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Ann Thorac Surg 2001;72:503-508
© 2001 The Society of Thoracic Surgeons

Original article: cardiovascular

Cerebral oxygenation monitoring for total arch replacement using selective cerebral perfusion

Katsushi Yamashita, MDa, Teruhisa Kazui, MDa, Hitoshi Terada, MDa, Naoki Washiyama, MDa, Kazuchika Suzuki, MDa, Abul Hasan Muhammad Bashar, MBBSa

a First Department of Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan

Accepted for publication April 3, 2001.

Address reprint requests to Dr Yamashita, First Department of Surgery, Hamamatsu University School of Medicine, 3600 Handa-cho, Hamamatsu 431-3192, Japan
e-mail: surglss{at}akiha.hama-med.ac.jp


   Abstract
Top
 Abstract
Introduction
 Material and methods
 Results
 Comment
 References
 
Background. This study was undertaken to verify the safety of our total arch replacement assisted by selective cerebral perfusion with respect to cerebral oxygenation.

Methods. Subjects to be evaluated were selected between February 1999 and March 2000 and comprised 13 patients who underwent total arch replacement (TAR) (TAR group) and 18 patients who had undergone coronary artery bypass grafting or valve replacement (control group). They were monitored throughout the operation by two-channel near-infrared spectroscopy. Changes in intracranial oxyhemoglobin and the tissue oxygenation index were compared between the two groups. Additionally, jugular venous oxygen saturation was simultaneously measured in 10 patients from each group. Maximum changes in these variables from baseline in the TAR group were compared with those in the control group. Bilateral oxygenation differences between two hemispheres were also evaluated.

Results. There was no incidence of postoperative cerebral infarction, and no significant difference was observed in the maximum decrease in these variables between the two groups. Bilateral oxygenation differences between the two hemispheres in the TAR group were similar to those in the control group, except for the tissue oxygenation index in the rewarming phase.

Conclusions. From the standpoint of cerebral oxygenation, our technique of total arch replacement was nearly as safe as an ordinary cardiac operation.


   Introduction
Top
 Abstract
 Introduction
Material and methods
 Results
 Comment
 References
 
We have adopted selective cerebral perfusion (SCP) as a cerebral protection method in total arch replacement (TAR) because it is the safest method of cerebral protection with respect to brain energy metabolism and time limitation [1, 2]. However, some patients have suffered postoperative neurological dysfunction either due to low cerebral perfusion or embolism even with the use of SCP. Although it may be difficult for the usual near-infrared spectroscopy (NIRS) to detect microembolism, as it evaluates only a part of the region of anterior cerebral artery, it may be possible that it will be able to adequately evaluate cerebral perfusion during SCP and may thus prevent low perfusion injury. The purpose of this study was to evaluate the safety of our TAR technique from the standpoint of cerebral oxygenation using NIRS and jugular venous oxygen saturation (SjO2).


   Material and methods
Top
 Abstract
 Introduction
 Material and methods
Results
 Comment
 References
 
After obtaining written informed consent, 13 patients who underwent total arch replacement (TAR group) and 18 who underwent the ordinary cardiac operations (control group; 15 coronary artery bypass grafting cases and three valve replacement cases) were monitored during operation by NIRS from February 1999 to March 2000. We used two-channel NIRS (NIRO300; Hamamatsu Photonics KK, Hamamatsu, Japan), in which two probes are placed on the forehead bilaterally. Using this system, changes in intracranial oxygenation were recorded every 2 seconds during operation. We paid particular attention to the changes in oxyhemoglobin and tissue oxygenation index (TOI). TOI is the ratio of oxygenated-to-total tissue hemoglobin, and it is calculated using photon diffusion theory in NIRO300 [3]. Moreover, SjO2 was measured in 10 patients in each group. For the estimate of SjO2, a 4F fiberoptic oximetry catheter (Dual-lumen oximetry catheter; Baxter, Deerfield, IL) was inserted into the right internal jugular vein in a retrograde fashion. The tip of the catheter was placed in the jugular bulb, which was confirmed by roentgenogram. At the beginning of the surgery, samples were drawn slowly at about 1 mL/min by hand and were immediately analyzed using an automated blood gas analyzer (Stat Profile M; Nova Biomedical Corp, Waltham, MA).

After the data from the NIRS were calculated using moving average (n = 15; 30 minutes), maximum changes in oxyhemoglobin, TOI, and SjO2 from their preoperative levels were compared between the TAR and the control groups. Baseline was defined as the values obtained at the beginning of measurement before cardiopulmonary bypass. Measurement samples in the TAR group are shown in Figures 1–3. Measurement samples in the control group are shown in Figures 4–6. In the TAR group, bilateral differences in oxyhemoglobin and TOI levels during the cooling, SCP, and rewarming phases were compared with those in the control group.



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  		Fig 1. Sample measurement of oxyhemoglobin levels in the total arch replacement (TAR) group. Maximum changes from the preoperative levels were measured. Maximum bilateral differences during the cooling, SCP, and rewarming phases were also measured. (CA = cardiac arrest; SCP = selective cerebral perfusion; Thick line, right; thin line, left.)

