Early- and mid-term results of emergent aortic arch replacement using moderate hypothermic circulatory arrest and unilateral selective antegrade cerebral perfusion_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

BAO Chunrong ,  MEI Ju , DING Fangbao , ZHU Jiaquan , ZHANG Junwen , ZHANG Yunjiao , HUANG Jianbin , ZHANG Li , YANG Qi

Department of Cardiothoracic Surgery, Xinhua Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, 200092, P.R.China;

Corresponding author：

MEI Ju, Email: ju_mei63@126.com

Keywords：

Aortic arch replacement; hypothermic circulatory arrest; antegrade cerebral perfusion

DOI：

10.7507/1007-4848.201810006

Video：

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Objective To investigate the results of emergent aortic arch replacement using moderate hypothermic circulatory arrest and unilateral antegrade cerebral perfusion (MHCA+UACP).Methods We retrospectively analyzed the clinical data of 146 patients who underwent emergent aortic arch replacement using MHCA+UACP in our institution from January 2008 to June 2018. There were 111 males and 35 females aged 60.3±7.2 years. According to different surgical approaches, patients were divided into two groups: a total arch replacement (TAR) group (n=104) and a semi arch replacement (SAR) group (n=42). Right axillary artery was cannulated for cardiopulmonary bypass (CPB) and cerebral perfusion. Core temperature at the onset of MHCA was 23.4±1.4 ℃. UACP was initiated at 18-22 ℃ with the flow of 5-10 ml/(kg·min). Flow was adjusted to maintain cerebral perfusion pressure of 50–60 mm Hg.Results CPB time was 235.0±42.0 min. Aortic clamp time was 154.0±29.0 min. Circulatory arrest (CA) time was 48.1±13.0 min. The CPB time and CA time of the TAR group were longer than those of SAR group. Overall mortality rate was 9.6%. Complications included permanent neurological dysfunction (PND), temporary neurological dysfunction (TND), acute kidney injury (AKI) requiring dialysis and delayed extubation (mechanical ventilation time >72 hours). Overall incidence of PND and TND was 2.7% and 6.8%, respectively. The incidence of AKI requiring dialysis was 4.1%. The incidence of delayed extubation was 21.9%. No difference of mortality rate or incidence of complications was found between the two groups. The average follow-up was 63.0±33.1 months. The 5-year survival rate was 72.6% in the TAR group and 85.5% in the SAR group.Conclusion Emergent aortic arch replacement using MHCA+UACP can be accomplished with excellent results.

Citation： BAO Chunrong, MEI Ju, DING Fangbao, ZHU Jiaquan, ZHANG Junwen, ZHANG Yunjiao, HUANG Jianbin, ZHANG Li, YANG Qi. Early- and mid-term results of emergent aortic arch replacement using moderate hypothermic circulatory arrest and unilateral selective antegrade cerebral perfusion. Chinese Journal of Clinical Thoracic and Cardiovascular Surgery, 2019, 26(8): 754-758. doi: 10.7507/1007-4848.201810006 Copy

