Selective Antegrade Cerebral Perfusion Research Articles

A Technique for Safe Redo Sternotomy in Patients with Aortic Proximity to the Sternum.

The risk of redo sternotomy is greatly elevated in the setting of aortic proximity to the sternum. Current strategies to avoid catastrophic neurologic injury upon sternal reentry include establishment of peripheral bypass with the use of deep hypothermia and low-flow bypass, both of which may increase risk of neurologic complications. Here, we describe a technique for safe sternal reentry and illustrate its successful use in a patient with close proximity of the aorta to the sternum. With this technique, peripheral cardiopulmonary bypass is established prior to sternal reentry via cannulation of the right axillary artery and femoral vein, and the patient is cooled as the innominate artery is dissected, mobilized, and controlled. This permits the rapid institution of selective antegrade cerebral perfusion (SACP) in the event of aortic injury during sternal reentry. Once the innominate artery is isolated and SACP is initiated, one can safely complete the redo sternotomy, dissection, and distal ascending aortic cross-clamping to continue the operation without interruption in cerebral blood flow. This technique offers a safe approach in select patients and should be utilized in similar high-risk cases.

Total Aortic Arch Replacement: Case Report of the first successful total arch replacement in Nepal and Review of contemporary techniques in arch surgery

Aortic arch replacement is formidable cardiac surgery that is fraught with complications like brain injury, coagulopathy along with high mortality. Over the past several years, various techniques like deep hypothermic circulatory arrest, retrograde cerebral perfusion, and selective antegrade cerebral perfusion along with branched graft techniques have been developed with better early outcomes. We share our experience of successful replacement of ascending and total aortic arch in a 60 years old female, who presented with ascending and aortic arch aneurysm.

63 The “Brighton Connector”: A Simple, Reproducible and Cost-Effective Technique for Bilateral Antegrade Cerebral Perfusion During Aortic Arch Surgery

Abstract Aim Surgery of the aortic arch presents significant technical and physiological challenges. Selective antegrade cerebral perfusion (SACP) during arch surgery has been shown to improve mortality and neurological outcomes in these patients. At our centre, we aimed to develop a safe, reliable, and cost-effective technique to provide bilateral antegrade cerebral perfusion without the need of another pump head. Method We developed our system using equipment that is included in the accessory packaging for the Sorin Xtra cell saver system, which is readily available in cardiac surgical units nationwide, but often discarded as it is not required. An EOPA arterial return cannula and the TRUE FLOW RDB SACP cannula were joined using our novel connection. Results A single surgeon has used the “Brighton Connector” for 6 patients in the last two years. All patients made a satisfactory recovery with a 0% rate of mortality or permanent neurological deficit. Conclusions All components in our circuit are already approved for use in cardiac theatres, and the connection tubing would normally be discarded, making our method cost neutral. We demonstrate through a case series that mortality and neurological outcomes are good and comparable with other techniques.

WHOLE BODY PERFUSION STRATEGY FOR AORTIC ARCH REPAIR UNDER NORMOTERMIA AND BEATING HEART TECHNIQUE IN PEDIATRIC PATIENTS. THREE CLINICAL CASES

