Shorter Circulatory Arrest Time Research Articles

Influence of a regional network combined with a systematic multidisciplinary approach on the outcomes of patients with acute type A aortic dissection

BackgroundWhether in patients with acute type A aortic dissection reduction of intervals between onset of symptoms and diagnosis influences patient outcomes is still not completely defined. MethodsIn 199 patients with acute type A aortic dissection, the efficacy of a systematic multidisciplinary approach and institution of a regional network were evaluated; 90 patients operated before 2016 (Group1) were compared with 109 repaired after 2016 (Group2) for early and late outcomes. ResultsMortality was reduced from 13% in Group1 to 4% in Group2 (p = 0.013). In Group2 a more patients (46%) had arch replacement compared to Group1 (29%)(p = 0.06). In Group2 axillary artery cannulation was almost routinely used (91% vs 67%, p < 0.001) with shorter circulatory arrest time (37 vs 44 min, p < 0.001). The interval from diagnosis to surgery dropped from 210 min in Group1 to 160 min in Group2 (p < 0.001); this reduction was evident both in patients admitted to the emergency department of a spoke and/or a hub center. Patients presenting with or developing shock were reduced from Group1 to Group2 and in particular those reaching the hub center from spoke centers. Survival at 1 and 5 years was 82 ± 4% and 70 ± 5% in Group1 vs 92 ± 3% and 87 ± 8% in Group2 (p = 0.007). ConclusionsOutcomes of patients with acute type A aortic dissection improved using a systematic multidisciplinary approach while a network between spoke and hub centers reduced intervals between diagnosis, transportation to hub center and repair, limiting the incidence of tamponade and shock.

Does deep hypothermic circulatory arrest with versus without retrograde cerebral perfusion affect the outcomes after proximal aortic arch aneurysm and acute type A aortic dissection repair? Different pathologies and cerebral protection techniques with similar results.

Hypothermic circulatory arrest is used for proximal and total aortic arch correction in patients with aortic arch aneurysm and acute or chronic type A aortic dissection. Different cerebral perfusion techniques have been proposed for reducing morbidity and mortality rate. The study of Arnaoutakis et al. showed that deep hypothermic circulatory arrest with or without retrograde cerebral perfusion for proximal aortic aneurysm and acute type A aortic dissection correction had similar results with regard to morbidity and mortality rate. In addition, the short circulatory arrest time contributes for favorable outcomes of these patients. Although antegrade cerebral perfusion with hypothermic circulatory is widely used by many cardiac surgeons, deep hypothermic circulatory arrest with or without retrograde cerebral perfusion remains an alternative and safe method for brain protection in patients undergoing proximal aortic arch aneurysm or acute type A aortic dissection repair.

Aortic Balloon Occlusion Technique Does Not Improve Peri-Operative Outcomes for Acute Type A Acute Aortic Dissection Patients With Lower Body Malperfusion.

BackgroundThe management of malperfusion is vital to improve the outcomes of surgery for acute type A acute aortic dissection (ATAAD). Open arch repair under hypothermic circulatory arrest with selective antegrade cerebral perfusion (HCA/sACP) is safe and efficient but associated with inevitable hypothermia and ischemia-reperfusion injury. The aortic balloon occlusion (ABO) technique is shown to be organ protective by allowing higher temperature and shorter circulatory arrest time. In this study, we aimed to evaluate the safety and efficacy of this new technique for ATAAD patients with lower body malperfusion.MethodsBetween January 2013 and November 2020, 355 ATAAD patients with lower body malperfusion who underwent arch repair in our institute were enrolled. The patients were divided into 2 groups: ABO group (n = 85) and HCA/sACP group (n = 271). Propensity score matching was performed to correct baseline differences.ResultsUsing the propensity score matching, 85 pairs were generated. Circulatory arrest time was significantly lower in the ABO group compared with the HCA/sACP group (median, 8 vs. 22 min; p < 0.001). The incidence of in-hospital mortality (10.6 vs. 12.9%; p = 0.812), stroke (7.1 vs. 7.1%; p = 1.000), dialysis (25.9 vs. 32.9%; p = 0.183), hepatic dysfunction (52.9 vs. 57.6%; p = 0.537), tracheostomy (4.7 vs. 2.4%; p = 0.682), paraplegia (1.2 vs. 4.7%; p = 0.368) were comparable between ABO and HCA/sACP groups. Other outcomes and major adverse events were comparable. The multivariable logistic analysis did not recognize ABO technique protective against any major adverse outcomes.ConclusionsFor ATAAD patients with lower body malperfusion, the ABO technique allows the performance of arch repair with frozen elephant trunk (FET) under higher temperature and shorter circulatory arrest time. However, ABO technique did not improve perioperative outcomes. Future studies are warranted to evaluate the efficacy of this technique.