 


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  		Fig 2. Sample measurement of tissue oxygenation index in the total arch replacement (TAR) group. Maximum changes from the preoperative levels were measured. Maximum bilateral differences during the cooling, SCP, and rewarming phases were also measured. (CA = cardiac arrest; SCP = selective cerebral perfusion; Thick line, right; thin line, left.)

 


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  		Fig 3. Sample measurement of SjO2 in the TAR group. Maximum changes from the preoperative levels were measured. (CA = cardiac arrest; SCP = selective cerebral perfusion.)

 


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  		Fig 4. Sample measurement of oxyhemoglobin levels in the control group. Maximum changes from the preoperative levels were measured. Maximum bilateral difference during pump was also measured. (Thick line, right; thin line, left.)

 


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  		Fig 5. Sample measurement of tissue oxygenation index in the control group. Maximum changes from the preoperative levels were measured. Maximum bilateral difference during pump was also measured. (Thick line, right; thin line, left.)

 


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  		Fig 6. Sample measurement of SjO2 in the control group. Maximum changes from the preoperative levels were measured.

 
Moreover, the relationship between TOI and SjO2 was investigated from the data on the following four occasions in the TAR group: (1) at the start of CPB, (2) at a rectal temperature of 22°C, (3) at the end of SCP, and (4) at the end of CPB. We used mean TOI values of the right and left hemispheres in this analysis.

Table 1 shows patient profiles of both groups. The values of intraoperative hematocrits that have the most significant influence on this measurement were not significantly different between the two groups. Lowest rectal temperature in the TAR group was significantly lower than that in the control group. Pump time, SCP time, circulatory arrest time, and myocardial ischemic time in the TAR group were 159.8 ± 25.6, 76.8 ± 12.7, 38.6 ± 11.1, and 92.5 ± 16.4 minutes, respectively. Pump time and myocardial ischemic time in the control group were 142.2 ± 40.0 and 100.2 ± 32.2 minutes, respectively.


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  		Table 1. Profile of Patients in the TAR Group and the Control Group

 
Operation and perfusion techniques in total arch replacement
Our technique of TAR has been described previously [4–6]. The following is a brief description of the operative techniques. After instituting cardiopulmonary bypass (CPB), cooling was initiated. Arterial blood pH was managed according to the alpha-stat strategy. When the patient was cooled down to a rectal temperature of 22°C, systemic circulation was arrested and the innominate (IA) and the left common carotid arteries (LCCA) were cannulated. Cannula size for IA and LCCA were 18F and 14F, respectively. SCP was then started at the rate of 10 mL/kg/min using a roller pump. The left subclavian artery (LSA) was kept clamped during reconstruction. The distal side of the branched arch graft (Boston Scientific, Natick, MA) was anastomosed to the stump of the descending aorta. Once CPB from the fourth limb was started, the third limb was anastomosed to LSA and rewarming was begun. Then, the proximal graft was anastomosed to the stump of the ascending aorta. Next, the first and second limbs were anastomosed in succession to IA and LCCA. After rewarming up to about 36°C, the patient was weaned off the CPB.

Operation and perfusion techniques in control group
CPB was established by cannulating the ascending aorta and the vena cava. For the venous cannulation, either a two-staged venous cannula or two separate venous cannulas were used. Cardiac arrest was induced using antegrade with or without retrograde cold blood cardioplegia. Total flow rate in CPB was 2.4 L/min/m2 and cooling was not done. Mean number of coronary anastomoses in CABG cases was 3.5 ± 1.1. Mitral valve replacement or repair was done in two cases and double-valve replacement in one case.

Postoperative neurological evaluation
Electroencephalogram and neurological examination were performed in all patients by the surgeon and physicians at the intensive care unit. Computed tomography was done and the patient was examined by a psychiatrist whenever necessary.

Statistical analysis
Data are expressed as mean ± standard deviation. Mann-Whitney U test was used for comparison between the two groups.


   Results
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 Abstract
 Introduction
 Material and methods
 Results
Comment
 References
 
Hospital death and postoperative temporary or permanent neurological dysfunction did not occur in either group.

Oxyhemoglobin changed most sharply in accordance with changes in circulation. As soon as the SCP started functioning, oxyhemoglobin recovered to the precirculatory arrest level. Transition of oxyhemoglobin during SCP was more than the precirculatory arrest level or almost the same level, except in one case when oxyhemoglobin decreased gradually during SCP, and this was possibly due to hemodilution.

Table 2 shows maximum increase and decrease in oxyhemoglobin, TOI, and SjO2 in both groups. Maximum decreases in oxyhemoglobin and TOI levels did not significantly differ between the TAR and control groups. Maximum increases in TOI levels in the TAR group were significantly larger than those in the control group because cerebral metabolism was depressed due to cooling. Changes in SjO2 levels were similar to those in TOI levels. However, maximum increases in SjO2 in the TAR group were much larger than those in TOI in the control group and reflected the effect of cooling more prominently. Maximum decreases in SjO2 in the TAR group had a tendency to be smaller than those in the control group.


