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Ann Thorac Surg 1996;62:94-104
© 1996 The Society of Thoracic Surgeons
Department of Thoracic Surgery, Nagoya University School of Medicine, Nagoya, Japan
Accepted for publication January 27, 1996.
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Abstract |
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 Top Abstract IntroductionPatients and MethodsResultsCommentAcknowledgmentsReferences |
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Methods. A survey of 49 institutions was performed to investigate the early results of RCP in Japan. There were 228 patients collected, 46 (20.2%) of whom sustained brain complications. Twenty-seven patients had permanent and 19, temporary neurologic dysfunction. There were 31 early deaths (13.6%) and an additional 14 hospital deaths (6.1%). Significant predictors of brain complications and mortality were evaluated by univariate analysis and multivariate analysis using stepwise logistic regression.
Results. By multivariate analysis, preoperative cardiac arrest (odds ratio 8.901, p= 0.0004) and RCP duration longer than 60 minutes (odds ratio 3.234, p = 0.0352) were significant predictors of permanent neurologic dysfunction. Preoperative hemodynamic compromise (odds ratio 6.150, p = 0.0070), presence of preoperative neurologic symptoms (odds ratio 7.155, p = 0.0283), and left thoracotomy (odds ratio 2.37, p = 0.0335) were significant predictors of early death. Duration of RCP was the single RCP–related factor predictive of a brain complication (odds ratio 1.025 per minute, p < 0.0001). The incidence of permanent neurologic dysfunction was less than 10% when the RCP time was shorter than 60 minutes but increased abruptly when the RCP time exceeded 100 minutes, and it remained approximately 15% between 60 and 99 minutes.
Conclusions . Less than 60 minutes of RCP can be tolerated with minimal risk of brain complication. Retrograde cerebral perfusion is one method of cerebral protection during circulatory arrest. This method is not the complete answer for brain protection, but, given specific guidelines, it may help prolong the safe time of circulatory arrest.
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Introduction |
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TopAbstractIntroductionPatients and MethodsResultsCommentAcknowledgmentsReferences |
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During operations on the aortic arch, protection of the brain is a primary concern. Selective cerebral perfusion and hypothermic circulatory arrest are two commonly used adjuncts for cerebral protection. However, neither technique is entirely satisfactory. Hypothermic circulatory arrest must be limited in duration [1–4], and selective cerebral perfusion requires extracorporeal circuits and complicated techniques for cannulation. Retrograde cerebral perfusion (RCP) through the superior vena cava (SVC) is a new and simple technique to protect the brain during deep hypothermic circulatory arrest. Its first reported use was to manage massive air embolism during cardiopulmonary bypass [5]. As a technique for protecting the brain during aortic arch operations, intermittent retrograde perfusion was reported by Lemole and associates [6] in 1982, and continuous RCP was reported by Ueda and colleagues [7] in 1990. In our experimental work [8, 9], RCP can supply one third of the oxygen provided by antegrade perfusion and has been shown to minimize ischemic damage to the brain. Therefore, deep hypothermic RCP may be useful to extend the length of time the cerebral circulation can be safely interrupted.
In Japan, RCP has been used for brain protection since 1986. Interest in the method has spread rapidly, but the techniques vary by institution. Thus the optimum perfusion conditions have not been established. We founded the Retrograde Organ Perfusion Study group, which comprises 49 Japanese institutions, and have collected clinical data on RCP since June 1990 (Appendix 1). Our first questionnaire concerning the early results of RCP for aortic arch operations was conducted in August 1992, and the results are detailed here.
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Patients and Methods |
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TopAbstractIntroductionPatients and MethodsResultsCommentAcknowledgmentsReferences |
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Clinical profiles were based on age, sex, and type of aortic disease. Aortic pathology was classified as aortic dissection types A and B and true aneurysm. Annuloaortic ectasia and Marfan's syndrome were also noted. Preoperative status was determined by the timing of the operation (emergent or elective) and the presence of neurologic symptoms, hemodynamic compromise, or cardiac arrest. Emergent operation was defined as operation within 24 hours of admission. Operations included proximal arch replacement, entire aortic arch replacement, distal aortic arch replacement, aortic root replacement, and miscellaneous procedures.