Introduction The incidence of aortic arch pathology in older children is rare. Most often this occurs as a result of a previous aortic arch operation and less often it could be detected primarily. Previously, we successfully used normothermic perfusion during neonatal aortic arch repair. In this paper we evaluate the effectiveness of the method of selective whole body perfusion with coronary perfusion on the beating heart during aortic arch reconstruction in older children. Methods Between October 2019 and February 2021, 3 children underwent aortic arch surgery at our institution using the defined protocol. During the cardiopulmonary bypass (CPB), antegrade cerebral perfusion (ACP), antegrade coronary perfusion on beating heart and distal retrograde femoral aortic perfusion at a constant blood temperature 36 C were used. During the surgery, cerebral and visceral perfusion were monitored using near-infrared spectroscopy (NIRS) and transcranial dopplerography, electrocardiography and arterial blood gases. The data was collected prospectively. Results Patient one. Male, 6 years old, 27 kg. Elective admission. Diagnosis: Aortic arch hypoplasia. Surgery: Aortic arch reconstruction. CPB: Normothermic. Selective ACP, antegrade coronary perfusion on beating heart and distal retrograde femorall aortic perfusion. Flow 2,5 l/min. CPB time – 78 min, ACP – 44 min. BCA cannula – 14 fr, coronary cannula – 4fr, femoral artery cannula – 10 fr. Ultrafiltration during CPB. Mechanical ventilation - 18 hours post/op. Blood lactate 6 hours post/op – 1,8 mmol/l. ICU admission – 24 hours. Hospital discharge 12 days. Patient two, 17 y.o., 38 kg. Elective admission. Diagnosis: Aortic arch hypoplasia. The history of coarctation of the aorta surgery. Surgery: Aortic arch reconstruction. CPB: Normothermic. Selective ACP, antegrade coronary perfusion on beating heart and distal retrograde femorall aortic perfusion. Flow 2,5 l/min. CPB time – 136 min, ACP time – 54 min. BCA cannula – 14 fr, coronary cannula – 4fr, femoral artery cannula – 15 fr. Ultrafiltration during CPB. Mechanical ventilation – 4 hours post/op. Blood lactate 6 hours post/op – 2,6 mmol/l. ICU admission – 16 hours. Hospital discharge 17 days. Patient three. Female, 4 years old, 15 kg. Admitted urgently. Diagnosis: Critical aortic arch stenosis. Brachiocephalic artery (BCA) and left common carotid artery (LCCA) stenosis. The history of coarctation of the aorta surgery. Low ejection fraction. Surgery: Aortic arch, BCA and LCCA repair. CPB: Normothermic. Selective ACP, antegrade coronary perfusion on beating heart and distal retrograde femorall aortic perfusion. Flow 3 l/min. CPB time – 107 min, ACP – 68 min. BCA cannula – 12 fr, coronary cannula – 4fr, femoral artery cannula – 12 fr. Ultrafiltration during CPB. Mechanical ventilation - 44 hours post/op. Blood lactate 6 hours post/op – 1,6 mmol/l. ICU admission – 5 days. Hospital discharge 26 days. During surgery, laboratory and instrumental parameters were within reference values. Patients had no neurological deficiency during hospital stage. Discussion These clinical cases show that the whole-body perfusion with coronary perfusion on beating heart provide safe conditions during aortic arch surgery in children using normothermia. Using this protocol, we were able to eliminate risk factors: circulatory arrest, hypothermia, cardioplegia, extended

Total arch replacement in octogenarians.

OBJECTIVESWe investigated the effect of a preoperative age ≥80 years on postoperative outcomes in patients who underwent isolated elective total arch replacement using mild hypothermic lower body circulatory arrest with bilateral antegrade selective cerebral perfusion.METHODSA total of 140 patients who had undergone isolated elective total arch replacement between January 2007 and December 2020 were enrolled in the present study. We compared postoperative outcomes between 30 octogenarian patients (≥80 years old; Octogenarian group) and 110 non-octogenarian patients (≤79 years old; Non-Octogenarian group).RESULTSOverall 30-day mortality and hospital mortality were 0% in both groups, and there was no significant difference in overall survival between the 2 groups (log-rank test, P = 0.108). Univariable Cox proportional hazard analysis showed that age as continuous variable was only the predictor of mid-term all-cause death (hazard ratio 1.08, 95% confidence interval 1.01–1.16; P = 0.037), but not in the Octogenarians subgroup (P = 0.119).CONCLUSIONSPreoperative age ≥80 years is not associated with worse outcomes postoperatively after isolated elective total arch replacement with mild hypothermic lower body circulatory arrest and bilateral antegrade selective cerebral perfusion.

