Antegrade Cerebral Perfusion With Mild Hypothermia for Aortic Arch Replacement: Single-Center Experience in 245 Consecutive Patients

Zierer, Andreas; Detho, Faisal; Dzemali, Omer; Aybek, Tayfun; Moritz, Anton; Bakhtiary, Farhad

doi:10.1016/j.athoracsur.2011.02.077

Cited by 83 publications

(53 citation statements)

References 32 publications

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“…All patients were operated at our centre following the standardized institutional surgical and perfusion as well as temperature management protocol as previously described in detail [14][15][16][17][18][19].…”

Section: Operative Techniquesmentioning

confidence: 99%

Minimally invasive approach for aortic arch surgery employing the frozen elephant trunk technique

Ahmad

Risteski

Papadopoulos

et al. 2016

Eur J Cardiothorac Surg

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OBJECTIVES: Classically, repair of extensive thoracic aortic pathologies including the aortic arch and descending aorta required two separate major surgical procedures via full sternotomy and a subsequent left lateral thoracotomy. We describe herein our preliminary institutional experience with minimally invasive single-stage extended thoracic aortic replacement employing the frozen elephant trunk (FET) technique via partial upper sternotomy (PUS) in 14 patients. METHODS:Between December 2013 and January 2015, 14 consecutive patients with elective indications for FET underwent minimally invasive FET via PUS (PUS-FET) during moderate systemic hypothermia (28°C) and selective antegrade cerebral perfusion (ACP) using the E-vita Open® hybrid prosthesis ( Jotec GmbH, Hechingen, Germany). The patients' mean age was 66 ± 6 years, and 9 patients (64%) were male. The arch vessels were reimplanted en bloc in all patients. Clinical data were prospectively entered into our institutional database. RESULTS:The surgical procedure was successful in all patients with no need for conversion to full sternotomy. An additional David procedure was performed in 1 patient, whereas 2 patients received a concomitant Bentall procedure. There was no perioperative death or 30-day mortality. The mean cardiopulmonary bypass time was 214 ± 35 min, and the myocardial ischaemic time was 125 ± 14 min. The ACP time was 54 ± 9 min, whereas the ventilation time reached 11 ± 4 h. Intensive care unit stay was 2 ± 3 days. Chest tube drainage within the first 24 h was 460 ± 130 ml. None of the 14 patients required re-exploration for bleeding. Patients were discharged after a hospital length of stay of 9 ± 2 days. No postoperative permanent neurological complication occurred. Two patients (14%) experienced temporary delirium with complete resolution of symptoms prior to discharge from the hospital. CONCLUSIONS: Our preliminary experience suggests that minimally invasive single-stage extended thoracic aortic replacement can safely and reproducibly be performed by employing the concept of PUS-FET.

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Section: Operative Techniquesmentioning

confidence: 99%

Minimally invasive approach for aortic arch surgery employing the frozen elephant trunk technique

Ahmad

Risteski

Papadopoulos

et al. 2016

Eur J Cardiothorac Surg

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“…The maximum DHCA interval is approximately 80 min. Prolonged DHCA (100 min in recent clinical reports [3,4]) is associated with an increased risk of adverse neurological outcomes. For this reason, it is necessary to determine, clinically, which cerebral protection strategy should be adopted preoperatively (especially for prolonged DHCA), such as complex aortic arch reconstruction and congenital heart disease.…”

Section: Introductionmentioning

confidence: 99%

Selective Antegrade Cerebral Perfusion Attenuating the TLR4/NF-κB Pathway during Deep Hypothermia Circulatory Arrest in a Pig Model

