The methodologies of hypothermic circulatory arrest and of antegrade and retrograde cerebral perfusion for aortic arch surgery.
(18/89)
In spite of recent advances in thoracic aortic surgery, postoperative neurological injury still remains the main cause of mortality and morbidity after aortic arch operation. The use of cardiopulmonary bypass (CPB) and hypothermic circulatory arrest, temporary interruption of brain circulation, transient cerebral hypoperfusion, and manipulations on the frequently atheromatic aorta all produce neurological damages. The basic established techniques and perfusion strategies during aortic arch replacement number three: hypothermic circulatory arrest (HCA), antegrade cerebral perfusion (ACP), and retrograde cerebral perfusion (RCP). During the past decade and after several experimental studies, RCP lost its previous place in the armamentarium of brain protection, giving it up to ACP as a major method of brain perfusion during HCA. HCA should be applied at a temperature of asymptotically equal to 20 degrees C with long-lasting cooling and rewarming and should not exceed by itself the time of 20-25 min. RCP does not seem to prolong safe brain-ischemia time beyond 30 min, but it appears to enhance cerebral hypothermia by its massive concentration inside the brain vein sinuses. HCA combined with ACP, however, could prolong safe brain-ischemia time up to 80 min. Cold ACP at 10 degrees -13 degrees C should be initially applied through the right subclavian or axillary artery and continued bihemispherically through the left common carotid artery at first and later the anastomosed graft, with a mean perfusion pressure of 40-70 mm Hg. The safety of temporary perfusion is being confirmed by the meticulous monitoring of brain perfusion through internal jugular bulb O2 saturation, electroencephalogram, and transcranial comparative Doppler velocity of the middle cerebral arteries. (+info)
Rapid and safe establishment of cardiopulmonary bypass in repair of acute aortic dissection: improved results with double cannulation.
(19/89)
Outcome of less invasive proximal arch replacement with moderate hypothermic circulatory arrest followed by aggressive rapid re-warming in emergency surgery for type A acute aortic dissection.
(21/89)
BACKGROUND: The mid-term outcome of quick proximal arch replacement with moderate hypothermia followed by aggressive rapid re-warming in emergency surgery for type A acute aortic dissection (AAD) was assessed. METHODS AND RESULTS: Eighty-five patients were divided into 2 groups: group I consisted of 43 patients undergoing surgery for deep hypothermic circulatory arrest and selective cerebral perfusion; and group II consisted of 42 patients who recently underwent aggressive rapid re-warming. During open distal anastomosis in group II patients with a rectal temperature of 28 degrees C but who did not suffer any cerebral perfusion, circulating blood in the cardiopulmonary bypass (CPB) circuit was warmed to 40 degrees C. As soon as distal anastomosis was completed, rapid re-warming was initiated by a 40 degrees C blood perfusion. The duration of CPB (I: 182.1 vs II: 85.3 min), overall operation (305.0 vs 150.8 min), postoperative mechanical ventilation (44.3 vs 9.1 h), and hospital stay (31.4 vs 9.6 days) were significantly shorter in group II patients. The incidence of postoperative brain complication (I: 14.0 vs II: 2.4%), renal failure (14.0 vs 0%), pneumonia (18.6 vs 4.8%), and mortality (9.3 vs 0%) was significantly less in group II patients. CONCLUSIONS: Moderate hypothermia followed by a rapid re-warming procedure was safe and effective in the proximal arch replacement for AAD. (+info)
Plasma prohepcidin as a negative acute phase reactant after large cardiac surgery with a deep hypothermic circulatory arrest.
(22/89)
Hepcidin is a key regulator of iron metabolism and a mediator of anemia in inflammation. Recent in vitro studies recognized prohepcidin as a type II acute phase protein regulating via interleukin-6. The aim of the present study was to investigate the time course of plasma prohepcidin after a large cardiac surgery in relation to IL-6 and other inflammatory parameters. Patients with chronic thromboembolic hypertension (n=22, males/females 14/8, age 51.9+/-10.2 years) underwent pulmonary endarterectomy using cardiopulmonary bypass and deep hypothermic circulatory arrest were included into study. Arterial concentrations of prohepcidin, IL-1beta, IL-6, IL-8, tumor necrosis factor-alpha, and C-reactive protein were measured before/after sternotomy, after circulatory arrest, after separation from bypass, and then 12, 18, 24, 36, 48 h and 72 h after the separation from bypass. Hemodynamic parameters, hematocrit and markers of iron metabolism were followed up. Pulmonary endarterectomy induced a 48% fall in plasma prohepcidin; minimal concentrations were detected after separation from cardiopulmonary bypass. Prohepcidin decline correlated with an extracorporeal circulation time (p<0.01), while elevated IL-6 levels were inversely associated with duration of prohepcidin decline. Postoperative prohepcidin did not correlate with markers of iron metabolism or hemoglobin concentrations within a 72-h period after separation from CPB. Prohepcidin showed itself as a negative acute phase reactant during systemic inflammatory response syndrome associated with a cardiac surgery. Results indicate that the evolution of prohepcidin in postoperative period implies the antagonism of stimulatory effect of IL-6 and contraregulatory factors inhibiting prohepcidin synthesis or increasing prohepcidin clearance. (+info)
Modulation of nuclear factor-kappaB improves cardiac dysfunction associated with cardiopulmonary bypass and deep hypothermic circulatory arrest.
(23/89)
Total arch replacement with endarterectomy of the ascending aorta in a patient with aortic arch aneurysm and porcelain aorta.
(24/89)
We describe total arch replacement for aortic arch aneurysm with a severely calcified ("porcelain") aorta. Cardiovascular surgery is challenging under such conditions because the calcified plate interferes with clamping, incising, and suturing of the aorta. We performed this surgery under hypothermic circulatory arrest with antegrade cerebral perfusion. Calcification manifested particularly in the ascending aorta and prevented the use of a needle. We exfoliated the calcified intimal plate using an elevator designed for hand surgery, and then covered both the inner and outer sides of the endarterectomized aorta with a strip of bovine pericardium to reinforce the anastomotic region and cover the rough surface. No complications developed during or after surgery. (+info)