Unilateral Cerebral Perfusion Research Articles

Clinical outcome of a branch-first approach with a novel continuous whole-brain perfusion strategy for total arch surgery

BackgroundCerebral protection strategies have been investigated since the introduction of aortic arch surgery and have been modified over the centuries. However, the cerebral protective effects of unilateral and bilateral antegrade cerebral perfusion are similar, with opportunities for further improvement.MethodsA total of 30 patients who underwent total arch surgery were enrolled in this study. Patients were assigned to the novel continuous whole-brain or unilateral antegrade cerebral perfusion group according to the cerebral perfusion technique used. Preoperative clinical data and 1-year postoperative follow-up data were collected and analyzed.ResultsThere were no significant differences between the two groups in terms of the incidence of permanent neurological deficit, mortality, or therapeutic efficacy. However, the incidence of temporary neurological dysfunction in the novel whole-brain perfusion group was significantly lower than that in the unilateral antegrade cerebral perfusion group.ConclusionsIn this study, the branch-first approach with a novel whole-brain perfusion strategy had no obvious disadvantages compared with unilateral antegrade cerebral perfusion in terms of cerebral protection and surgical safety. These findings suggest that this new technique is feasible and has application value for total arch surgery.

Cannula Placement for Cerebral Protection Without Circulatory Arrest in Patients Undergoing Hemiarch Aortic Aneurysm Repair.

Aortic aneurysms involving the proximal aortic arch, which require hemiarch-type repair, typically require circulatory arrest with antegrade cerebral perfusion. Left carotid antegrade cerebral perfusion (LCP) via distal arch cannulation without circulatory arrest was used in this study's patient population. The goal was to assess the operative efficiency and clinical outcomes of using a distal arch cannulation technique that would not require any hypothermic circulatory arrest (HCA) time compared with more traditional brachiocephalic artery cannulation with right-sided unilateral antegrade cerebral perfusion (RCP) and HCA. A single-center retrospective review of patients with replacement of the distal ascending aorta involving the proximal arch was performed. Patients with an intramural hematoma or dissection were excluded. Between January 2015 and December 2019, 68 adult patients had undergone a hemiarch repair because of aneurysmal disease. Analysis of baseline demographics, operative data, and clinical outcomes was performed. Comparing the 68 patients: 21 patients were treated with RCP (via brachiocephalic artery graft with HCA), and 47 patients were treated with LCP (via distal aortic arch cannulation with cross-clamp between the brachiocephalic and left common carotid arteries without HCA). Baseline characteristics and outcomes were evaluated for both groups. The LCP group was younger (LCP median [IQR] age, 60 [53-65] years vs RCP median [IQR] age, 67 [59-71] years]. Sex, race, body mass index, comorbidities, and ejection fraction were similar between the groups. Cardiopulmonary bypass time (LCP, 123 minutes vs RCP, 149 minutes) and unilateral cerebral perfusion time (LCP, 17 minutes vs RCP, 22 minutes) were longer in the RCP group. Bleeding, prolonged ventilatory support, kidney failure, and length of stay were similar. In-hospital mortality was 2% in the LCP group vs 0% in the RCP group. Stroke occurred in 2 patients (4.2%) in the LCP group and in 0% of the RCP group. Mortality at 6 months in the LCP and RCP groups was 3% and 10%, respectively. Distal arch cannulation with LCP without HCA is a reasonable and safe alternative strategy for patients requiring hemiarch replacement for aneurysmal disease. This technique may provide additional benefits by avoiding circulatory arrest in these complex cases.

Meta-analysis: Bilateral and Unilateral Cerebral Perfusion in Type A Dissection.