Methods of RCP were classified by perfusion site-SVC perfusion [10], SVC and inferior vena cava (IVC) perfusion [11], and SVC and arterial perfusion-or the central venous pressure elevation method [12]. Cardiopulmonary bypass time, cardiac ischemic time, RCP time, SVC pressure, SVC flow rate during RCP, and minimum nasopharyngeal or esophageal temperature were used to characterize the operative conditions. Additional methods of brain protection including drugs and head cooling with icing were recorded. Clinical results were based on rapidity of awakening and duration of endotracheal intubation.
Outcomes were based on operative complications (cardiac, pulmonary, hepatic, or renal), neurologic dysfunction (temporary or permanent), and mortality (early death or hospital death). A cardiac complication was defined as need of a circulatory assist device (left ventricular assist device, percutaneous cardiopulmonary support, or intraaortic balloon pump). A pulmonary complication was defined as respirator use for longer than 7 days. Hepatic complication was defined as severe jaundice (total bilirubin >10 mg/dL). A renal complication was defined as need of artificial dialysis. Any kind of neurologic dysfunction that occurred after operation and did not resolve was defined a permanent neurologic dysfunction. When the dysfunction resolved completely during the hospital stay, it was considered temporary. Early death was defined as death within 30 days after operation, and hospital death was defined as death before discharge from the hospital after operation.
The data were evaluated using the Statistical Analysis System. The results were expressed as the mean ± the standard deviation. Significance between groups was determined using the 
2 test and univariate unconditional logistic regression. A p value of less than 0.05 was considered significant (see Appendices 2 through 4). Variables that were determined to have a significant influence on neurologic outcome and mortality by univariate analysis were examined by multivariate analysis using stepwise logistic regression. The results were expressed as odds ratios and p values.
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Results |
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TopAbstractIntroductionPatients and MethodsResultsCommentAcknowledgmentsReferences |
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Neurologic Outcome
Forty-six patients (20.2%) experienced neurologic dysfunction (Table 1
). Thirteen of them died early, 14 had permanent neurologic deficits, and 19 recovered without residual deficits. Five patients died in the hospital; 3 had permanent neurologic dysfunction and 2, temporary dysfunction.
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Twenty-seven patients who experienced neurologic dysfunction underwent a computed tomographic scan of the head after operation. The findings were brain infarctions in 13 patients and cerebral edema in 3; the results were negative in the other 11 patients (Table 2).
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Temporary neurologic dysfunction occurred in 19 patients (8.3%). Univariate analysis revealed the following factors as significant predictors: sex, type of operation, and RCP method. Only sex remained by multivariate analysis (see Table 3).
Surgical Risk Factors for Neurologic Dysfunction
Duration of RCP for more than 60 minutes was the significant operative risk factor for permanent neurologic dysfunction by multivariate analysis (see Table 3). The RCP time of patients with neurologic dysfunction was significantly longer than that of the other patients (69.1 ± 36.3 minutes versus 50.5 ± 21.6 minutes; p < 0.001). Retrograde cerebral perfusion time emerged as the dominant factor predictive of overall neurologic dysfunction (odds ratio 1.025 per minute, p < 0.0001). The incidence of overall neurologic dysfunction increased as the RCP time lengthened. When RCP time was divided into four periods by 30-minute increments-0 through 29 minutes, 30 through 59, 60 through 89, and 90 minutes or greater-the incidence of overall neurologic dysfunction was 4.0%, 17.1%, 25.0%, and 41.7%, respectively. Compared with the 0- through 29-minute group, the odds ratios were 2.788 (p = 0.1425) in the 30- through 59-minute group, 4.548 (p = 0.0511) in the 60- through 89-minute group, and 11.09 (p = 0.0062) in the 90-minute or greater group by multivariate analysis.