Total aortic arch replacement using the thoraflex hybrid prosthesis: early- and medium-term results from a Scandinavian center

Objective. The purpose of this study was to assess our early experience with the Thoraflex hybrid prosthesis. Design. This was a retrospective, single-center cohort study. Results. Between December 2014 and December 2019, 34 patients underwent total aortic arch replacement with the Thoraflex hybrid prosthesis. Fifteen of the patients had pre-operative chronic aortic dissection. The mean cardiopulmonary bypass time was 200 ± 35 min, aortic cross clamp time 114 ± 34 min, deep circulatory arrest time to the lower body 60 ± 22 min, and selective antegrade cerebral perfusion time 67 ± 24 min. The rate of stroke was 11.7% (4/34), paraparesis was 8.8% (3/34) and renal failure was 11.7% (4/34). No patient required permanent dialysis. Three (8.8%) patients died within the first 30 days postoperatively. All early deaths were due to stroke or spinal cord complications. During follow-up, an additional four patients died. Average follow-up was 32.4 ± 19.4 months (1102 patient-months) and was 100% complete. Survival at 12 months and 36 months was 88% ± 7.2% and 75% ± 12.7%, respectively. Conclusions. The Thoraflex hybrid prosthesis can be used in the setting of total aortic arch replacement with good early- and medium-term results. Stroke and spinal cord complications remain an important source of early mortality.

The frozen elephant trunk technique: impact of proximalization and the four-sites perfusion technique.

OBJECTIVESTo improve organ protection with the frozen elephant trunk (FET) procedure, a so-called four-sites perfusion in combination with proximalization for the distal aortic anastomosis was performed. The impact of these techniques on patient outcome is reported.METHODSBetween February 2005 and April 2020, a total of 357 patients underwent the FET procedure for acute (54%) or chronic (22%) aortic dissection or aneurysmal disease (24%). The level of the distal FET anastomosis was defined according to aortic arch zones 0–3. Patients were divided into 3 groups according to the intraoperative perfusion strategy: (i) selective antegrade cerebral perfusion (SACP) alone (N = 96, 2 sites); (ii) SACP plus left subclavian artery or distal aorta (N = 84, 3 sites) and (iii) SACP plus left subclavian artery plus distal aorta (N = 177, 4 sites). Early outcome was addressed by a composite end point: occurrence of either a disabling stroke, a disabling spinal cord injury, extracorporeal circulatory support, kidney dialysis or death within 90 days.RESULTSPreoperative characteristics were similar among the groups. Surgery in group C was characterized by FET proximalization in arch zone ≤2, moderate hypothermia at 28°C and shorter periods of extracorporeal circulation, SACP, hypothermic circulatory arrest and cardioplegic arrest (P < 0.001, respectively). Occurrence of the composite end point was reduced in group C (P = 0.008). The combination of FET proximalization and four-sites perfusion was a protective factor for the composite outcome in multivariable analysis (P = 0.009). The 5-year survival was improved in patients who underwent FET proximalization in zone ≤2 (hazard ratio 0.7, 95% confidence interval 0.4–1.0; P = 0.036).CONCLUSIONSFET proximalization in combination with four-sites perfusion has the potential to improve patient outcomes in terms of survival and major events.Subject collection120; 161.

A new tool in the arsenal.

We would like to clarify 3 important issues regarding the AV Flow (MedEurope Srl, Bologna, Italy), a new cannula for antegrade selective cerebral perfusion (ASCP). Its unique feature consists in the possibility of guidewire introduction.

Reply: Will the new tool used for cerebral perfusion be able to "keep it simple" or not?

We appreciate the comments provided by the authors about the new AV Flow cannula (MedEurope Srl, Bologna, Italy), used for antegrade selective cerebral perfusion in arch surgery. They better clarify the positive features of this interesting device, including the possibility of guidewire introduction and suture of epiaortic vessels in the graft without having the bulk of the cannula.1 Nevertheless, a very important concept to observe in surgery is to standardize and simplify the procedure to reduce complications and achieve durable outcomes, especially in complex scenarios.

Early outcome and mid-term survival after open arch repair using selective antegrade cerebral perfusion.