This meta-analysis compared the outcomes of bilateral cerebral perfusion (BCP) and unilateral cerebral perfusion (UCP) in aortic surgery for acute type A aortic dissection. A systematic literature search identified 12 studies involving 4,547 patients. Pooled odds ratios (OR) with 95% confidence intervals (CI) were calculated to analyze perioperative characteristics, short-term mortality rates, and postoperative neurological complications. No significant differences were found between the BCP and UCP groups in terms of cardiopulmonary bypass time, aortic cross clamp time, lowest body temperature, and lower body circulatory arrest time. Short-term mortality rates (OR [95% CI] = 0.87 [0.64-1.19], p = 0.40) and permanent neurological deficits (OR [95% CI] = 1.01 [0.69-1.47], p = 0.96) were comparable between the groups. However, subgroup analysis of studies exclusively involving total arch replacement showed a lower short-term mortality rate (OR [95% CI] = 0.42 [0.28-0.63], p < 0.01) and permanent neurological deficits (OR [95% CI] = 0.53 [0.30-0.92], p = 0.03) in the BCP group. The BCP group also had a lower rate of temporary neurological deficits (OR [95% CI] = 0.70 [0.53-0.93], p = 0.01), particularly in studies exclusively involving total arch replacement (OR [95% CI] = 0.58 [0.40-0.85], p < 0.01). This meta-analysis suggests that BCP and UCP yield comparable outcomes. However, BCP may be associated with lower short-term mortality rates and reduced incidence of neurological complications, particularly in cases requiring total arch replacement. BCP should be considered as a preferred cerebral perfusion in specific patient populations.

Factors Associated with Newly Developed Postoperative Neurological Complications in Patients with Emergency Surgery for Acute Type A Aortic Dissection.

Background and Objectives: Postoperative neurological complications (NCs) are an important cause of mortality in patients with acute type A aortic dissection (ATAAD). The aim of the study was to determine the association between intraoperative risk factors and newly developed postoperative NCs in patients after emergency surgery for ATAAD. Materials and Methods: A total of 203 patients requiring emergency surgery were included in the study. Patients with preoperative neurological dysfunction, deceased on the operating table or within the first 48 h after intensive care admission, with uncertain postoperative neurologic status or with incomplete records were excluded. Results: Mean age was 57.61 ± 12.27 years. Hyperlipidemia was the most frequent comorbidity (69%). A bicuspid aortic valve was present in 12.8% of cases, severe acute aortic regurgitation was present in 29.1% of patients, and cardiac tamponade was present in 27.1% of cases. The innominate artery was the most frequently dissected supra-aortic artery in 27.1% of cases. In 65% of cases, the primary entry tear was at the level of the ascending aorta. The incidence of newly developed postoperative NCs was 39.4%. The most common surgical technique performed was supra-coronary ascending aorta and hemiarch replacement, in 53.2% of patients. Using logistic regression, cardiopulmonary bypass time (OR = 1.01; 95% CI = 1.01-1.02; p < 0.001), aortic cross-clamp time over 3 h (OR = 2.71, 95% CI = 1.43-5.14, p = 0.002) and cerebral perfusion time (OR = 1.02; 95% CI = 1.002-1.03; p = 0.027) were independently associated with newly developed postoperative NCs. Conclusions: Based on the results of the study, all efforts should be made to reduce operative times. Using a simple surgical technique, like the supra-coronary ascending aorta and hemiarch technique, whenever possible, and using a simpler technique for cerebral perfusion like unilateral cerebral perfusion via the right axillary artery, could reduce operating times.

A comparison of bilateral and unilateral cerebral perfusion for total arch replacement surgery for non-marfan, type A aortic dissection.

Acknowledging lacking of consensus exist in total aortic arch (TAA) surgery for acute type A aortic dissection (AAD), this study aimed to investigate the neurologic injury rate between bilateral and unilateral cerebrum perfusion on the specific population. A total of 595 AAD patients other than Marfan syndrome receiving TAA surgery since March 2013 to March 2022 were included. Among them, 276 received unilateral cerebral perfusion (via right axillary artery, RCP) and 319 for bilateral cerebral perfusion (BCP). The primary outcome was neurologic injury rate. Secondary outcomes were 30-day mortality, serum inflammation response (high sensitivity C reaction protein, hs-CRP; Interleukin-6, IL-6; cold-inducible RNA binding protein, CIRBP) and neuroprotection (RNA-binding motif 3, RBM3) indexes. The BCP group reported a significantly lower permanent neurologic deficits [odds ratio: 0.481, Confidence interval (CI): 0.296-0.782, p = 0.003] and 30-day mortality (odds ratio: 0.353, CI: 0.194-0.640, p < 0.001) than those received RCP treatment. There were also lower inflammation cytokines (hr-CRP: 114 ± 17 vs. 101 ± 16mg/L; IL-6: 130 [103,170] vs. 81 [69,99] pg/ml; CIRBP: 1076 [889, 1296] vs. 854 [774, 991] pg/ml, all p < 0.001), but a higher neuroprotective cytokine (RBM3: 4381 ± 1362 vs 2445 ± 1008pg/mL, p < 0.001) at 24h after procedure in BCP group. Meanwhile, BCP resulted in a significantly lower Acute Physiology, Age and Chronic Health Evaluation (APACHE) Ⅱscore (18 ± 6 vs 17 ± 6, p < 0.001) and short stay in intensive care unit (4 [3,5] vs. 3 [2,3] days, p < 0.001) and hospital (16 ± 4 vs 14 ± 3days, p < 0.001). This present study indicated that BCP compared with RCP was associated with lower permanent neurologic deficits and 30-day mortality in AAD patients other than Marfan syndrome receiving TAA surgery.

