A modified procedure in aortic arch replacement with no deep hypothermic circulatory arrest

Deep hypothermia or circulation arrest is widely used during total aortic arch replacement. However, conventional procedures have high morbidity and mortality.1 We use the “branch-first” technique2,3 combined with clamping the distal aorta, incorporating a stented elephant trunk to avoid deep hypothermia and circulation arrest. This technique brings us closer to the goal of arch surgery without cerebral or visceral circulatory arrest and the morbidity of deep hypothermia. Early results are encouraging.

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Risk Factor Analysis of Clinical Outcomes of Total Aortic Arch Replacement and Frozen Elephant Trunk With Aortic Balloon Occlusion

10.21203/rs.3.rs-554555/v1 ◽

2021 ◽

Author(s):

Luchen Wang ◽

Yunfeng Li ◽

Yaojun Dun ◽

Xiaogang Sun

Keyword(s):

Hospital Stay ◽

Aortic Arch ◽

Circulatory Arrest ◽

Balloon Occlusion ◽

Conventional Group ◽

Frozen Elephant Trunk ◽

Elephant Trunk ◽

Aortic Arch Replacement ◽

Total Aortic Arch Replacement ◽

Aortic Balloon Occlusion

Abstract Background: Total aortic arch replacement (TAR) with frozen elephant trunk (FET) requires hypothermic circulatory arrest (HCA) for 20 minutes, which increases the surgical risk. We invented an aortic balloon occlusion technique that requires 5 minutes of HCA on average to perform TAR with FET and investigated the possible merit of this new method in this study. Methods: This retrospective study included consecutive patients who underwent TAR and FET (consisting of 130 cases of aortic balloon occlusion group and 230 cases of conventional group) in Fuwai Hospital between August 2017 and February 2019. In addition to the postoperative complications, the alterations of blood routine tests, alanine transaminase (ALT) and aspartate transaminase (AST) during the in-hospital stay were also recorded. Results: The 30-day mortality rates were similar between the aortic balloon occlusion group (4.6%) and the conventional group (7.8%, P = 0.241). Multivariate analysis showed aortic balloon occlusion reduced postoperative acute kidney injury (23.1% vs 35.7%, P = 0.013) and hepatic injury (12.3% vs 27.8%, P = 0.001), and maintained similar cost to patients (25.5 vs 24.9 kUSD, P = 0.298). We also found that AST was high during intensive care unit (ICU) stay and recovered to normal before discharge, while ALT was not as high as AST in ICU but showed a rising tendency before discharge. The platelet count showed a rising tendency on postoperative day 3 and may exceed the preoperative value before discharge. Conclusions: The aortic balloon occlusion achieved the surgical goal of TAR with FET with an improved recovery process during the in-hospital stay.

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Moderate and Deep Hypothermic Circulatory Arrest Have Comparable Effects on Severe Systemic Inflammatory Response Syndrome After Total Aortic Arch Replacement in Patients With Type A Aortic Dissection

Frontiers in Surgery ◽

10.3389/fsurg.2021.758854 ◽

2021 ◽

Vol 8 ◽

Author(s):

Yinejie Du ◽

Zhongrong Fang ◽

Yanhua Sun ◽

Congya Zhang ◽

Guiyu Lei ◽

...

Keyword(s):

