Moderate Hypothermic Circulatory Arrest (≥ 28°C) with Selective Antegrade Cerebral Perfusion for Total Arch Replacement with Frozen Elephant Trunk Technique

2018 ◽  
Vol 67 (05) ◽  
pp. 345-350 ◽  
Author(s):  
Ali El-Sayed Ahmad ◽  
Petar Risteski ◽  
Mahmut Ay ◽  
Nestoras Papadopoulos ◽  
Anton Moritz ◽  
...  
Keyword(s):  
Aortic Arch ◽  
Cerebral Perfusion ◽  
Circulatory Arrest ◽  
Hypothermic Circulatory Arrest ◽  
Total Arch Replacement ◽  
Frozen Elephant Trunk ◽  
Elephant Trunk ◽  
Cord Injury ◽  
Selective Antegrade Cerebral Perfusion ◽  
Antegrade Cerebral Perfusion

Objectives The optimal hypothermic level during circulatory arrest in aortic arch surgery remains controversial, particularly in frozen elephant trunk (FET) procedures. We describe herein our experience for total arch replacement with FET technique under moderate systemic hypothermic circulatory arrest (≥ 28°C) during selective antegrade cerebral perfusion. Methods Between January 2009 and January 2016, 38 consecutive patients underwent elective total arch replacement for various aortic arch pathologies with FET technique using the E-vita Open hybrid prosthesis (Jotec GmbH, Hechingen, Germany). Selective unilateral or bilateral cerebral perfusion under moderate systemic hypothermic circulatory arrest (28.7°C ± 0.5°C) was used in all patients. Minimally invasive total arch replacement with FET via partial upper sternotomy was performed in 15 patients (39%) and in the remaining 23 patients (61%) via full sternotomy. Mean late follow-up was 3 ± 2 years and was 98% complete. Clinical data were prospectively entered into our institutional database. Results Cardiopulmonary bypass time accounted for 198 ± 58 minutes and the myocardial ischemic time 109 ± 29 minutes. Selective antegrade cerebral perfusion time was 55 ± 6 minutes. Lower body circulatory arrest time was 39 ± 11 minutes. Unilateral cerebral perfusion was performed in 31 patients (82%), and bilateral in 7 patients (18%). Intensive care unit stay was 4 ± 3 days. Thirty-day mortality was 5% (n = 2). Late survival at 3 years was 87 ± 3%. Two patients (5%) required reexploration for bleeding. Patients were discharged after a hospital length of stay of 7 ± 2 days. Postoperative permanent neurologic complication occurred in two patients (5%). Three patients (8%) experienced a transient neurologic disorder. New transient renal replacement therapy was necessary in three patients (8%). No spinal cord injury was noted. Conclusions Our data suggest that moderate systemic hypothermic circulatory arrest (≥ 28°C) in combination with antegrade cerebral perfusion can safely be applied for total aortic arch replacement with FET and offers sufficient neurologic and visceral organ protection.

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

2020 ◽  
Vol 15 (1) ◽  
Author(s):  
Song-Bo Dong ◽  
Jian-Xian Xiong ◽  
Kai Zhang ◽  
Jun Zheng ◽  
Shang-Dong Xu ◽  
...  
Keyword(s):  
Cerebral Perfusion ◽  
Circulatory Arrest ◽  
Total Arch Replacement ◽  
Red Blood Cell Transfusion ◽  
Acute Type ◽  
Elephant Trunk ◽  
Type A Aortic Dissection ◽  
Selective Antegrade Cerebral Perfusion ◽  
Antegrade Cerebral Perfusion ◽  
Duration Of Ventilation

Abstract Background The 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. Methods From 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. Results There 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. Conclusions The 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.

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

2020 ◽  
Author(s):  
Song-Bo Dong ◽  
Jian-Xian Xiong ◽  
Kai Zhang ◽  
Jun Zheng ◽  
Shang-Dong Xu ◽  
...  
Keyword(s):  
Cerebral Perfusion ◽  
Circulatory Arrest ◽  
Total Arch Replacement ◽  
Red Blood Cell Transfusion ◽  
Acute Type ◽  
Elephant Trunk ◽  
Type A Aortic Dissection ◽  
Selective Antegrade Cerebral Perfusion ◽  
Antegrade Cerebral Perfusion ◽  
Duration Of Ventilation

Abstract Background: The optimal hypothermic level in total arch replacement with stented elephant trunk implantation for acute type A aortic dissection (aTAAD) was uncertain, and the superiority of unilateral or bilateral cerebral perfusion remained a controversial topic. We evaluated the application of moderate hypothermic circulatory arrest (MHCA) with a core temperature of 29℃ and bilateral selective antegrade cerebral perfusion in aTAAD treated by total arch replacement with stented elephant trunk implantation. Methods: From July 2019 to January 2020, 25 aTAAD patients underwent total arch replacement with stented elephant trunk implantation via MHCA (29℃) and bilateral selective antegrade cerebral perfusion (modified group). Thirty-six patients treated by the same procedure with MHCA (25℃) and unilateral selective antegrade cerebral perfusion during this period were selected as controls. Results: No difference existed among patients in both groups in terms of age, gender, incidence of hypertension, malperfusion, and pericardial effusion, except a higher incidence of cardiac tamponade in modified group (control 2.8%, modified 20%; P = 0.038). Lowest mean circulatory arrest temperature was 24.6±0.9℃ in control group, and 29±0.8℃ in 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.Conclusions: The early results of MHCA (29℃) 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.

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