Correlation between cerebral oxygen saturation monitored by near-infrared spectroscopy during operation and risk of stroke after acute type A aortic dissection surgery

Objective: Near-infrared spectroscopy (NIRS) is widely used for intraoperative cerebral oxygen saturation monitoring in patients with acute type A aortic dissection. This study aimed to investigate the correlation between NIRS-derived oxygen saturation and risk of postoperative stroke. Methods: This study included 193 patients with acute type A aortic dissection undergoing emergency surgery and elective unilateral cerebral perfusion via the right axillary artery at the Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital, Nanjing, China, from 2018 to 2020. NIRS was used for intraoperative cerebral oxygen saturation monitoring, and the basal values and the lowest values of cerebral oxygen saturation during deep hypothermic circulatory arrest (DHCA) were recorded. The patients were divided into no-stroke group (n=178, 92.2%) and stroke group (n=15, 7.8%) according to the absence or presence of postoperative stroke. The differences in preoperative, operative and postoperative clinical differences between the two groups were compared, and the relationship between the lowest cerebral oxygen saturation value and the change in cerebral oxygen saturation value ((base-lowest)/basal) and postoperative stroke were analyzed. Results: The proportion of preoperative atrial fibrillation (6.7% vs. 0.6%, P=0.026), and the proportion of preoperative hypotension (26.7% vs. 9.0%, P=0.031) were significantly higher in the stroke group than no-stroke group. There were no differences in the surgical approach between the two groups. Cardiopulmonary bypass (CPB) time ((256.1±84.8) h vs.(217.8±58.4) h, P=0.020), postoperative mechanical ventilation time ((139.3±172.8) h vs. (35.6±45.6) h, P<0.001) were significantly longer in stroke group as compared to no-stroke group. Incidence of postoperative tracheotomy (20.0% vs. 1.1%, P<0.001), acute kidney injury (73.3% vs. 30.3%, P=0.001) and continuous renal replacement therapy (46.7% vs. 11.8%, P<0.001) as well as mortality (20.0% vs. 5.1%, P=0.022) were significantly higher in the stroke group than in non-stroke group. There was no significant difference in the basal NIRS value and the lowest NIRS value during DHCA between the two groups. Patients in the stroke group had a significantly greater intraoperative change rate of right NIRS as compared to no-stroke group (15.2%±15.7% vs. 9.2%±7.0%, P=0.006). Conclusions: NIRS is valuable for monitoring cerebral oxygen saturation during acute type A aortic dissection surgery, and the rate change of NIRS during operation correlates significantly with postoperative stroke.

Initial Surgical Strategy for the Treatment of Type A Acute Aortic Dissection: Does Proximal or Distal Extension of the Aortic Resection Influence the Outcomes?

(1) Background: We sought to analyze and compare the outcomes in terms of early and late mortality and freedom from a redo operation in patients undergoing surgical treatment for a type A acute aortic dissection in relation to the initial surgical treatment strategy, i.e., proximal or distal extension of the aortic segment resection, compared with isolated resection of the supracoronary ascending aorta. (2) Methods: This is a retrospective study in which we included 269 patients who underwent operations for a type A acute aortic dissection in the Department of Cardiac Surgery of Tor Vergata University from May 2006 to May 2016. The patients were grouped according to the extent of the performed surgical treatment: isolated replacement of the supracoronary ascending aorta (NE, no extension), replacement of the aortic root (PE, proximal extension), replacement of the aortic arch (DE, distal extension), and both (BE, bilateral extension). The analyzed variables were in-hospital mortality, postoperative complications (incidence of neurological damage, renal failure and need for prolonged intubation), late mortality and need for a redo operation. (3) Results: Unilateral cerebral perfusion was performed in 49.3% of the patients, and bilateral perfusion—in 50.6%. The overall in-hospital mortality was 31.97%. In the multivariate analysis, advanced age, cardiopulmonary bypass time and preoperative orotracheal intubation were independent predictors of in-hospital mortality. In the population of patients who survived the surgery, the probability of survival at 92 months was 70 ± 5%, the probability of freedom from a redo operation was 71.5 ± 5%, the probability of freedom from the combined end-point death and a redo operation was 50 ± 5%. The re-intervention rate in the general population was 16.9%. The overall probability of freedom from re-intervention was higher in patients undergoing aortic root replacement, although not reaching a level of statistical significance. Patients who underwent aortic arch treatment showed reduced survival. (4) Conclusions: In the treatment of type A acute aortic dissection, all the surgical strategies adopted were associated with satisfactory long-term survival. In the group of patients in which the aortic root had not been replaced, we observed reduced event-free survival.