Direct Innominate Artery Cannulation versus Side Graft for Selective Antegrade Cerebral Perfusion during Aortic Hemiarch Replacement.

Background Selective antegrade cerebral perfusion (SACP) has become our preferred method for cerebral protection during open arch cases. While the initial approach involved sewing a graft to the innominate artery as the arterial cannulation site, our access strategy has since evolved to central aortic cannulation with use of a percutaneous cannula in the innominate for SACP. We hypothesized that SACP delivered via direct innominate cannulation using a 12- or 14-Fr cannula results in equivalent outcomes to cases utilizing a side graft. Methods This was a single-center, retrospective analysis of 211 adult patients who underwent elective hemiarch replacement using hypothermic circulatory arrest with SACP via the innominate artery between 2012 and 2020. Urgent and emergent cases were excluded. Results A side graft sutured to the innominate was utilized in 81% ( n = 171) of patients, while direct innominate artery cannulation was performed in 19% ( n = 40) of patients. Baseline patient characteristics were similar between groups aside from a higher baseline creatinine in the direct cannulation group (1.3 vs. 0.9, p = 0.032). Patients undergoing direct cannulation demonstrated shorter cardiopulmonary bypass time (132.7 vs. 154.9 minutes, p = 0.020) and shorter circulatory arrest time (8.1 vs. 10.9 minutes, p = 0.004). Nadir bladder temperature did not significantly differ between groups (27.2°C for side graft vs. 27.6°C for direct cannulation, p = 0.088). There were no significant differences in postoperative outcomes. Conclusion Direct cannulation of the innominate artery with a 12- or 14-Fr cannula for SACP during hemiarch replacement is a safe alternative to using a sutured side graft. While cardiopulmonary bypass and circulatory arrest times appear improved, this is likely attributable to accumulation of experience and proficiency in technique. However, direct innominate artery cannulation may facilitate quicker completion of these procedures by eliminating the time necessary to suture a graft to the innominate artery.

Comparison of the conventional frozen elephant trunk implantation technique with a modified implantation technique in zone 1.

The aim of the study was to compare the conventional frozen elephant trunk implantation technique with a modified implantation technique with an aortic anastomosis in zone 1 and extra-anatomic revascularization of the left subclavian artery during reperfusion. Between May 2014 and March 2018, 40 patients (26 male; mean age 60.2 ± 11.2 years) underwent complete aortic arch replacement with the Thoraflex Hybrid prosthesis™ (Vascutek, Inchinnan, Scotland) at our institution. Seventeen patients underwent conventional arch replacement (group 1) and 23 patients the modified procedure (group 2). Indication for arch replacement included all types of acute and chronic diseases. Cardiopulmonary bypass time (213.1 ± 53.5 vs 243.8 ± 67.0 min, P = 0.13) and aortic cross-clamp time (114.4 ± 40.7 vs 117.3 ± 56.6 min, P = 0.86) did not differ significantly between group 1 and 2. There was a trend towards a shorter circulatory arrest time (50.72 ± 9.6 vs 44.7 ± 15.5 min; P = 0.20) in group 2. Perioperative mortality was 10% (5.9% vs 13%; P = 0.62). Stroke occurred in 10% (5.9% vs 13%; P = 0.62) of patients. Spinal cord injury occurred in 7.5% of patients (11.8% vs 4.3% P = 0.57). Due to the a proximal aortic anastomosis, there was a significantly shorter coverage of the descending aorta with the prosthesis ending at vertebral level Th7.5 (6.75-8) in group 1 versus Th6.0 (5.0-6.0) in group 2 (P-value = 0.004). Implantation of the frozen elephant trunk prosthesis in zone 1 allows for a more proximal aortic anastomosis that could make the procedure more feasible especially in patients with difficult anatomies or in an acute setting.