1.	Settepani F, Cappai A, Basciu A, et al. Outcome of open total arch replacement in the modern era. J Vasc Surg, 2016, 63(2): 537-545.
2.	Newman MF, Mathew JP, Grocott HP, et al. Central nervous system injury associated with cardiac surgery. Lancet, 2006, 368(9536): 694-703.
3.	Griepp RB, Stinson EB, Hollingsworth JF, et al. Prosthetic replacement of the aortic arch. J Thorac Cardiovasc Surg, 1975, 70(6): 1051-1063.
4.	Estrera AL, Miller CC 3rd, Lee TY, et al. Ascending and transverse aortic arch repair: the impact of retrograde cerebral perfusion. Circulation, 2008, 118(14 Suppl): S160-S166.
5.	Leshnower BG, Myung RJ, Kilgo PD, et al. Moderate hypothermia and unilateral selective antegrade cerebral perfusion: a contemporary cerebral protection strategy for aortic arch surgery. Ann Thorac Surg, 2010, 90(2): 547-554.
6.	肖亦敏, 肖明第, 王连才, 等. Stanford A 型主动脉夹层的外科治疗. 中国胸心血管外科临床杂志, 2014, 21(3): 361-363.
7.	Khaladj N, Shrestha M, Meck S, et al. Hypothermic circulatory arrest with selective antegrade cerebral perfusion in ascending aortic and aortic arch surgery: a risk factor analysis for adverse outcome in 501 patients. J Thorac Cardiovasc Surg, 2008, 135(4): 908-914.
8.	Okita Y, Minatoya K, Tagusari O, et al. Prospective comparative study of brain protection in total aortic arch replacement: deep hypothermic circulatory arrest with retrograde cerebral perfusion or selective antegrade cerebral perfusion. Ann Thorac Surg, 2001, 72(1): 72-79.
9.	董逸飞, 卢安东, 闵凯, 等. Stanford A 型主动脉夹层的外科治疗. 中国胸心血管外科临床杂志, 2013, 20(6): 647-652.
10.	Kouchoukos NT. Total aortic arch replacement in 2013: where do we go from here? Eur J Cardiothorac Surg, 2013, 43(6): 1084-1086.
11.	Leshnower BG, Myung RJ, Thourani VH, et al. Hemiarch replacement at 28℃: an analysis of mild and moderate hypothermia in 500 patients. Ann Thorac Surg, 2012, 93(6): 1910-1915.
12.	Shelstad RC, Reeves JG, Yamanaka K, et al. Total aortic arch replacement: advantages of varied techniques. Semin Cardiothorac Vasc Anesth, 2016, 20(4): 307-313.
13.	Sun L, Qi R, Zhu J, et al. Total arch replacement combined with stented elephant trunk implantation: a new "standard" therapy for type a dissection involving repair of the aortic arch? Circulation, 2011, 123(9): 971-978.
14.	秦卫, 黄福华, 肖立琼, 等. 夜间急诊主动脉夹层手术并不增加住院死亡率. 中国胸心血管外科临床杂志, 2013, 20(5): 542-545.
15.	Angeloni E, Benedetto U, Takkenberg JJ, et al. Unilateral versus bilateral antegrade cerebral protection during circulatory arrest in aortic surgery: a meta-analysis of 5100 patients. J Thorac Cardiovasc Surg, 2014, 147(1): 60-67.
16.	Shimamoto T, Komiya T. Clinical dilemma in the surgical treatment of organ malperfusion caused by acute type A aortic dissection. Gen Thorac Cardiovasc Surg, 2014, 62(7): 398-406.
17.	Hu Z, Wang Z, Ren Z, et al. Similar cerebral protective effectiveness of antegrade and retrograde cerebral perfusion combined with deep hypothermia circulatory arrest in aortic arch surgery: a meta-analysis and systematic review of 5060 patients. J Thorac Cardiovasc Surg, 2014, 148(2): 544-560.
18.	Okita Y, Miyata H, Motomura N, et al. A study of brain protection during total arch replacement comparing antegrade cerebral perfusion versus hypothermic circulatory arrest, with or without retrograde cerebral perfusion: analysis based on the Japan Adult Cardiovascular Surgery Database. J Thorac Cardiovasc Surg, 2015, 149(2 Suppl): S65-S73.
19.	秦卫, 黄福华, 陈鑫, 等. 深低温停循环联合顺行性脑灌注对患者认知功能的影响. 中国胸心血管外科临床杂志, 2014, 21(1): 71-74.
20.	Ergin MA, Uysal S, Reich DL, et al. Temporary neurologic dysfunction after deep hypothermic circulatory arrest: a clinical marker of long-term functional deficit. Ann Thorac Surg, 1999, 67(6): 1887-1894.
21.	Apostolakis E, Koletsis EN, Dedeilias P, et al. Antegrade versus retrograde cerebral perfusion in relation to postoperative complications following aortic arch surgery for acute aortic dissection type A. J Card Surg, 2008, 23(5): 480-487.
22.	王柏春, 刘宗泓, 孟维鑫, 等. 不同体、脑灌注方式对 Stanford A 型主动脉夹层患者的脑保护研究. 中国胸心血管外科临床杂志, 2013, 20(5): 529-532.
23.	Mora Mangano CT, Neville MJ, Hsu PH, et al. Aprotinin, blood loss, and renal dysfunction in deep hypothermic circulatory arrest. Circulation, 2001, 104(12 Suppl 1): I276-I281.
24.	Cooper WA, Duarte IG, Thourani VH, et al. Hypothermic circulatory arrest causes multisystem vascular endothelial dysfunction and apoptosis. Ann Thorac Surg, 2000, 69(3): 696-702.