P48 RETROSPECTIVE POSTOPERATIVE NEAR INFRARED SPECTROSCOPY MONITORING ANALYSIS TO DETECT POTENTIAL CRITERIA TO IMPROVE POSTOPERATIVE PREDICTION OF UNFAVOURABLE OUTCOME FOLLOWING AORTIC SURGERY

Abstract Objective Near Infrared Spectroscopy (NIRS) monitoring has become a frequent practice during aortic surgery. The real impact of NIRS in predicting postoperative outcomes, however is still debated, as many cases of “false negative” with severe cerebral damage despite apparently normal NIRS monitoring during surgical procedure. We applied extended retrospective postoperative NIRS monitoring analysis in order to investigate potential criteria to enhance postoperative unfavorable outcome prediction. Materials and Methods Data of NIRS monitoring of 41 patients undergoing aortic surgery (19 acute dissection) were retrospectively analyzed. Partial circulatory arrest with selective bilateral (21 pts) or unilateral (20 pts) cerebral perfusion (CP) was used in all patients. Double channel (R and L) NIRS value was continuously recorded (every 30 sec) from anaesthetic induction to patient’s transfer to ICU. Postoperatively all data were downloaded in excel format and retrospectively analyzed. Baseline, maximum, and minimum value with percentage drop and R/L channel gap were all analyzed considering 5 different phases of surgery: before extracorporeal circulation (EC); in EC before circulatory arrest and selective cerebral perfusion (CA–SCP); in EC following CA–SCP, following EC. Overall time &amp;lt;25% (in each channel) or with a &amp;gt; 20% gap were also evaluated. Results Overall 661±125 values were recorded for each patient. Baseline value on the Left (61±7) was significantly lower then Right (66±12). Maximum drop did not differed in two channels (Fig 1a) but varied according surgical phases (Fig 1). R/L asymmetry also varied according surgical phases with a peak value during rewarming and not during CA–SCP despite unilateral SCP and complexity of procedure (Figure 2 and 3). Conclusion Extended postoperative analysis of NIRS recorded value shows different trend and behavior according surgical phase and cerebral perfusion strategy. Accurate extended NIRS analysis is therefore mandatory in order to improve knowledge of physiological cerebral perfusion during SCP and early identification of patients at high risk of postoperative cerebral complications.

Unilateral versus bilateral anterograde cerebral perfusion in acute type A aortic dissection repair: A systematic review and meta-analysis.

The aim of the study is to compare the safety and efficacy of unilateral anterograde cerebral perfusion (UACP) and bilateral anterograde cerebral perfusion (BACP) for acute type A aortic dissection (ATAAD). A systematic review of the MEDLINE (PubMed), Scopus, and Cochrane Library databases (last search: August 7th, 2021) was performed according to the PRISMA statement. Studies directly comparing UACP versus BACP for ATAAD were included. Random-effects meta-analyses were performed. Eight retrospective cohort studies were identified, incorporating 2416 patients (UACP: 843, BACP: 1573). No statistically significant difference was observed regarding in-hospital mortality (odds ratio [OR]:1.05 [95% Confidence Interval (95% CI):0.70-1.57]), permanent neurological deficit (PND) (OR: 0.94 [95% CI: 0.52-1.70]), transient neurological deficit (TND) (OR: 1.37 [95% CI: 0.98-1.92]), renal failure (OR: 0.96 [95% CI: 0.70-1.32]), and re-exploration for bleeding (OR: 0.77 [95% CI: 0.48-1.22]). Meta-regression analysis revealed that PND and TND were not influenced by differences in rates of total arch repair, Bentall procedure, and concomitant CABG in UACP and BACP groups. Cardiopulmonary bypass time (Standard Mean Difference [SMD]: -0.11 [95% CI: -0.22, 0.44]), Cross clamp time (SMD: -0.04 [95% CI: -0.38, 0.29]), and hypothermic circulatory arrest time (SMD: -0.12 [95% CI: -0.55, 0.30]) were comparable between UACP and BACP. Intensive care unit stay was shorter in BACP arm (SMD:0.16 [95% CI: 0.01, 0.31]); however, length of hospital stay was shorter in UACP arm (SMD: -0.25 [95% CI: -0.45, -0.06]). UACP and BACP had similar results in terms of in-hospital mortality, PND, TND, renal failure, and re-exploration for bleeding rate in patients with ATAAD. ICU stay was shorter in the BACP arm while LOS was shorter in the UACP arm.