Aortic Dissection ◽

Aortic Arch ◽

Circulatory Arrest ◽

Type A ◽

Deep Hypothermic Circulatory Arrest ◽

Hypothermic Circulatory Arrest ◽

Aortic Arch Replacement ◽

Type A Aortic Dissection ◽

Total Aortic Arch Replacement ◽

Before And After

Background: The objective of this study was to compare the incidence of severe systemic inflammatory response syndrome (sSIRS) after total aortic arch replacement between patients who underwent moderate hypothermic circulatory arrest (MHCA) and those who underwent deep hypothermic circulatory arrest (DHCA).Methods: At Fuwai Hospital, 600 patients who underwent total aortic arch replacement with MHCA or DHCA from January 2013 to December 2016 were consecutively enrolled and divided into DHCA (14.1–20.0°C) and MHCA (20.1–28.0°C) groups. Preliminary statistical analysis revealed that some baseline indicators differed between the two groups; therefore, propensity score matching (PSM) was used to balance the covariates. Post-operative sSIRS as the primary outcome was compared between the groups both before and after PSM.Results: A total of 275 (45.8%) patients underwent MHCA, and 325 (54.2%) patients underwent DHCA. After PSM analysis, a total of 191 matched pairs were obtained. The overall incidence of sSIRS was 27.3%. There was no significant difference in post-operative sSIRS between the MHCA group and the DHCA group in either the overall cohort or the PSM cohort (no-PSM: P = 0.188; PSM: P = 0.416); however, post-operative sSIRS was increased by ~4% in the DHCA group compared with the MHCA group in both the no-PSM and PSM cohorts (no-PSM: 29.5 vs. 24.7%; PSM: 29.3 vs. 25.1%). Both before and after PSM, the rates of gastrointestinal hemorrhage and pulmonary infection and post-operative length of stay were significantly increased in the DHCA group compared with the MHCA group (P < 0.05), and the remaining secondary outcomes were not significantly different between the groups.Conclusions: MHCA and DHCA are associated with comparable incidences of sSIRS in patients following total aortic arch replacement for type A aortic dissection. However, the MHCA group had a shorter cardiopulmonary bypass time, a shorter post-operative length of stay and lower pulmonary infection and gastrointestinal hemorrhage rates than the DHCA group. We cautiously recommend the use of MHCA for most total arch replacements in patients with type A aortic dissection.

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Severe systemic inflammatory response syndrome in patients following Total aortic arch replacement with deep hypothermic circulatory arrest

Journal of Cardiothoracic Surgery ◽

10.1186/s13019-019-1027-3 ◽

2019 ◽

Vol 14 (1) ◽

Author(s):

Jun Li ◽

Lijing Yang ◽

Guyan Wang ◽

Yuefu Wang ◽

Chunrong Wang ◽

...

Keyword(s):

Systemic Inflammatory Response Syndrome ◽

Inflammatory Response ◽

Aortic Arch ◽

Circulatory Arrest ◽

Deep Hypothermic Circulatory Arrest ◽

Hypothermic Circulatory Arrest ◽

Systemic Inflammatory Response ◽

Hospital Death ◽

Aortic Arch Replacement ◽

Total Aortic Arch Replacement

Abstract Background This cohort study aims to retrospectively investigate the incidence of severe systemic inflammatory response syndrome (sSIRS) in patients following total aortic arch replacement (TAR) under deep hypothermic circulatory arrest (DHCA) with selective cerebral perfusion and its effect on clinical outcomes. Methods All patients who underwent TAR with DHCA were consecutively enrolled from January 2013 until December 2015 at our institute. sSIRS was diagnosed between 12 and 48 h postoperatively if patients met all four criteria of the SIRS definition. Results Of the 522 patients undergoing TAR with DHCA, 31.4% developed sSIRS. Patients aged under 60 yr were characterized by a higher prevalence of sSIRS (OR = 2.93; 95% CI 2.01–4.28; P <0.001). Higher baseline serum creatinine (OR = 1.61; 95% CI 1.18–2.20; P = 0.003), concomitant coronary disease (OR = 2.00; 95% CI 1.15–3.48; P = 0.015) and extended cardiopulmonary time (OR = 1.63; 95% CI 1.23–2.18; P = 0.001) independently contributed to a greater likelihood of postoperative sSIRS onset, while the preferred administration of ulinastatin (OR = 0.69; 95% CI 0.51–0.93; P = 0.015) and dexmedetomidine (OR = 0.36; 95% CI 0.23–0.56; P < 0.001) attenuated it. Patients with sSIRS had a greater risk of developing postoperative major adverse complications compared with the no sSIRS group [56.7%(93/164) vs 26.8% (96/358), P < 0.001]. sSIRS was found to be a significant risk factor for major adverse complications (OR, 4.52; 95% CI, 3.40–6.01; P < 0.001). A significant difference was revealed in in-hospital death following TAR between the sSIRS group and the no-sSIRS group [4.88% (8/164) vs 1.12% (4/358), P = 0.019]. The Kaplan-Meier curve indicated that the time to discharge from the intensive care unit was significantly prolonged in the sSIRS group compared with patients without it (log-rank p < 0.001). Conclusions sSIRS occurs commonly in patients following TAR with DHCA. There is an inverse association between age and sSIRS onset, whereby age over 60 yr can lower the risk of it. sSIRS development can increase the likelihood of major postoperative major adverse events.