Cardiac ischemic time longer than 120 minutes had a significant influence on overall neurologic dysfunction by multivariate analysis. The cardiac ischemic time of patients with neurologic dysfunction was significantly longer than that of the other patients (127 ± 55 minutes versus 107 ± 50 minutes; p = 0.045). Cardiac ischemic time also emerged as the dominant factor predictive of overall neurologic dysfunction (odds ratio 1.018 per minute, p = 0.0024). When cardiac ischemic time was divided into 1-hour increments, the incidence of overall neurologic dysfunction was 17.5% in the first hour, 12.5% in the second hour, 29.2% in the third hour, and 30.0% for more than 4 hours. Compared with the 2-hour group, the odds ratios were 1.382 (p = 0.2425) in the 1-hour group, 2.216 (p = 0.1511) in the 3-hour group, and 2.033 (p = 0.1416) in the greater than 4-hour group by multivariate analysis. There were no significant differences between groups (Fig 1).
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The overall neurologic dysfunction rate also varied according to RCP method: 15.4% for SVC perfusion, 37.5% for SVC and IVC perfusion, 21.1% for SVC and arterial perfusion, and 30.4% for the central venous pressure elevation method. Compared with SVC perfusion, the odds ratios were 2.231 (p = 0.1294) for SVC and IVC perfusion, 1.136 (p = 0.8146) for SVC and arterial perfusion and 2.239 (p = 0.1779) for the central venous pressure elevation method. There were no significant differences between the RCP methods.
Mortality
There were 31 early deaths (13.6%) and 14 hospital deaths (6.1%). One hundred eighty-three patients (80.3%) survived the operation and were discharged from the hospital. The causes of early death were cardiac related in 8 patients, multiorgan failure in 8, brain complication in 6, rerupture in 5, infection in 2, and necrotic pancreatitis in 2. The causes of hospital death were multiorgan failure in 6 patients, infection in 4, respiratory failure in 2, and brain complication in 2.
By univariate analysis, several preoperative and operative factors were predictive of early death. They were presence of preoperative neurologic symptoms, preoperative hemodynamic compromise, cardiac arrest and rupture, type of operation, surgical approach, pump time longer than 240 minutes, and RCP time longer than 60 minutes. Multivariate analysis revealed three simultaneously predictive variables: preoperative hemodynamic compromise, preoperative neurologic symptoms, and operative approach. As postoperative factors, late awakening (after the second postoperative day), permanent neurologic dysfunction, and cardiac, pulmonary, hepatic, and renal complications were predictive of early death by univariate analysis. On multivariate stepwise logistic regression analysis, late awakening, cardiac complication, and renal complication retained significance (Table 4).
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Comment |
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TopAbstractIntroductionPatients and MethodsResultsCommentAcknowledgmentsReferences |
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Of preoperative factors, an episode of cardiac arrest had significant influence for permanent neurologic dysfunction, and presence of rupture was a predictor of overall neurologic dysfunction. Hemodynamic compromise and preoperative neurologic symptoms had a significant influence on early mortality, and age greater than 70 years was a predictor of hospital mortality. Emergency operation had no influence on either neurologic dysfunction or mortality, but an emergency situation such as cardiac arrest, hemodynamic compromise, rupture, or preoperative neurologic symptoms had a significant influence on neurologic dysfunction and mortality.
Of operative factors, RCP duration longer than 60 minutes and cardiac ischemic time longer than 120 minutes had significance for neurologic dysfunction, and surgical approach was the single significant predictor of early mortality. As RCP duration is the strongest predictor of permanent neurologic dysfunction, there must be limits of duration for its safe use. In fact, relative risk increased as RCP time lengthened. The odds ratio for neurologic dysfunction increased 1.025 per minute of RCP time. However, it is difficult to determine the safe limits of RCP duration.