Unilateral versus bilateral antegrade cerebral perfusion during surgical repair for patients with acute type A aortic dissection

ObjectivesTo compare unilateral versus bilateral antegrade cerebral perfusion (ACP) techniques on cerebral protection during acute type A aortic dissection repair. MethodsUsing an institutional database, we retrospectively reviewed patients who underwent acute type A aortic dissection repair with selective ACP techniques from October 2008 to December 2019. Primary end point was the detection of neurologic dysfunctions. The secondary end point was mortality. For baseline adjustment, the propensity score matching method was used. Multivariable logistic regression analysis was performed to determine the predictor of neurologic events. ResultsAmong 522 patients (aged 62.0 ± 14.9 years; 45.7% women), unilateral and bilateral ACP techniques were used in 357 (64.7%) and 165 (35.3%) patients, respectively. Transient (19.6% vs 21.2%; P = .65) and permanent (7.0% vs 10.3%; P = .70) neurologic dysfunction rates were not significantly different in patients with unilateral versus bilateral ACP, respectively. Observed mortality rate was higher in the patients with bilateral ACP (hazard ratio, 2.05; 95% CI, 1.33-3.14; P = .001). Propensity-score matching yielded 94 pairs of patients. In matched analysis, bilateral ACP did not significantly lower the risks for transient (odds ratio, 0.87; 95% CI, 0.42-1.81; P = .71) and permanent (odds ratio, 1.42; 95% CI, 0.55-3.85; P = .47) neurologic dysfunction or death (hazard ratio, 1.65; 95% CI, 0.87-3.15; P = .13). In the multivariable analysis, the ACP technique was not significantly associated with perioperative neurologic deficit. ConclusionsDespite additional supply, the patients undergoing bilateral ACP during acute type A aortic dissection repair did not have superior outcomes in neurologic and death events compared with the patients undergoing unilateral ACP.

Unilateral cerebral perfusion is gaining increased interest, but more evidence is still necessary.

The history of unilateral cerebral perfusion can be traced to the early 1980s [1]; however, this protection strategy had not gained popularity until the introduction of supra-aortic cannulation techniques [2]. In connection with the cannulation of a supra-aortic artery, regardless if it is the brachio-cephalic, subclavian or carotid artery, the execution of unilateral perfusion is very simple, fast and can be performed without any interruption of cerebral perfusion [2, 3]. Since then, the efficacy of unilateral versus bilateral antegrade cerebral perfusion is being continuously discussed, and no consensus seems to be in sight because of the existing heterogeneity of the perfusion and cerebral protection strategies, which could be demonstrated in a large multicentre series published in the Journal a few years ago [4]. This makes any attempt to strive for evidence-based recommendations very difficult, if not impossible, because as stated in this multicentre report mentioned above: ‘…the problem in conducting prospective multicentre trials on aortic arch surgery lies on the credo of particular aortic surgeons who develop a strong attachment to their distinct perfusion and temperature management protocol with which they achieve good clinical outcomes and are not willing to switch their routine for clinical trials’ [4].

Unilateral versus bilateral cerebral perfusion during aortic surgery for acute type A aortic dissection: a multicentre study.