Tang

Chen²,

Liang³

et al. 2014

Cardiology

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Objectives: The alteration of the Toll-like receptor/nuclear factor-kappa B (TLR4/NF-κB) signaling pathway during deep hypothermia circulatory arrest (DHCA) has not yet been defined. The aim of this study was to explore the expression of the TLR4/NF-κB pathway cytokine in cerebral injury resulting from DHCA as well as the effect of selective antegrade cerebral perfusion (SACP) on TLR4/NF-κB pathway expression. Methods: Twelve pigs were randomly assigned to DHCA alone (n = 6) or DHCA with SACP (n = 6) at 18°C for 80 min. Serum interleukin (IL)-6 was assayed by ELISA. Apoptosis and NF-κB proteins were detected by fluorescence TUNEL and Western blot, respectively. The level of TLR4 mRNA and protein were determined through qRT-PCR and Western blot. Results: The serum IL-6 level of the SACP group was significantly lower than that of the DHCA group at the end of circulation arrest and experimentation. Apoptotic index and NF-κB protein were apparently lower in SACP animals (p < 0.05). Compared to the DHCA group, the levels of TLR4 protein and mRNA in the SACP group were lower with significance (p < 0.05). Conclusions: The TLR4/NF-κB signaling pathway plays a critical role in the pathogenesis of DHCA cerebral injury. Attenuation of the TLR4/NF-κB inflammatory cytokines probably contributes to the neuroprotective effect of SACP. The TLR4/NF-κB inflammatory signaling pathway may be a novel therapeutic target for developing a new strategy for neuroprotection in DHCA.

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“…HCA with SACP prevents a series of adverse effects caused by deep hypothermia [15-17] and shows excellent clinical outcomes. Given continuous improvements in aortic surgical techniques and perfection of CPB equipment in recent years, several surgeons have completed aortic arch surgery under mild hypothermia (30°C to 32°C) with satisfactory results [6,11,12,18]. Andreas Zierer and colleagues [6] reported on 245 aortic arch operations completed using selective cerebral perfusion under mild hypothermia (30.5°C ± 1.4°C) in 2011 and obtained an operative mortality rate of 8% ( n = 20) and post-operative PND and TND morbidity rates of 6% (n = 14) and 5% ( n = 12), respectively.…”

Section: Discussionmentioning

confidence: 99%

“…A radial artery pressure of 60–80 mmHg was maintained by adjusting the flow rate of the centrifugal pump. According to previous reports [6,11], cerebral blood flow accounts for 20%–30% of the cardiac output under normal physiological status. Therefore, a mean flow of 27.9 mL/kg/min ± 5.3 mL/kg/min (1971 mL/min ± 326 mL/min) should sufficiently meet brain oxygen demands under mild hypothermia.…”

Section: Discussionmentioning

confidence: 99%

Right axillary and femoral artery perfusion with mild hypothermia for aortic arch replacement

Guo

Wang

Zhu

et al. 2014

J Cardiothorac Surg

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ObjectivesAortic arch replacement is associated with increased mortality and morbidity especially in acute type-A aortic dissection. Although hypothermic circulatory arrest with selective antegrade cerebral perfusion has been widely used because of its excellent cerebral protection, its optimal perfusion characteristics are unknown. The present study investigates clinical results obtained after perfusion method modification and temperature management during cardiopulmonary bypass (CPB).MethodsBetween July 2010 and August 2012, 16 consecutive adult patients (mean age 50.0 yr ± 14.1 yr, range 25 yr to 73 yr, 12 males, 4 females) who presented with acute Stanford type-A aortic dissection underwent aortic arch replacement (total arch, n = 11; hemiarch, n = 5) under mild hypothermia (31.1°C ± 1.5°C) with right axillary and femoral artery perfusion.ResultsThe mean CPB time was 201 min ± 53 min, and the mean myocardial ischemic time was 140 min ± 42 min. The mean selective cerebral perfusion time was 80 min ± 16 min, and the mean lower-body circulatory arrest time was 20 min ± 13 min. No patient death occurred within 30 post-operative days. The following details were observed: new post-operative permanent neurologic deficit in 1 patient (6.3%), temporary neurologic deficit in 2 patients (12.5%), acute renal dysfunction (creatinine level > 230 umol/L) in 3 patients (18.8%) and mechanical ventilation > 72 h in 5 patients (31.2%).ConclusionsAortic arch replacement for acute type-A aortic dissection under mild hypothermia with right axillary and femoral artery perfusion could be safely performed in the patient cohort.

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Antegrade Cerebral Perfusion With Mild Hypothermia for Aortic Arch Replacement: Single-Center Experience in 245 Consecutive Patients

Cited by 83 publications

References 32 publications

Minimally invasive approach for aortic arch surgery employing the frozen elephant trunk technique

Minimally invasive approach for aortic arch surgery employing the frozen elephant trunk technique

Selective Antegrade Cerebral Perfusion Attenuating the TLR4/NF-κB Pathway during Deep Hypothermia Circulatory Arrest in a Pig Model

Right axillary and femoral artery perfusion with mild hypothermia for aortic arch replacement

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