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

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.

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

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 &lt; 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.

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

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.

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

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.

Improvement of Clinical Outcomes of Total Aortic Arch Replacement and Frozen Elephant Trunk Surgery With Aortic Balloon Occlusion

Background: Total aortic arch replacement (TAR) with frozen elephant trunk (FET) surgery provides improved long-term results, but the surgery itself is associated with higher risks compared with isolated proximal reconstructions. We applied an aortic balloon occlusion (ABO) technique to reduce the circulatory arrest (CA) time and improve other clinical outcomes.Methods: All patients who underwent TAR with FET surgery (130 with ABO technique, 230 with the conventional approach) in Fuwai Hospital from August 2017 to February 2019 were reviewed in this retrospective observational cohort study. Intra- and early-postoperative results and clinical characteristics were analyzed.Results: After 1:1 propensity score matching (130 cases in each group), the 30-day mortality of the ABO group and the conventional group were 4.6% and 10.8% (p = 0.063), respectively. Although the reduction in complications was not statistically significant, the complication rate in the ABO group was relatively low, having fewer cases of postoperative renal (23.1 vs. 38.5%, p = 0.007) and hepatic (12.3 vs. 30.0%, p &lt; 0.001) injury, lower postoperative wake-up time (15.2 ± 23.6 h vs. 20.1 ± 26.5 h, respectively, p &lt; 0.001), reduced chest tube output (176.03 ± 143.73 ml vs. 213.29 ± 130.12 ml, respectively, p = 0.003), lower red blood cell transfusion volume (4.98 ± 6.53 u vs. 7.28 ± 10.41 u, respectively, p = 0.008), and no fatal events.Conclusions: The ABO technique is a simple method that can reduce the CA time and improve the recovery stage following TAR with FET surgery. The technique represents a practical strategy to treat patients with high operative risks due to its lower complication rate compared with the conventional approach.

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

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.