The aim of this retrospective multicentre study was to investigate and compare clinical outcomes of unilateral and bilateral antegrade cerebral perfusion (ACP) strategies on cerebral protection during surgery for type A aortic dissection. Data from 646 patients who underwent surgical repair of thoracic type A aortic dissection using unilateral and bilateral ACP with moderate hypothermic circulatory arrest in 3 cardiac surgical institutions between 2008 and 2018 were analysed. Propensity matching was performed to assess which technique ensured better outcomes. Unilateral and bilateral ACP techniques were performed in 250 (39%) and in 396 (61%) patients, respectively. Propensity score analysis identified 189 matched pairs. In the matched cohort, the lowest core temperature was 27.5°C and 28°C in the bilateral and unilateral groups, respectively (P < 0.001). The unilateral technique required significantly shorter aortic cross-clamp and cardiopulmonary bypass times than bilateral technique [82 min vs 100 min (P < 0.001); 170 min vs 195 min (P < 0.001)]. The 30-day mortality was comparable (P = 0.325). The bilateral group reported a significantly higher incidence of permanent neurologic deficits (P < 0.001), left brain hemisphere stroke (P = 0.007) and all-combined complications (P < 0.001). Ten-year survival was comparable (P = 0.45). Unilateral and bilateral ACP are both valid brain protection strategies in the landscape of aortic arch surgery. While admitting all the study limitations, unilateral technique could offer some clinical advantages. 76049.

The first results of surgical reconstruction of the aorta using the domestic aortic hybrid stent-graft MedEng

Objective . To analyze the early clinical results of frozen elephant trunk repair using the domestic hybrid stent-graft MedEng (Penza, Russia). Material and Methods. From September, 2019 to September, 2020, a total of 12 patients underwent surgical reconstruction of the thoracic aorta with an implantation of the MedEng hybrid stent-graft. All interventions were performed under conditions of moderate hypothermia (25–28 °C) and antegrade unilateral cerebral perfusion through the brachiocephalic trunk. Results. The technical success of the operation was achieved in 100% of cases. In the early postoperative period, there were no cases of acute cerebrovascular accidents, episodes of delirium, and paraplegia. There was no need for a resternotomy for bleeding. The extended respiratory support was required in two cases (16.7%). One patient (8.3%) required renal replacement therapy for acute renal injury. Hospital mortality rate reached 16.7%. Conclusion. Surgical reconstruction of the thoracic aorta using the MedEng hybrid stent-graft was characterized by satisfactory clinical results in the early postoperative period.

Impact of obesity on early postoperative outcomes after frozen elephant trunk procedure

Despite the great interest in the issue of obesity in cardiac surgery patients, its effect on the outcomes surgical treatment of thoracic aortic diseases has hardly been studied. Aim. To assess the effect of obesity on the results of the aortic arch reconstruction using the frozen elephant trunk (FET) technique. Material and methods . In the period from March 2012 to May 2020, 84 patients with thoracic aortic diseases were operated on. All patients underwent surgical aortic arch reconstruction using the FET technique. Interventions were performed under moderate hypothermic circulatory arrest (25-28° C) and unilateral cerebral perfusion via innominate artery. In accordance with the body mass index, all patients were divided into 2 groups: 30 kg/m 2 (group 2, n=28). Results . Neurological complication rates did not differ between the groups. Respiratory failure requiring tracheostomy and dialysis rate due to acute kidney injury occurred in 28,5% vs 35,7% (p=0,626) and 28,5% vs 17,9% (p=0,273), in patients with obesity and normal body weight, respectively. The reoperation rates due to bleeding was nonsignificantly higher in obese patients (14,3% vs 3,6%, p=0,092). The short-term mortality rate was 9,5% without significant differences in studied groups. Conclusion . Aortic arch surgery using FET technique has comparable early results in obese and normal body weight patients.

Unilateral or bilateral cerebral perfusion in hemiarch replacement: A prospective randomized study.

We designed a prospective randomized clinical study to compare unilateral and bilateral antegrade cerebral perfusion (ACP) under moderate hypethermia in open distal aortic hemiarch replacement in ascending aortic aneurysm. Forty-two patients were prospectively randomized into two groups; unilateral ACP to Group 1 and bilateral ACP to Group 2. Inclusion criteria were pathological aortic aneurysm in the ascending aorta and/or aortic arch, elective operation, normal preoperative carotid Doppler ultrasonography, and nonexistence of preoperative neurological event. Patients were evaluated with preoperative and postoperative biochemical blood analysis, magnetic resonance imaging (MRI), and neurological disorders. The primary endpoints were permanent neurological disorder and death. There were 21 patients in each group. Mean age was 56.57 ± 10.06 years in Group 1 and 50.95 ± 15.64 years in Group 2 (p = .170). No significant difference was found according to demographic data. ACP times were significantly higher in bilateral ACP (Group 1: 12.62 ± 5.04 min, Group 2: 18.23 ± 9.04 min, p = .018) whereas cross-clamp time and cardiopulmonary bypass times were not (p = .693 and p = .584 sequentially). Transient neurological disorder was found in seven patients in Group 1 and in 4 patients in Group 2 (p = .484). Postoperative MRI revealed new milimetric ischemic zones in three patients in Group 1 but none in Group 2. No permanent neurological disorder or mortality was seen. The present randomized clinical prospective study could not prove the superiority of one of the technique in cerebral protection probably because, our overall ACP time was too short.