In our experimental work [8, 9, 13], RCP provides about half of the blood flow to the brain and a third of the oxygen to the body compared with antegrade perfusion. Retrograde cerebral perfusion maintained aerobic metabolism, kept a high level of cerebral tissue adenosine triphosphate, and kept cerebral tissue temperature low. Therefore, RCP can reduce ischemic damage to the brain and theoretically extend the time of cerebral circulation interruption. However, RCP is nonphysiologic and cannot be performed uniformly in each case.
In the present survey, there was no permanent neurologic dysfunction with less than 30 minutes of RCP. The incidence of permanent neurologic dysfunction with every 10-minute increment between 30 and 59 minutes was not consecutive: 10.4%, 4.5%, and 9.7%, respectively (Fig 3). The incidence was relatively higher in the 30- to 39-minute group, but there were 2 patients with cardiac arrest and 2 with neurologic deficits preoperatively in this group. There was only 1 patient whose brain complication was considered due to insufficient RCP. Therefore, the rate of permanent neurologic dysfunction was less than 10% in patients in whom RCP duration was less than 60 minutes.
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). Postoperative brain complications after aortic arch operations can also be caused by embolization of atheromas, thrombi, or air. In addition, insufficient cerebral perfusion can occur during simple cardiopulmonary bypass in patients with aortic aneurysms. Therefore, it is extremely difficult to precisely determine the safe time limits of RCP. As a guide, RCP lasting less than 30 minutes should not cause brain complications, and RCP of less than 60 minutes can be tolerated with minimal risk of permanent neurologic dysfunction. However, RCP must be limited to less than 100 minutes. It is also difficult to determine causes of neurologic dysfunction. Even the results of head computed tomography do not always reveal the cause. In 4 of 11 patients with coma, the findings were negative. The cause might be related to insufficient perfusion, which can result from several factors during RCP. Competent venous valves in the SVC system is a major factor. Completely competent venous valves, in which there is no regurgitation through the SVC to the internal jugular vein as determined by angiography, have been reported in 4 (10.5%) of 38 patients [14]. To overcome the obstruction in venous valves, selective cannulation of the internal jugular vein using a central venous catheter and a guidewire has been developed [15]. This technique should reduce the incidence of insufficient RCP.
Cardiac ischemic time was another significant predictor of brain complications. The incidence of permanent neurologic dysfunction increased when cardiac ischemic time exceeded 3 hours (30%). In most patients, RCP was performed during cardiac arrest, and therefore, cardiac ischemic time should have a strong correlation with RCP time. In fact, the correlation coefficient between cardiac ischemic time and RCP time was 0.533 (p = 0.001).
The main aim of this survey was to develop guidelines for the use of RCP. The duration of RCP is the most important determinant. However, RCP method had a significant influence on both permanent and temporary neurologic dysfunction by univariate analysis. Superior vena cava perfusion, which was associated with the lowest complication rate, was significantly better than SVC and IVC perfusion by univariate analysis. However, the average duration of RCP for each RCP method was 49 ± 24 minutes for SVC perfusion, 66 ± 33 minutes for SVC and IVC perfusion, 60 ± 27 minutes for SVC and arterial perfusion, and 64 ± 26 minutes for the central venous pressure elevation method. Superior vena cava perfusion has the lowest average RCP duration. However, by multivariate analysis, SVC perfusion lost its superiority over SVC and IVC perfusion.
In this survey, SVC pressure was not a significant predictor of brain complication, but SVC pressure between 15 and 24 mm Hg showed the least risk for neurologic dysfunction. When SVC pressure exceeded 35 mm Hg, risk of brain complication increased significantly. It may be best to maintain SVC pressure between 15 and 24 mm Hg whenever possible.
Operative approach was the single surgical factor that influenced early mortality. Left thoracotomy on a patient in the decubitus position had a significantly higher risk for neurologic dysfunction than did median sternotomy. This may be because many patients having distal arch replacement underwent operation through a left thoracotomy.