The introduction of selective antegrade cerebral perfusion technique as method of cerebral protection improved the outcome of open arch surgery. The aim of this study was to report early outcomes using this technique. Between 1997 and 2017, data were collected retrospectively for all patients who underwent surgical replacement of the aortic arch using selective antegrade cerebral perfusion (n = 938). To confirm the effectiveness of this cerebral protection method, early outcome and results were evaluated. The incidence of postoperative permanent neurological dysfunction was 6.4%. Overall hospital mortality was 11.9% (n = 112). On multivariable analysis, age >75 years, female gender, euroscore at increment of 1 point, chronic renal failure, extension of thoracic aorta replacement and CPB time emerged as independent risk factors for hospital mortality. The mid-term survival at 1, 5, 10 and 15 years was 92%, 78%, 60% and 49%, respectively. The competing risk analysis for permanent neurological dysfunction and aortic reoperations was performed excluding the patients who died during the hospital stay. The cumulative incidence of permanent neurological dysfunction and aortic reoperations was 2% at 3 years, 3% at 5 years, 6% at 10 years, 12% at 3 years, 15% at 5 years and 19% at 10 years, respectively. From the early 90s to the present day, the selective antegrade cerebral perfusion has confirmed to be a useful and "safe" method of brain protection in aortic arch surgery in terms of postoperative neurological complications.

Cannulation strategies in aortic surgery: techniques and decision making.

Arterial cannulation for cardiopulmonary bypass (CPB) is an important determinant of outcome in aortic surgery. Unlike traditional cardiac operations, aortic pathology may preclude the cannulation of the distal ascending aorta. In other cases, special need of the pathology/operation may demand an alternative cannulation site. Choosing the right cannulation site, especially in type A aortic dissection, is the most crucial initial step. The decision about cannulation sites should be individualized and patient-specific. Various cannulation techniques include femoral, right axillary, innominate, carotid, central aortic, direct true lumen, transapical, and trans-atrial left ventricle cannulation. The ideal cannulation should be easy, quick, and suitable for all clinical scenarios. It should allow smooth conduct of CPB without malperfusion or cerebral embolization. The cannulation strategy should also provide an option for selective antegrade cerebral perfusion and it should be free from neurovascular and local site complications. There is no ideal cannulation technique. Each technique has its pros and cons. Excellent results and drawbacks have been reported with each technique. Final selection of the cannulation site is dependent upon several factors. However, a surgeon's familiarity with a particular technique plays a major role in selection. Despite this, there is a definite shift in surgeons' preference from femoral to central cannulation (axillary, carotid, innominate, aortic) over the last few decades. The aim of this review is to give a brief overview of the cannulation techniques in aortic surgery and discuss the decision-making process.

Reoperative Total Arch Repair Using a Trifurcated Graft and Selective Antegrade Cerebral Perfusion

BackgroundThis study reviews the outcomes of our reoperative total arch repair technique using a trifurcated graft and selective antegrade cerebral perfusion. MethodsFifty patients underwent reoperative total arch repair from January 2005 to September 2020, with either a one-stage repair (n = 9) or two-stage repair (n = 41). The two-stage technique includes minimal dissection of the mediastinal structures, an arch-first technique using a trifurcated graft, and construction of a classical elephant trunk through a partial transverse incision distally in the old graft or in the aorta just distal to the old graft. ResultsThe median age was 63 years. Chronic dissection was the most frequent indication (88%), and 98% had undergone a previous proximal aortic repair at a median interval of 3 years. The median cardiopulmonary bypass, myocardial ischemic, selective antegrade cerebral perfusion, and lower body circulatory arrest times were 226, 103, 97, and 98 minutes, respectively. The minimum nasopharyngeal and bladder temperature were 16.5°C and 20.0°C, respectively. Operative mortality was 2%, the incidence of stroke was 2%, and the incidence of spinal cord injury was 0%. Stage II repair was performed in 37 patients (open, 33 patients; endovascular, 4 patients), with 2 mortalities and no spinal cord injury. The median duration between stage I and II was 63 days. Survival and aortic event free rates at 3 years were 88.4% ± 4.9%, and 89.8% ± 5%, respectively. ConclusionsWe report a reoperative total arch repair technique that minimizes dissection of the cardiac structures, simplifies the distal anastomosis, and protects vital organs, such as the brain, heart, and spinal cord.