Critical left coronary main trunk stenosis, chronic occluded right coronary artery, left subclavian artery occlusion, severe aortic regurgitation and porcelain aorta in a patient with aortitis

BackgroundCoronary involvement is rare but can be critical in patients with aortitis. Although cardiac ischemia can be resolved by coronary artery bypass grafting (CABG), patients complicated with cardiac ischemia, calcified aorta, and valve insufficiency pose difficult problems for surgeons.Case presentationA 71-year-old woman was referred to our institution because of unstable angina. She had been previously diagnosed with aortitis and left subclavian artery occlusion. Contrast-enhanced computed tomography revealed severe left coronary main trunk stenosis, right coronary artery occlusion, and porcelain aorta. Ultrasonic echocardiogram showed severe aortic regurgitation. We performed emergent coronary artery bypass grafting, aortic valve replacement and ascending aorta replacement under hypothermic circulatory arrest.ConclusionsThe technique of circumferential calcified intimal removal and reinforcement with felt strips was effective for secure anastomosis. Unilateral cerebral perfusion from the right subclavian artery enabled good visualization and sufficient time to perform distal anastomosis.

Different hypothermic and cerebral perfusion strategies in extended arch replacement for acute type a aortic dissection: a retrospective comparative study

BackgroundThe optimal hypothermic level in total arch replacement with stented elephant trunk implantation for acute type A aortic dissection (aTAAD) has not been established, and the superiority of unilateral or bilateral cerebral perfusion remains a controversial issue. Therefore, we evaluated the application of moderate hypothermic circulatory arrest (MHCA) with a core temperature of 29 °C and bilateral selective antegrade cerebral perfusion in aTAAD treated by total arch replacement with stented elephant trunk implantation.MethodsFrom July 2019 to January 2020, 25 aTAAD patients underwent total arch replacement with stented elephant trunk implantation via MHCA (29 °C) and bilateral selective antegrade cerebral perfusion (modified group). Thirty-six patients treated by the same procedure with MHCA (25 °C) and unilateral selective antegrade cerebral perfusion during this period were selected as controls.ResultsThere were no differences between the two groups of patients in terms of age, sex, incidence of hypertension, malperfusion, and pericardial effusion, although the incidence of cardiac tamponade was higher in the modified group (control 2.8%, modified 20%; P = 0.038). The lowest mean circulatory arrest temperature was 24.6 ± 0.9 °C in the control group, and 29 ± 0.8 °C in the modified group (P < 0.001). In-hospital mortality was 4.9% (3/61) for the entire cohort (control 8.3%, modified 0; P = 0.262). The incidence of permanent neurologic deficit was 4.9% (control 8.3%, modified 0; P = 0.262). There were no significant differences in the occurrence of temporary neurological deficit, renal failure, and paraplegia between groups. The rate of major adverse events in the modified group was lower (30.6% vs. 4%, P = 0.019). A shorter duration of ventilation and ICU stay was identified in the modified group, as well as a reduced volume of drainage within the first 48 h and red blood cell transfusion.ConclusionsThe early results of MHCA (29 °C) and bilateral selective antegrade cerebral perfusion applied in total arch replacement with stented elephant trunk implantation for aTAAD were acceptable, providing similar inferior cerebral and visceral protection compared with that of the conventional strategy. A higher core temperature may account for the shorter duration of ventilation and ICU stay, as well as a reduced volume of drainage and red blood cell transfusion.