1. Settepani F, Cappai A, Basciu A, et al. Outcome of open total arch replacement in the modern era. J Vasc Surg, 2016, 63(2): 537-545.
2. Newman MF, Mathew JP, Grocott HP, et al. Central nervous system injury associated with cardiac surgery. Lancet, 2006, 368(9536): 694-703.
3. Griepp RB, Stinson EB, Hollingsworth JF, et al. Prosthetic replacement of the aortic arch. J Thorac Cardiovasc Surg, 1975, 70(6): 1051-1063.
4. Estrera AL, Miller CC 3rd, Lee TY, et al. Ascending and transverse aortic arch repair: the impact of retrograde cerebral perfusion. Circulation, 2008, 118(14 Suppl): S160-S166.
5. Leshnower BG, Myung RJ, Kilgo PD, et al. Moderate hypothermia and unilateral selective antegrade cerebral perfusion: a contemporary cerebral protection strategy for aortic arch surgery. Ann Thorac Surg, 2010, 90(2): 547-554.
6. 肖亦敏, 肖明第, 王连才, 等. Stanford A 型主动脉夹层的外科治疗. 中国胸心血管外科临床杂志, 2014, 21(3): 361-363.
7. Khaladj N, Shrestha M, Meck S, et al. Hypothermic circulatory arrest with selective antegrade cerebral perfusion in ascending aortic and aortic arch surgery: a risk factor analysis for adverse outcome in 501 patients. J Thorac Cardiovasc Surg, 2008, 135(4): 908-914.
8. Okita Y, Minatoya K, Tagusari O, et al. Prospective comparative study of brain protection in total aortic arch replacement: deep hypothermic circulatory arrest with retrograde cerebral perfusion or selective antegrade cerebral perfusion. Ann Thorac Surg, 2001, 72(1): 72-79.
9. 董逸飞, 卢安东, 闵凯, 等. Stanford A 型主动脉夹层的外科治疗. 中国胸心血管外科临床杂志, 2013, 20(6): 647-652.
10. Kouchoukos NT. Total aortic arch replacement in 2013: where do we go from here? Eur J Cardiothorac Surg, 2013, 43(6): 1084-1086.
11. Leshnower BG, Myung RJ, Thourani VH, et al. Hemiarch replacement at 28℃: an analysis of mild and moderate hypothermia in 500 patients. Ann Thorac Surg, 2012, 93(6): 1910-1915.
12. Shelstad RC, Reeves JG, Yamanaka K, et al. Total aortic arch replacement: advantages of varied techniques. Semin Cardiothorac Vasc Anesth, 2016, 20(4): 307-313.
13. Sun L, Qi R, Zhu J, et al. Total arch replacement combined with stented elephant trunk implantation: a new "standard" therapy for type a dissection involving repair of the aortic arch? Circulation, 2011, 123(9): 971-978.
14. 秦卫, 黄福华, 肖立琼, 等. 夜间急诊主动脉夹层手术并不增加住院死亡率. 中国胸心血管外科临床杂志, 2013, 20(5): 542-545.
15. Angeloni E, Benedetto U, Takkenberg JJ, et al. Unilateral versus bilateral antegrade cerebral protection during circulatory arrest in aortic surgery: a meta-analysis of 5100 patients. J Thorac Cardiovasc Surg, 2014, 147(1): 60-67.
16. Shimamoto T, Komiya T. Clinical dilemma in the surgical treatment of organ malperfusion caused by acute type A aortic dissection. Gen Thorac Cardiovasc Surg, 2014, 62(7): 398-406.
17. Hu Z, Wang Z, Ren Z, et al. Similar cerebral protective effectiveness of antegrade and retrograde cerebral perfusion combined with deep hypothermia circulatory arrest in aortic arch surgery: a meta-analysis and systematic review of 5060 patients. J Thorac Cardiovasc Surg, 2014, 148(2): 544-560.
18. Okita Y, Miyata H, Motomura N, et al. A study of brain protection during total arch replacement comparing antegrade cerebral perfusion versus hypothermic circulatory arrest, with or without retrograde cerebral perfusion: analysis based on the Japan Adult Cardiovascular Surgery Database. J Thorac Cardiovasc Surg, 2015, 149(2 Suppl): S65-S73.
19. 秦卫, 黄福华, 陈鑫, 等. 深低温停循环联合顺行性脑灌注对患者认知功能的影响. 中国胸心血管外科临床杂志, 2014, 21(1): 71-74.
20. Ergin MA, Uysal S, Reich DL, et al. Temporary neurologic dysfunction after deep hypothermic circulatory arrest: a clinical marker of long-term functional deficit. Ann Thorac Surg, 1999, 67(6): 1887-1894.
21. Apostolakis E, Koletsis EN, Dedeilias P, et al. Antegrade versus retrograde cerebral perfusion in relation to postoperative complications following aortic arch surgery for acute aortic dissection type A. J Card Surg, 2008, 23(5): 480-487.
22. 王柏春, 刘宗泓, 孟维鑫, 等. 不同体、脑灌注方式对 Stanford A 型主动脉夹层患者的脑保护研究. 中国胸心血管外科临床杂志, 2013, 20(5): 529-532.
23. Mora Mangano CT, Neville MJ, Hsu PH, et al. Aprotinin, blood loss, and renal dysfunction in deep hypothermic circulatory arrest. Circulation, 2001, 104(12 Suppl 1): I276-I281.
24. Cooper WA, Duarte IG, Thourani VH, et al. Hypothermic circulatory arrest causes multisystem vascular endothelial dysfunction and apoptosis. Ann Thorac Surg, 2000, 69(3): 696-702.

Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Early- and mid-term results of emergent aortic arch replacement using moderate hypothermic circulatory arrest and unilateral selective antegrade cerebral perfusion

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