Simple retrograde cerebral perfusion is as good as complex antegrade cerebral perfusion for hemiarch replacement.

Cerebral complication is a major concern after aortic arch surgery, which may lead to death. Thus, cerebral protection strategy plays the key role to obtain respectable results in aortic arch repair. Deep hypothermic circulatory arrest was introduced in 1970s to decrease the ischemic insults to the brain. However, safe duration of circulatory arrest time was limited to 30 minutes. The 1990s was the decade of evolution for cerebral protection, in which two adjuncts for deep hypothermic circulatory arrest were introduced: retrograde and antegrade cerebral perfusion (ACP) techniques. These two cerebral perfusion techniques significantly decreased incidence of postoperative neurological dysfunction and mortality after aortic arch surgery. Although there are no large prospective studies that demonstrate which perfusion technique provide better outcomes, multiple retrospective studies implicate that ACP may decrease cerebral complications compared to retrograde cerebral perfusion (RCP) when a long circulatory arrest time is required during aortic arch reconstructions. To date, many surgeons favor ACP over RCP during a complex aortic arch repair, such as total arch replacement and hybrid arch replacement. However, the question is whether the use of ACP is necessary during a short, limited circulatory arrest time, such as hemiarch replacement? There is a paucity of data that proves the advantages of a complex ACP over a simple RCP for a short circulatory arrest time. RCP with deep hypothermic circulatory arrest is the simple, efficient cerebral protection technique with minimal interference to the surgical field-and it potentially allows to flush atheromatous debris out from the arch vessels. Thus, it is the preferred adjunct to deep hypothermic circulatory arrest during hemiarch replacement in our institution.

Moderate Hypothermic Circulatory Arrest with Antegrade Cerebral Perfusion for Rapid Total Arch Replacement in Acute Type A Aortic Dissection

The optimal hypothermic level during circulatory arrest is controversial. The aim of our study was to comprehensively assess the impact of moderate hypothermic circulatory arrest with antegrade cerebral perfusion (ACP) on total aortic arch replacement. From 2010 to 2013, data were collected from 99 consecutive patients with acute type A aortic dissection. All patients underwent total arch replacement plus frozen elephant trunk procedure. There were 51 patients in the deep hypothermia circulatory arrest (DHCA) group and 47 in the moderate hypothermia circulatory arrest (MHCA) group. Either unilateral or bilateral ACP was applied for cerebral protection. Perioperative data and measured outcomes were compared. Overall mean circulatory arrest time was 29.9 ± 6.0 minutes. Temporary neurologic dysfunction incidence was lower in the MHCA group compared with the DHCA group (21.3 vs. 40.4%, p = 0.041). The total 30-day mortality was 17.2% (14.9 vs. 19.2%, p = 0.568) and permanent neurologic dysfunction morbidity was 3.0% overall. In MHCA, less blood products were used than in DHCA. Moderate hypothermia was a protective factor for the composite outcome of temporary and permanent neurologic dysfunctions (odds ratio = 0.385; 95% confidence interval = 0.162-0.919). Hypothermic level did not significantly affect the perioperative alanine aminotransferase and serum creatinine levels. Within a short circulatory arrest time, MHCA combined with ACP seemed to be a safe and effective method to protect cerebral and visceral organs during total aortic arch replacement.

