Pharmacological Cerebral Protection in Cardiac Surgery: An Update

ObjectiveNeurological dysfunction remains a devastating postoperative complication in patients undergoing cardiac surgery with cardiopulmonary bypass (CPB), and previous studies have shown that inhalation anaesthesia and total intravenous anaesthesia (TIVA) may produce different degrees of cerebral protection in these patients. Therefore, we conducted a systematic literature review and meta-analysis to compare the neuroprotective effects of inhalation anaesthesia and TIVA.DesignSearching in PubMed, EMBASE, Science Direct/Elsevier, China National Knowledge Infrastructure and Cochrane Library up to August 2016, we selected related randomised controlled trials for this meta-analysis.ResultsA total of 1485 studies were identified. After eliminating duplicate articles and screening titles and abstracts, 445 studies were potentially eligible. After applying exclusion criteria (full texts reported as abstracts, review article, no control case, lack of outcome data and so on), 13 studies were selected for review. Our results demonstrated that the primary outcome related to S100B level in the inhalation anaesthesia group was significantly lower than in the TIVA group after CPB and 24 hours postoperatively (weighted mean difference (WMD); 95% CI (CI): −0.41(–0.81 to –0.01), −0.32 (−0.59 to −0.05), respectively). Among secondary outcome variables, mini-mental state examination scores of the inhalation anaesthesia group were significantly higher than those of the TIVA group 24 hours after operation (WMD (95% CI): 1.87 (0.82 to 2.92)), but no significant difference was found in arteriovenous oxygen content difference, cerebral oxygen extraction ratio and jugular bulb venous oxygen saturation, which were assessed at cooling and rewarming during CPB.ConclusionThis study demonstrates that anaesthesia with volatile agents appears to provide better cerebral protection than TIVA for patients undergoing cardiac surgery with CPB, suggesting that inhalation anaesthesia may be more suitable for patients undergoing cardiac surgery.

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Noteworthy Cardiac Literature 2019: Cerebral Protection, Zone 2 Arch, Intravascular Ultrasonography in Dissection, Heart Allocation, and Mitral Durability

Seminars in Cardiothoracic and Vascular Anesthesia ◽

10.1177/1089253220920146 ◽

2020 ◽

Vol 24 (2) ◽

pp. 187-191

Author(s):

Christian V. Ghincea ◽

T. Brett Reece ◽

Muhammad Aftab ◽

Joseph C. Cleveland ◽

Jay D. Pal

Keyword(s):

Cardiac Surgery ◽

Heart Transplant ◽

Surgical Techniques ◽

Cerebral Protection ◽

Intravascular Ultrasonography ◽

Protection Zone ◽

Allocation System ◽

Mitral Repair

The year of 2019 continues to have notable literature advancing the practice of cardiac surgery. In this article, topics of discussion will include the evolution of cerebral protection, the advancement of arch surgical techniques, the heart transplant allocation system, and mitral repair approach and durability.

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Cerebral Protection in Infant Cardiac Surgery

Annals of Surgery ◽

10.1097/01.sla.0000097774.69326.6f ◽

2003 ◽

Vol 238 (Supplement) ◽

pp. S100-S103 ◽

Cited By ~ 1

Author(s):

Ross M. Ungerleider

Keyword(s):

Cardiac Surgery ◽

Cerebral Protection

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Hypothermia and cerebral protection strategies in aortic arch surgery: a comparative effectiveness analysis from the STS Adult Cardiac Surgery Database

European Journal of Cardio-Thoracic Surgery ◽

10.1093/ejcts/ezx133 ◽

2017 ◽

Vol 52 (3) ◽

pp. 492-498 ◽

Cited By ~ 33

Author(s):

Brian R. Englum ◽

Xia He ◽

Brian C. Gulack ◽

Asvin M. Ganapathi ◽

Joseph P. Mathew ◽

...

Keyword(s):

Cardiac Surgery ◽

Aortic Arch ◽

Comparative Effectiveness ◽

Cerebral Protection ◽

Aortic Arch Surgery ◽

Effectiveness Analysis ◽

Protection Strategies ◽

Comparative Effectiveness Analysis ◽

Adult Cardiac Surgery

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Physical and Pharmacological Neuroprotection in Cardiac Surgery

Seminars in Cardiothoracic and Vascular Anesthesia ◽

10.1053/vc.2000.6485 ◽

2000 ◽

Vol 4 (2) ◽

pp. 80-85

Author(s):

Simon J. Mitchell ◽

Timothy Willcox ◽

F. Paget Milsom ◽

Des F. Gorman

Keyword(s):

Cardiac Surgery ◽

Venous Return ◽

Cerebral Embolism ◽

Cerebral Protection ◽

Ultra Sound ◽

Left Heart ◽

Neurocognitive Deficits ◽

Double Blind ◽

Neuroprotective Strategy ◽

Blood Volumes

Stroke and neurocognitive deficits may follow cardiac surgery and have been linked to perioperative cerebral embolism. Alteration of cardiopulmonary bypass (CPB) or surgical technique to reduce embolism is, therefore, a rational neuroprotective strategy. Pharmacological cerebral protection has been advocated as an ideal "back-stop" to such "physical" interventions. A series of relevant studies conducted at Green Lane Hospital, Auckland, New Zeatand is described. Doppler ultra sound was used to monitor cerebral embolism during left heart valve surgery. Subsequently, salvaged CPB circuits were used to investigate several unexpected sources of emboli. The efficacy of a novel left heart deairing technique was audited using the Doppler de vice. Finally, a randomized double-blind trial of lidocaine in cerebral protection during cardiac surgery was con ducted. Most cerebral emboli were recorded after aortic declamping. However, cerebral emboli counts increased during stable CPB when the hard shell venous reservoir (HSVR) was operated at lower blood volumes and when air was seen in the venous return line. In vitro 2 HSVRs were found to generate bubbles when operated at blood volumes in excess of the manufacturer's recom mended minimum. Air in the venous return line was found to readily transit the CPB circuit and vacuum- assisted venous drainage markedly exacerbated this phenomenon. The novel deairing technique was mark edly superiorto conventional methods. Lidocaine admin istered in a standard antiarrhythmic dose for 48 hours from induction of anesthesia reduced the incidence of neuropsychological deficits at 10 days and 10 weeks postoperatively.

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