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Risks and Association of Impaired Cerebral Autoregulation With Outcomes in Aortic Arch Surgery: A Single-center, Retrospective Cohort Study

10.21203/rs.3.rs-1220637/v1 ◽

2022 ◽

Author(s):

Ling Peng ◽

Dan Guo ◽

Yinhui Shi ◽

Jiapei Yang ◽

Wei Wei

Keyword(s):

Aortic Arch ◽

Cerebral Autoregulation ◽

Circulatory Arrest ◽

Cerebral Oximetry ◽

Elephant Trunk ◽

Aortic Arch Replacement ◽

Aortic Arch Surgery ◽

Total Aortic Arch Replacement ◽

Independent Association ◽

New Onset

Abstract BackgroundImpairment of cerebral autoregulation (CA) has been observed in patients undergoing cardiopulmonary bypass (CPB), but little is known about its risks and associations with outcomes. The objective of this study was to analyze the risks of impaired CA, based on cerebral oximetry index (COx), in patients undergoing total aortic arch replacement with CPB and moderate hypothermic circulatory arrest (MHCA). We also evaluated the association between impaired CA and patient outcomes.MethodsOne hundred fifteen four adult patients who underwent total aortic arch replacement with stented elephant trunk implantation under CPB and MHCA at our hospital were retrospectively analyzed. Patients were defined as having new-onset impaired CA if post-CPB COx > 0.3, calculated based on a moving linear correlation coefficient between regional cerebral oxygen saturation (rScO2) and mean blood pressure (MAP). Pre- and intraoperative factors were tested for independent association with impaired CA. Postoperative outcomes were compared between patients with normal and impaired CA.ResultsIn our 154 patients, 46(29.9%) developed new-onset impaired CA after CPB with MHCA. Multivariate analysis revealed a prolonged low rScO2 (rScO2 <55%) independently associated with onset of impaired CA, and receiver operating charactoristic curve showed a cutoff value at 40 min (sensitivity, 89.5%; specificity, 68.0%). Compared with normal CA patients, those with impaired CA showed a significantly higher rates of in-hospital mortality and postoperative complications.ConclusionProlonged low rScO2 (rScO2 <55%) during aortic arch surgery was closely related to onset of impaired CA. Impaired CA remained associated with the increased rates of postoperative complications and in-hospital mortality.Trial registration: ChiCTR1800014545 with registered date 20/01/2018.