Of the postoperative factors, late awakening, cardiac complication, and renal complication caused a significant risk for early mortality, and long-term intubation was the single significant predictor of hospital death. Main causes of early death were cardiac and related multiorgan failure. Main causes of hospital mortality were multiorgan failure and infection. Permanent neurologic dysfunction, which had significance for early and hospital mortality by univariate analysis, lost its significance by multivariate analysis. However, half of the patients with permanent neurologic dysfunction died early. Brain complication must not be disregarded in the prognosis.
The overall mortality rate in the present survey was 19.7%. The hospital mortality rate in patients having an emergency operation was 24.3% and for patients having elective operation, 15.2%. This rate is higher than the rates in other series of circulatory arrest. Ergin and colleagues [3] reported an overall mortality rate of 15% in 200 patients, and Svensson and colleagues [4] had a 10% operative mortality rate and a 12% hospital mortality rate in 656 patients. Ergin and co-workers [3] showed that the presence of hemodynamic compromise was a strong independent predictor of overall mortality. Laas and associates [16] reported neurologic complications as the second most important cause of hospital mortality. Svensson and colleagues [4] found that length of cardiopulmonary bypass time was a better predictor of postoperative death than circulatory arrest time. In the present series, hemodynamic compromise and neurologic symptoms were the strongest preoperative predictors of early mortality, and cardiac complication was the most important postoperative predictor of early death.
In comparing this series with other series of circulatory arrest, it is difficult to estimate how much advantage RCP has for brain protection. The safe limits of circulatory arrest have often been reported. Treasure and colleagues [17] showed that the risk of neurologic dysfunction increased markedly after 45 minutes of circulatory arrest. Ergin and associates [3] reported that temporary neurologic dysfunction was related to the duration of circulatory arrest; it increased 30% when arrest time exceeded 40 minutes and 60% when arrest time was longer than 60 minutes. This group concluded that an arrest time exceeding 60 minutes is not advisable, especially in elderly patients. Svensson and colleagues [4] found that circulatory arrest time was not an independent determinant of death and postoperative stroke. Their results showed that only 15% of patients with a circulatory arrest period exceeding 1 hour had strokes, but these authors also suggested that after 40 minutes of circulatory arrest, the risk of stroke started increasing and the mortality markedly increased if circulatory arrest time exceeded 65 minutes. The present survey showed that the occurrence of neurologic dysfunction was less than 10% when RCP time was less than 60 minutes and increased markedly when it exceeded 100 minutes.
There was some evidence that RCP has additional advantages for circulatory arrest. Early awakening after operation and mental alertness after awakening of patients undergoing RCP show its advantages. This was noted in another report [4]. A prospective clinical study of circulatory arrest with and without RCP should clarify its advantages. This study presents clinical results at the beginning of use of the RCP procedure, and the clinical outcomes should improve.
Retrograde cerebral perfusion is an alternative method of cerebral protection during hypothermic circulatory arrest. This method can be performed without clamping or cannulation of the cervical arteries. This reduces the chances of cerebral thrombosis and does not obscure the operative field. Retrograde perfusion is not the complete answer to brain protection but, with guidelines, may help prolong, to some degree, the safe time of circulatory arrest. Further clinical studies such as prospective, randomized studies are necessary to refine the guidelines of the RCP procedure. As we use the RCP procedure, the clinical results should improve.
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Acknowledgments |
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TopAbstractIntroductionPatients and MethodsResultsCommentAcknowledgmentsReferences |
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TopAbstractIntroductionPatients and MethodsResultsCommentAcknowledgmentsReferences |
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Y. Okita, S. Takamoto, M. Ando, T. Morota, R. Matsukawa, and Y. Kawashima Mortality And Cerebral Outcome In Patients Who Underwent Aortic Arch Operations Using Deep Hypothermic Circulatory Arrest With Retrograde Cerebral Perfusion: No Relation Of Early Death, Stroke, And Delirium To The Duration Of Circulatory Arrest J. Thorac. Cardiovasc. Surg., January 1, 1998; 115(1): 129 - 133. [Abstract] [Full Text] [PDF]
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