Assessment of children`s psychomotor development in the remote period after aortic arch reconstruction with antegrade cerebral perfusion

Objective. To evaluate the psychomotor development of children after aortic arch reconstruction in the conditions of selective antegrade cerebral perfusion.&#x0D; Materials and methods. The results of surgical treatment and psychomotor development of 48 children aged 1 to 3 years, who underwent reconstruction of the aortic arch in terms of artificial circulation and selective antegrade cerebral perfusion at the age of 1 year at the Amosov National Institute of Cardiovascular Surgery and the Scientific and Practical Medical Center of Pediatric Cardiology and Cardiac Surgery in the period from 2014 to 2019 were analyzed. To study the cognitive sphere and motor development of children we used the 2nd edition of the method "Bayley Scales of Infant Development - II". In analyzing the results in children with psychomotor developmental delay, the values of the mental index and the index of psychomotor development were taken into account.&#x0D; Results. 2 (3.7%) patients died after surgery. Postoperative mortality was connected with neurological complications and technique of cerebral perfusion. In the remote period no patient died. According to neurosonography in the postoperative period, no pathological structural changes in the brain were detected. In 16 (33.3%) children at the age of 1 year there was a slight delay in mental and / or psychomotor development. Evaluation of the results of the survey in the dynamics showed that at the age of 3 years, 9 (18.7%) children had a slight development delay. The average values of the mental index in 1 year were 81.2 ± 8.6, and in 3 years - 96.4 ± 12.7 (p &lt;0.05), and the index of psychomotor development - respectively 83.3 ± 11.4 and 94.5 ± 10.2 (p &lt;0.05). The difference between the indicators of mental and psychomotor indices in children with congenital heart disease at 1 year and 3 years is statistically significant.&#x0D; Conclusions. A delay in psychomotor development at the age of 1 year was revealed in 33.3% of children after the aortic arch reconstruction in the conditions of selective antegrade cerebral perfusion. This indicates the need for further research and monitoring. A statistically significant difference between the indicators of mental and psychomotor development of children aged 1 and 3 years after aortic arch reconstruction indicates a positive dynamics and recovery of psychomotor development with age in most of children.

Less Invasive HeartMate 3 Left Ventricular Assist Device Implantation under Deep Hypothermic Circulatory Arrest for Severely Calcified Aorta

Introduction Left ventricular assist devices (LVADs) such as the HeartMate 3 (HM3) are becoming more frequently implanted in those with end-stage heart failure. We present one such patient with prior sternotomies and severely calcified ascending aorta in whom we planned a less invasive LVAD implantation via redo hemi-sternotomy and left thoracotomy with short-term deep hypothermic circulatory arrest (DHCA) to avoid cross-clamping of the aorta. Case Report A 70 year old male with history of two prior cardiac surgeries and heart failure presented in cardiogenic shock requiring temporary mechanical support with Impella CP. He continued to require increasing doses of inotropes and pressors; therefore, he was approved for high risk LVAD placement. A preoperative 4D CT scan revealed severely calcified ascending aorta with only a small area of focal sparing. First, a left anterior thoracotomy in the fifth intercostal space and redo upper hemi-sternotomy was performed. The LVAD outflow graft was positioned through the thoracotomy and brought up to the ascending aorta via the right pleural space, which was opened from the hemi-sternotomy. After initiation of cardiopulmonary bypass, the patient was cooled to 28°C with selective antegrade cerebral perfusion via the right axillary artery and systemic perfusion was temporarily arrested. DHCA was achieved. The LVAD outflow graft was then anastomosed to the aorta after which circulation was restarted and the patient rewarmed. The HM3 LVAD was then implanted in the LV apex and the rest of the operation was completed successfully. Summary Placing an LVAD via thoracotomy has theoretical advantages over a median sternotomy. Surgical trauma is minimized leading to less postoperative bleeding, improved maintenance of the chest stability, earlier recovery, and less cost. Additionally, there might be a reduction in post-operative right heart failure since the pericardium remains intact. Data from the LATERAL study and ELEVATE registry support the safety of this approach. While data support the safety of DHCA in other aortic arch procedures, there are only two case reports of DHCA for LVAD implantation. Our unique case validates the safety of LVAD implantation via thoracotomy and highlights the use of preoperative CT as well as DHCA in placement of an LVAD in a patient with severely calcified ascending aorta.