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Risk factor analysis of clinical outcomes of total aortic arch replacement and frozen elephant trunk with aortic balloon occlusion

Journal of Cardiothoracic Surgery ◽

10.1186/s13019-021-01643-3 ◽

2021 ◽

Vol 16 (1) ◽

Author(s):

Luchen Wang ◽

Yunfeng Li ◽

Yaojun Dun ◽

Xiaogang Sun

Keyword(s):

Hospital Stay ◽

Aortic Arch ◽

Circulatory Arrest ◽

Balloon Occlusion ◽

Conventional Group ◽

Frozen Elephant Trunk ◽

Elephant Trunk ◽

Aortic Arch Replacement ◽

Total Aortic Arch Replacement ◽

Aortic Balloon Occlusion

Abstract Background Total aortic arch replacement (TAR) with frozen elephant trunk (FET) requires hypothermic circulatory arrest (HCA) for 20 min, which increases the surgical risk. We invented an aortic balloon occlusion (ABO) technique that requires 5 min of HCA on average to perform TAR with FET and investigated the possible merit of this new method in this study. Methods This retrospective study included consecutive patients who underwent TAR and FET (consisting of 130 cases of ABO group and 230 cases of conventional group) in Fuwai Hospital between August 2017 and February 2019. In addition to the postoperative complications, the alterations of blood routine tests, alanine transaminase (ALT) and aspartate transaminase (AST) during in-hospital stay were also recorded. Results The 30-day mortality rates were similar between ABO group (4.6%) and conventional group (7.8%, P = 0.241). Multivariate analysis showed ABO reduced postoperative acute kidney injury (23.1% vs. 35.7%, P = 0.013) and hepatic injury (12.3% vs. 27.8%, P = 0.001), and maintained similar cost to patients (25.5 vs. 24.9 kUSD, P = 0.298). We also found that AST was high during intensive care unit (ICU) stay and recovered to normal before discharge, while ALT was not as high as AST in ICU but showed a rising tendency before discharge. The platelet count showed a rising tendency on postoperative day 3 and may exceed the preoperative value before discharge. Conclusions The ABO achieved the surgical goal of TAR with FET with an improved recovery process during the in-hospital stay.

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The Occurrence and Association of Impaired Cerebral Autoregulation With Outcomes in Aortic Arch Surgery: A Single-Center, Retrospective Study

10.21203/rs.3.rs-712359/v1 ◽

2021 ◽

Author(s):

Ling Peng ◽

Wei Wei ◽

Jun Zeng ◽

Jiapei Yang ◽

Rurong Wang

Keyword(s):

Postoperative Complications ◽

Hospital Mortality ◽

Aortic Arch ◽

Cerebral Autoregulation ◽

Circulatory Arrest ◽

Cerebral Oximetry ◽

Elephant Trunk ◽

Aortic Arch Replacement ◽

Total Aortic Arch Replacement ◽

New Onset

Abstract Backgroundː Impairment of cerebral autoregulation (CA) has been observed in patients undergoing cardiopulmonary bypass (CPB), but little is known about its occurrence and associations with outcomes. The objective of this study was to analyze the occurrence of impaired CA, based on cerebral oximetry index (COx), in patients undergoing total aortic arch replacement with CPB and moderate hypothermic circulatory arrest (MHCA). We also evaluated the association between impaired CA and patient outcomes.Methodsː Sixty-four patients who underwent total aortic arch replacement with stented elephant trunk implantation under CPB and MHCA at our hospital were retrospectively analyzed. Patients were defined as having new-onset impaired CA if post-CPB COx > 0.3, calculated based on a moving linear correlation coefficient between regional cerebral oxygen saturation (rScO2) and mean blood pressure (MAP). Postoperative complication and in-hospital mortality were compared between patients with normal and impaired CA.Resultsː Of the 64 patients, 19(29.7%) developed new-onset impaired CA after CPB with MHCA. Compared with normal CA patients, those with impaired CA showed a significantly longer duration of rScO2 <55%, and significantly higher rates of in-hospital mortality and postoperative complications (acute kidney injury, delirium, mechanical ventilation > 24h, and respiratory infection). Conclusionsː In our cohort, 29.7% of patients who underwent total aortic arch replacement developed new-onset impaired CA after CPB with MHCA. Impaired CA might be associated with significantly increased rates of postoperative complications and in-hospital mortality. Clinical trial registration: ChiCTR1800014545 with registered date 20/01/2018.

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