Early experience on aortic arch surgery at King Fahd Armed Forced Hospital (KFAFH), Jeddah

To our knowledge KFAFH cardiac department is one of the few centers performing aortic arch surgery in Saudi Arabia. The optimal strategy for management of the circulation during aortic arch surgery remains controversial and neurologic dysfunction due to cerebral ischemia remains a significant concern. We report our early experience on aortic arch surgery performed with Deep or Moderate Hypothermic Circulatory Arrest (DHCA or MHCA) and Antegrade Selective brain Perfusion (SAP). 14 consecutive patients (pts) underwent aortic arch repair between 2008 and 2012. 4 pts were operated on emergency basis because of type A aortic dissection or impending rupture, 10 pts on elective basis. 5 pts (35.7%) had complete arch replacement and 9 pts (64.3%) had emiarch repair. Axillary cannulation was performed in 12 pts (85.7%), femoral cannulation in 2 pts (14.3%). Our brain protection strategy consisted in DHCA (18–20 C) in 11 pts (78.6%), MHCA (23–25 C) in 3 pts (21.4%). Selective monolateral antegrade perfusion (uSAP) trough axillary artery was performed in 12 pts (85.7%), selective bilateral antegrade perfusion (bSAP) in 2 pts (14.3%). Mean circulatory arrest was 29 ± 15 min, Cerebral oximetry has been employed to monitoring brain perfusion. In-hospital mortality rate was 0, no pt had permanent neurological deficit. 1 pts (7.1%) had a temporary neurological deficit, 2 pts renal impairment (21.4%), 1 pt vocal cord paralysis (7.1%), 3 pts bleeding (21.4%). Temperature was not identified as independent predictor of transient neurological deficit ( p 0.5). MHCA was significantly associated to reduced blood loss after surgery ( p < 0.01). Mean follow-up (22 months): no pt died, 1 pt presented aortic pseudoaneurysm 6 months after surgery (Marfan syndrome with aortic dissection). Early KFAFH experience on aortic arch surgery has been performed with very good outcome. HCA arrest with SAP represents a very effective technique of brain protection. For short circulatory arrest time MHCA is safe and can reduce coagulopathy problems related to DHCA.

The experience of stent "elephant trunk" procedure in treatment of DeBakey I aortic dissection

Objective To investigate the procedures and outcomes of stent elephant trunk tech-nique in the treatment of DeBakey Ⅰ aortic dissection. Methods Twelve patients (mean 48. 1 years old) with DeBakey Ⅰ aortic dissection were included in our study. During deep hypothermic circulatory arrest (DHCA), selected antegrade cerebral perfusion (SCP) was used to protect the brain. All patients received stent elephant trunk procedure (ascending aorta and arch replacement combined with transluminal stent graft of the descending aorta). Results One patient died after operation (8.3%). The average cardiopul-monary bypass time was (163.2±17.7) min. The average circulatory arrest time was (41.6 ± 12.3) min. Survival patients were followed up for 3 to 6 months and no subsequent death occurred during the fel-low-up period. Conclusion The stent elephant trunk procedure is a simple method with short circulato-ry arrest time. It seems to be effective and safe for DeBakey Ⅰ aortic dissection. Key words: Aortic dissection aneurysm; Stent elephant trunk procedure

Síndrome do coração esquerdo hipoplásico: estratégia cirúrgica e comparação de resultados com técnicas de Norwood x Sano

To report a surgical strategy for the Norwood procedure in the hypoplastic left heart syndrome (HLHS) that enables short hypothermic circulatory arrest time and aortic arch reconstruction with autologous pericardium patch. To compare the results of the modified Blalock-Taussig (mBT) shunt and the right ventricle-to-pulmonary artery (RV-PA) conduit procedures as the source of pulmonary blood flow. Retrospective study of 78 newborns consecutively operated between March, 1999 and June 2006. One technique for reconstruction of the neoaorta and two different techniques for reestablishment of the pulmonary blood flow: the mBT shunt in the first 37 newborns and RV-PA conduit in the last 41. Cannulation of the ductus arteriosus for systemic perfusion was the main part of the surgical strategy to reduce the hypothermic circulatory arrest time. In-hospital survival for the entire cohort was 74,35%, or 67.57% for the mBT shunt and 80,49% for RV-PA conduit groups (p=0,21). Hypothermic circulatory arrest times were 45.79+/-1.99 min and 36,8+/-1,52 min (p=0,0012), respectively. Mortality rates between first and second stages were 40% for the mBT shunt and 6,9% for RV-PA conduit groups (p=0,007). Late coarctation of the aorta occurred in five patients Actuarial survival curves(Kaplan-Meier) comparison showed better results with VD-AP conduit (p=0,003). This surgical strategy resulted in short circulatory arrest time, low mortality and low incidence of aortic coarctation. Although the higher rate of survival to first palliation stage with the RV-PA conduit was not significant, the lower interstage mortality and superior medium-term survival in RV-AP group were statistically advantageous.