A STUDY OF OVER 2 MILLION INDIVIDUALS FROM THE VANDERBILT UNIVERSITY MEDICAL CENTER REVEALS SEX- AND AGE-DEPENDENT COMORBIDITY PATTERNS IN PSYCHIATRIC DISORDERS

Cerebral protection strategies in aortic surgery have undergone significant evolution over the years, but its tenets remain rooted in maintenance of hypothermia and cerebral perfusion to limit adverse neurologic outcomes. While deep hypothermic circulatory arrest alone remains a viable approach in many instances, the need for prolonged duration of circulatory arrest and increasing case complexity have driven the utilization of adjunctive cerebral perfusion strategies. In this review, we present the most recent studies published on this topic over the last few years investigating the efficacy of deep hypothermic circulatory arrest, retrograde cerebral perfusion, and unilateral and bilateral antegrade cerebral perfusion, as well as the emerging trend toward mild and moderate HCA temperatures. We highlight the ongoing controversies in the field that underscore the need for large-scale randomized trials using well-defined neurologic endpoints to optimize evidence-based practice in cerebral protection.

Analysis of the neuronal damage severity and cognitive status in patients after operations on the aortic arch

Aim. To assess the neuronal damage severity and cognitive status in conditions of unilateral antegrade cerebral perfusion through the brachiocephalic trunk during surgical reconstruction of the thoracic aorta. Material and methods. The study included 144 patients with aneurysm and dissection of the thoracic aorta. Patients underwent reconstructive surgery under cardiopulmonary bypass, unilateral antegrade cerebral perfusion and circulatory arrest. Before and after the intervention, a cognitive status analysis was performed using the Montreal Cognitive Assessment (MoCA), Amatinu test and Schulte tables. The dynamics of neuron-specific enolase (NSE), a marker of neuronal damage, was determined perioperatively. Results. The duration of cardiopulmonary bypass was 155 [115; 201] min, cardioplegic arrest — 100 [72; 150] min, unilateral perfusion — 20 [15; 51] min,circulatory arrest — 20 [15; 30]min.Hospital mortality was 7% (10 cases). Neurological complications were noted in 12 (8%) cases. All patients in the postoperative period (within 24 hours) showed an increase in NSE compared with baseline values (3,3 μg/L and 2,07 μg/L, respectively, p=0,0003), but not exceeding the upper limit of normal (9,9 μg/l). According to the results of psychometric tests, which were carried out upon admission to the hospital and 2 weeks after the operation, there were no negative changes (MoCA test: 24 [21; 26] points — 26 [24; 27] points, p=0,00001; Schulte tables: 288 [240; 368] s — 278 [241; 328] s, p=0,01; Amatuni sample 264 [216; 297] s — 254 [221; 280] s, p=0,57). Conclusion. Based on the analysis of the perioperative dynamics of neuronspecific enolase and cognitive tests, unilateral cerebral perfusion through the brachiocephalic trunk is effective and relatively safe. This method of perfusion protection of the brain helps to minimize postoperative neurological complications during operations on the thoracic aorta.

Unilateral is comparable to bilateral antegrade cerebral perfusion in acute type A aortic dissection repair

ObjectiveTo compare the short- and long-term outcomes of unilateral and bilateral antegrade cerebral perfusion (uni-ACP and bi-ACP) in acute type A aortic dissection (ATAAD) repair. MethodsFrom 2001 to 2017, 307 patients underwent surgical repair of an ATAAD using uni-ACP (n = 140) and bi-ACP (n = 167). Data were collected through the Department of Cardiac Surgery Data Warehouse, medical record review, and the National Death Index database. ResultsThe demographics and preoperative comorbidities were similar between the uni-ACP and bi-ACP groups. Both groups had similar rates of procedures for aortic valve/root, ascending aorta, frozen elephant trunk, and other concomitant procedures. Perioperative outcomes were not significantly different between the 2 groups (30-day mortality: uni-ACP 3.4% vs bi-ACP 7.8%, P = .12) except reoperation for bleeding was significantly lower in uni-ACP (5% vs 12%, P = .03). Between the uni-ACP and bi-ACP groups, overall postoperative stroke rate (6% vs 9%, P = .4) and left brain stroke rate (0.7% vs 3.0%, P = .23) were not significantly different. The odds ratio of uni-ACP versus bi-ACP was 0.87 (P = .80) for postoperative stroke and 0.86 (P = .81) for operative mortality. The mid-term survival was better in the uni-ACP group, P = .027 (5-year: 84% vs 76%). The hazard ratio of all-time mortality for uni-ACP versus bi-ACP was 0.74 (95% confidence interval, 0.33-1.65), P = .46. ConclusionsIn ATAAD, both uni-ACP and bi-ACP are equally effective to protect the brain with low postoperative stroke rates and mortality in hemiarch to zone 3 arch replacement. Uni-ACP is recommended for its simplicity and less manipulation of arch branch vessels.