Femoral artery cannulation as a safe alternative for aortic dissection arch repair in the era of axillary artery cannulation.

BackgroundTo evaluate the safety and efficacy of femoral artery cannulation as an alternative to axillary artery cannulation, we retrospectively compared outcomes between patients with axillary or femoral artery cannulation during open aortic arch repair for type A aortic dissection (TAAD).MethodsBetween January 2014 and January 2019, 646 patients underwent open aortic arch repair with circulatory arrest for TAAD using antegrade selective cerebral perfusion (SACP) and were divided into two groups according to the site of arterial cannulation: an axillary artery group (axillary group, n=558) or a femoral artery group (femoral group, n=88). The axillary artery was considered as the primary cannulation site, and the femoral artery was used as an alternative when axillary artery cannulation was deemed unsuitable or had failed. Propensity score matching was performed to correct baseline differences.ResultsAfter propensity score matching, the patients’ characteristics were comparable between groups (n=85 in each). The incidence of in-hospital mortality (10.6% vs. 14.1%; P=0.642) and stroke (3.5% vs. 5.9%; P=0.720) were comparable between the axillary and femoral groups. The incidence of newly required dialysis was lower in the femoral group, but the difference was not statistically significant (34.1% vs. 20.0%; P=0.050). Other outcomes and major adverse events were comparable.ConclusionsFemoral artery cannulation produced similar perioperative outcomes to axillary cannulation after open arch repair for TAAD. The femoral artery can be used as a safe and effective alternative to the axillary artery for arterial cannulation in TAAD patients undergoing open arch repair.

Aortic arch surgery at 32°C: mild hypothermia and unilateral antegrade cerebral perfusion.

With development of antegrade cerebral perfusion, the necessity of deep hypothermic circulatory arrest (CA) in aortic arch surgery has been called into question. To minimize the adverse effects of hypothermia, surgeons now perform these procedures closer to normothermia. This study examined postoperative outcomes of hemiarch replacement patients using unilateral selective antegrade cerebral perfusion and mild hypothermic CA. Single-centre retrospective review of 66 patients undergoing hemiarch replacement with mild hypothermic CA (32°C) and unilateral selective antegrade cerebral perfusion between 2011 and 2018. Antegrade cerebral perfusion was delivered using right axillary artery cannulation. Postoperative data included death, neurological dysfunction, acute kidney injury and renal failure requiring new dialysis. Additional intraoperative metabolic data and blood transfusions were obtained. Eighty-six percent of patients underwent elective surgery. Mean age was 67 ± 3 years. Lowest mean core body temperature was 32 ± 2°C. Average CA was 17 ± 5 min. No intraoperative or 30-day mortality occurred. Survival was 97% at 1 year, 91% at 3 years and 88% at 5 years. Permanent and temporary neurological dysfunction occurred in 1 (2%) and 2 (3%) patients, respectively. Only 3 (5%) patients suffered postoperative stage 3 acute kidney injury requiring new dialysis. Intraoperative transfusions occurred in 44% of patients and no major metabolic derangements were observed. In patients undergoing hemiarch surgery, mild hypothermia (32°C) with unilateral selective antegrade cerebral perfusion via right axillary cannulation is associated with low mortality and morbidity, offering adequate neurological and renal protection. These findings require validation in larger, prospective clinical trials.