Síndrome da hipoplasia do coração esquerdo: a influência da estratégia cirúrgica nos resultados

To report a surgical strategy for the Norwood procedure in the hypoplastic left heart syndrome (HLHS) that enables short hypothermic circulatory arrest time and aortic arch reconstruction with autologous pericardium patch, and to compare the results of the modified Blalock-Taussig (mBT) shunt with the right ventricle-to-pulmonary artery (RV-PA) conduit procedures as the source of pulmonary blood flow. Retrospective study of 71 newborns with HLHS consecutively operated between March, 1999 and February, 2006. One technique for reconstruction of the neoaorta and two different techniques for reestablishment of the pulmonary blood flow were used: the mBT shunt in the first 37 newborns and RV-PA conduit in the last 34. Cannulation of the ductus arteriosus for arterial perfusion was the main part of the surgical strategy to reduce the hypothermic circulatory arrest time. In-hospital survival for the entire cohort was 74.64%, or 67.57% and 82.35% for the mBT shunt and RV-PA conduit groups, respectively (p=0.1808). Mortality rates between the first and second palliation stages were 40% and 4.4% for the mBT shunt and RV-PA conduit groups, respectively (p=0.0054). Hypothermic circulatory arrest times were 45.79+/-1.99 min and 36.62+/-1.62 min (p=0.0012), respectively. Late coarctation of the aorta occurred in five patients (7.2%). This surgical strategy resulted in short circulatory arrest time, low mortality and favorable morphology of the neoaorta, with low incidence of late coarctation of the aorta. The higher rate of survival to first palliation stage with the RV-PA conduit was not significant, but interstage mortality was statistically lower when compared with the modified Blalock-Taussig shunt procedure.

Tube-Graft Inversion for the Construction of an “Open” Distal Anastomosis During Ascending Aortic Replacement: A New Technique

For the construction of a distal "open" anastomosis during ascending aortic replacement, a tube-graft is placed opposite to the transected aorta. We describe an alternative technique. The tube-graft is inverted and positioned within the aortic arch in a way that brings the entire circumference of the distal end of the tube-graft next to the circumference of the transected aorta. An end-to-end anastomosis is then fashioned with a running suture, the needle of which goes through the aorta and the tube-graft in a single pass. This technique permits easy, accurate, and fast suture placement, producing a hemostatic distal anastomosis within a short circulatory arrest time.

Should circulatory arrest with deep hypothermia be revised in aortic arch surgery?

Our experience (January 1982-May 1987) concerns 41 patients, operated upon for aortic dissection (30 patients) or aneurysm (11 patients) using circulatory arrest with deep hypothermia. There were 24 male and 17 female patients (mean age: 55 years 9 months, range 32-73 years). The mean circulatory arrest time in minutes was 41 +/- 3 (mean rectal temperature before circulatory arrest was 18.4 degrees C +/- 0.3 degrees C). Total (24 patients) or partial (16 patients) replacement of the aortic arch was performed. One patient with a sacciform aneurysm had the aortic wall defect closed. Hospital mortality was 22% +/- 7% (9 patients): 8 of 30 patients with aortic dissection (26.6%) and 1 of 11 patients with aortic aneurysm (9%). Neurological complications occurred in 3 patients. These data lead us to prefer circulatory arrest with deep hypothermia as the method of choice for aortic arch surgery. However, when a short circulatory arrest time (less than 30 min) for the repair is foreseeable, mild hypothermia (20 degrees C-24 degrees C) may be preferred. In patients who will not tolerate excessive cardiopulmonary bypass times, expected difficulties with the repair should suggest mild hypothermia and short circulatory arrest in easier cases or moderate hypothermia with brachiocephalic perfusion in the others.