, LV: left ventricleOn the day of surgery, the baby was shifted to the operating room, and a multiparameter monitor was attached. All preparations were done before induction of anaesthesia to go on emergent cardiopulmonary bypass (CPB) if required. General anaesthesia with endotracheal intubation was induced with intravenous midazolam 0.1 mg/kg, fentanyl 5 μg/kg and vecuronium 0.1 mg/kg through an already placed peripheral cannula. Induction agents were given slowly while constantly monitoring the haemodynamics. Right radial arterial cannulation was done, and central venous catheter (CVC) was inserted carefully in the right internal jugular vein. Anaesthesia was maintained with 1.5% (v/v %) isoflurane and intermittent boluses of fentanyl and vecuronium. After midline sternotomy and full heparinisation, CPB was instituted through aorto-bicaval cannulation. Superior vena cava (SVC) cannulation was done through a higher approach, and other manipulations near the right atrium (RA) were done gently to avoid embolisation of the tumour. Under deep hypothermic circulatory arrest (DHCA), the RA was opened, and the mass was excised completely. The baby was weaned off CPB with inotropic support of intravenous milrinone 0.5 μg/kg/min. After completion of the surgery, the patient was shifted to the paediatric intensive care unit and was extubated after 8 hours. Postoperative TTE showed an intact IAS with no TR or residual mass in RA. RAMs usually present with breathlessness, cyanosis, feeding difficulty, and constitutional symptoms like fever, fatigue, anaemia, thrombocytopenia, malnourishment, and weight loss because of the release of interleukin-6 by RAM.[2] RAM can obstruct the TV causing jugular venous distension, peripheral oedema, hepatic congestion, ascites, and syncope.[3] Our patient looked malnourished, weighed only 1.7 kg along with low haemoglobin and platelet count. Arrhythmias commonly occur due to conduction defects caused by myxoma. Anaesthetic considerations in RAMs include hypoxaemia, low cardiac output, and potential pulmonary emboli due to their mobile nature. Aggravation of the patient’s symptoms and hypotension can occur at certain positions due to intermittent obstruction of TV by a mobile RAM along with a change in the character of the murmur. Evaluation of these positions must be done preoperatively, and induction should be done with careful positioning, with the administration of titrated doses of anaesthetic drugs, which avoid myocardial depression while maintaining the preload and preparation to go on emergent CPB. Placing a CVC and SVC cannulation can be difficult in the presence of a tumour in the RA and may result in its fragmentation and dislodgement. Hence, utmost care should be taken to avoid entering the RA. Intraoperative transoesophageal echocardiography (TOE) monitoring helps in the detection and diagnosis of tumour fragmentation or dislodgement, and in assessing volume status as TR caused by RAM renders CVP measurement unreliable for evaluation of volume status.[4] However, in our case, TOE examination was not done because of non-availability of a neonatal probe. DHCA provides excellent surgical exposure for tumour removal, but the duration of circulatory arrest must be limited to prevent complications.[5] Perioperative care in premature neonates also includes preventing hypoglycaemia, hypoxia and hypothermia.[6] Anaesthetic concerns range from difficult airways, risk reduction for adverse events and adequate pain management.[7] Thus, neonates with RAMs require early diagnosis, meticulous anaesthetic management and multidisciplinary approach to perioperative care. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.