Mild hypothermia with selective antegrade cerebral perfusion during cardiopulmonary bypass and short-term outcomes in children with congenital heart defects

Background: Among the known risk factors for children undergoing surgery for congenital heart defect (CHD), temperature and blood flow during cardiopulmonary bypass (CPB), are two risk factors, which may be altered to improve outcomes. Moderate - to - deep hypothermia (MDH), traditionally used, has been associated with short/long-term neurologic sequelae, so there is a move towards mild hypothermia (MH) with selective antegrade cerebral perfusion (SACP). Aims and Objectives: To assess feasibility of mild hypothermia with selective antegrade cerebral perfusion during cardiopulmonary bypass as a cardiopulmonary bypass strategy in neonates and infants undergoing surgery for congenital heart defect. Materials and Methods: We conducted a retrospective chart review of neonates and infants who underwent SACP on CPB during CHD surgery at our tertiary care children's hospital between January 2014 and February 2017. We categorized all the patients into 2 groups - MH + SACP or MDH + SACP. We gathered data on preoperative, intra-operative and post-operative parameters. We analyzed comparative data using student t-test and chi-squared test with a significant p-value &lt; 0.05. Results: There were 6 in the MH + SACP group and 7 in the MDH + SACP group, who underwent SACP on CPB during study period at our children's hospital. All the neonates and infants in the MH + SACP group survived at the hospital discharge with favorable neurologic outcomes. There was no statistically significant difference between the two groups for end organ dysfunction, ventilator days, hospital days, ICU and hospital mortality and PCPC/POPC at hospital discharge. Conclusions: Mild hypothermia with selective antegrade cerebral perfusion during cardiopulmonary bypass is a feasible cardiopulmonary bypass strategy in neonates and infants undergoing surgery for congenital heart defect.

Low-body-perfusion via an arterial sheath reduces inflammation after aortic arch reconstruction surgery

Pediatric cardiac surgeries involving aortic arch reconstruction are complex and require long cardiopulmonary bypass (CPB) times with deep hypothermic circulatory arrest (DHCA). Selective perfusion techniques have been developed to prevent the deleterious consequences of DHCA associated hypoperfusion. The effectivity of low body perfusion through cannulation of the femoral artery with an arterial sheath remains to be elucidated. We compared perfusion and inflammation in patients receiving selective antegrade cerebral perfusion (ACP) only to low body perfusion (LBP) in addition to ACP during DHCA for aortic arch reconstruction surgery. There was no difference in patient characteristics, cardiac pathologies, or performed procedures between ACP and LBP groups. Lactate levels increased after cardiac arrest in both groups. However, lactate levels were lower after 1 h reperfusion, at the end of extracorporeal circulation (ECC), and after surgery in LBP group compared to ACP only. Furthermore, creatinine was increased in ACP group on postoperative day 1 compared to LBP group but no acute kidney injury was observed in any group. IL-6 concentration increased in ACP group, while remained unchanged in LBP group compared to pre surgical values and were significantly lower compared to ACP group on postoperative days 1 and 2. LBP via an arterial sheath during cardiac arrest for aortic arch reconstruction surgery in addition to ACP, improves post ECC tissue perfusion as indicated by lower lactate levels and reduces creatinine levels suggesting milder kidney injury. LBP seems to prevent postoperative inflammation through a reduction in procedural duration or enhanced perfusion and thereby improves the outcome after aortic arch reconstruction surgery.

Aortic Arch Reconstruction in Infants Using Autologus Pericardium

&#x0D; Background. Aortic arch hypoplasia is a congenital anomaly of the development of the aortic arch characterized by hemodynamically significant narrowing of one or more segments of the aortic arch. This defect occurs either as an isolated condition or combined with other congenital heart defects. The materials used to enlarge aorta for successful repair and prevention of postoperative complications range from the patient’s own aortic tissue (in most cases) to other materials (autopericardium, xenopericardium, pulmonary artery tissues, synthetic patches). An autologous pericardial patch is the most common, available and cheap option.&#x0D; The purpose of this work is toanalyze immediate and long-term results of our experience using autologous pericardium to reconstruct the aortic arch.&#x0D; Materials and methods. From 2011 to 2019 at the National M.M. Amosov Institute of Cardiovascular Surgery of the NAMS of Ukraine and Ukrainian Children’s Cardiac Center 16 infants underwent aortic arch repair using autologous pericardial patch. The group included 6 (37.5%) male and 10 (62.5%) female patients. The mean age of the patients was 1.3 ± 0.9 months (from 0.06 to 4.5 months), the average body weight was 3.8 ± 1.6 kg (from 2.2 to 8.7 kg). The average body surface area was 0.24 ± 0.05 m?. Antegrade selective cerebral perfusion was performed in all the patients during the aortic arch reconstruction.&#x0D; Results. Hospital mortality was 6.2% (n = 1). The cause of death was not related to the reconstruction technique. The average duration of cardiopulmonary bypass was 142.5 ± 38.5 minutes, the aortic cross-clamp time was 76.9 ± 33.7 minutes, and the time of selective cerebral perfusion was 50.4 ± 25.4 minutes. Six patients (37.5%) in the early postoperative period had delayed sternal closure. According to echocardiographic data at discharge, the average pressure gradient at the site of aortic arch reconstruction was 15 ± 5.5 mm Hg, the left ventricular ejection fraction was 65.9 ± 5.9%.&#x0D; The mean follow-up period ranged from one month to 6.1 years (mean 2.8 ± 2.3 years). There were no deaths in the long-term period. Four (25%) patients developed aortic arch restenosis in the postoperative period. One patient presented with an aortic arch aneurysm 1 month after the initial operation. There were no cases of compression of the trachea, main bronchi, neurological complications in the follow-up period.&#x0D; Conclusions. The use of autologous pericardium in aortic arch reconstruction is an effective and safe procedure for infants with good immediate and long-term results. The study showed that autologous pericardium may be an acceptable alternative to reconstruct the aortic arch. A large percentage of reinterventions encourages more thorough removal of ductal tissues and determining the size of the autopericardial patch.

Does supply meet demand? A comparison of perfusion strategies on cerebral metabolism in a neonatal swine model

ObjectiveWe aimed to determine the effects of selective antegrade cerebral perfusion compared with other perfusion strategies on indices of cerebral blood flow, oxygenation, cellular stress, and mitochondrial function. MethodsOne-week-old piglets (n = 41) were assigned to 5 treatment groups. Thirty-eight were placed on cardiopulmonary bypass. Of these, 30 were cooled to 18°C and underwent deep hypothermic circulatory arrest (n = 10), underwent selective antegrade cerebral perfusion at 10 mL/kg/min (n = 10), or remained on continuous cardiopulmonary bypass (deep hypothermic cardiopulmonary bypass, n = 10) for 40 minutes. Other subjects remained on normothermic cardiopulmonary bypass (n = 8) or underwent sham surgery (n = 3). Novel, noninvasive optical measurements recorded cerebral blood flow, cerebral tissue oxyhemoglobin concentration, oxygen extraction fraction, total hemoglobin concentration, and cerebral metabolic rate of oxygen. Invasive measurements of cerebral microdialysis and cerebral blood flow were recorded. Cerebral mitochondrial respiration and reactive oxygen species generation were assessed after the piglets were killed. ResultsDuring hypothermia, deep hypothermic circulatory arrest piglets experienced increases in oxygen extraction fraction (P < .001), indicating inadequate matching of oxygen supply and demand. Deep hypothermic cardiopulmonary bypass had higher cerebral blood flow (P = .046), oxyhemoglobin concentration (P = .019), and total hemoglobin concentration (P = .070) than selective antegrade cerebral perfusion, indicating greater oxygen delivery. Deep hypothermic circulatory arrest demonstrated worse mitochondrial function (P < .05), increased reactive oxygen species generation (P < .01), and increased markers of cellular stress (P < .01). Reactive oxygen species generation was increased in deep hypothermic cardiopulmonary bypass compared with selective antegrade cerebral perfusion (P < .05), but without significant microdialysis evidence of cerebral cellular stress. ConclusionsSelective antegrade cerebral perfusion meets cerebral metabolic demand and mitigates cerebral mitochondrial reactive oxygen species generation. Excess oxygen delivery during deep hypothermia may have deleterious effects on cerebral mitochondria that may contribute to adverse neurologic outcomes. We describe noninvasive measurements that may help guide perfusion strategies.