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  		Table 2. Maximum Increases and Decreases in Oxyhemoglobin, Tissue Oxygenation Index, and Jugular Venous Saturation Levels From Their Preoperative Levels

 
Table 3 shows bilateral differences in oxyhemoglobin and TOI in both groups. Bilateral differences in oxyhemoglobin levels in the TAR group were similar to those in the control group. Bilateral differences in TOI levels in the rewarming phase were significantly larger than those in the control group. However, in the cooling and SCP phases, significant bilateral differences were not seen.


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  		Table 3. Comparison Between Bilateral Differences in Oxyhemoglobin and Tissue Oxygenation Index Levels in the TAR Group and Those in the Control Group

 
Correlation coefficient between TOI and SjO2 in the TAR group from data on the above-mentioned four occasions was 0.44 (Fig 7).



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  		Fig 7. Scattergram showing the correlation between mean TOI values of the right and left hemispheres and SjO2 in the total arch replacement (TAR) group. Data were derived from the following four occasions: (1) at the start of cardiopulmonary bypass (CPB), (2) at rectal temperature of 22°C, (3) at the end of selective cerebral perfusion (SCP), and (4) at the end of CPB. The correlation coefficient is 0.44. (SjO2 = jugular venous oxygen saturation; TOI = tissue oxygenation index.)

 

   Comment
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 Abstract
 Introduction
 Material and methods
 Results
 Comment
References
 
It has already been reported that NIRS is particularly useful when used with hypothermic circulatory arrest (HCA) with or without retrograde cerebral perfusion (RCP) [7, 8]. Even though the usual NIRS evaluates only a part of the region of the anterior cerebral artery, abnormality is easily detectable in case of a global cerebral crisis that may occur due to HCA with or without RCP. On the other hand, it may be difficult for the usual NIRS to detect a local crisis like microembolism during SCP. However, the real efficacy of NIRS during SCP lies in the adequate evaluation of cerebral blood flow and thereby preventing low perfusion related cerebral injury. Katoh and associates reported the safety of aortic arch operation assisted by SCP based on the result of monitoring cerebral oxygenation using one-channel NIRS [9]. Their data, however, were derived from various SCP procedures. We evaluated the safety of our routine TAR technique by monitoring the oxygenation of the two cerebral hemispheres.

The pressure and flow parameters of our SCP method are based on the previously reported experimental studies. Half of the physiological flow has been recommended as optimum at a rectal temperature of 25°C [10]. With regard to perfusion pressure, it has been reported that cerebral autoregulation is preserved under alpha-stat pH management at 20°C when the perfusion pressure is more than 40 mm Hg [11]. In pH-stat management, a more acidic environment promotes cerebral vasodilation, and cerebral blood flow quickly exceeds the level required for maintenance of cerebral metabolic requirements, resulting in the so-called "luxury perfusion" [12]. Therefore, we adopted a flow rate of 10 mL/kg/min and a perfusion pressure of more than 40 mm Hg during SCP under alpha-stat management.

We evaluated the cerebral oxygenation status during TAR in comparison with that during ordinary cardiac operations. Although drastic decreases in oxyhemoglobin, TOI, and SjO2 levels always indicate critical status, maximum decreases in these parameters in the TAR group were similar to those in the control group. It indicates that our technique of TAR with the aid of SCP has made cerebral protection as optimal as in the control group. Although LSA was not perfused during anastomoses of distal aorta and LSA, this technique was not supposed to be problematic from the standpoint of cerebral oxygenation.

We also evaluated bilateral differences in oxyhemoglobin and TOI levels using two probes. During SCP phase, bilateral differences in oxyhemoglobin and TOI levels in the TAR group were similar to those in the control group. Therefore, we think that our SCP technique supplied almost an equal amount of blood to both hemispheres. Although no significant bilateral differences in oxyhemoglobin levels were seen between the two groups during the rewarming phase, differences in TOI levels in the TAR group were significantly larger than those in the control group. This could be due to the heterogeneous recovery of cerebral metabolism and uncoupling between blood supply and metabolism during the rewarming phase. More investigations will be necessary to precisely understand this mechanism, though we did not experience any postoperative neurological dysfunction.

Daubeney and associates reported that regional cerebral oxygen saturation (rSO2) measured by INVOS 3100 cerebral oximeter (Somanetics Corp, Troy, MI) significantly correlated with SjO2 in pediatric cardiac surgery (r = 0.69), and the relationship was stronger in infants (r = 0.85) compared with that in children (r = 0.57) [13]. We measured TOI instead of rSO2, but the two variables are almost the same, because TOI had already shown an excellent correlation with the data from blood gas analyzer [3]. However, in our data from adults who underwent TAR, no significant correlation was seen (r = 0.44). Sapire and associates described that SjO2 appeared to be a better indicator of cerebral oxygenation than NIRS because, during the rewarming period, SjO2 reflected cerebral desaturation more sensitively [14]. In our results the changes in TOI in accordance with hypothermia were significantly smaller than those in SjO2. Minassian and associates [15] and Lewis and associates [16] reported that cerebral tissue oxygen saturation as determined by NIRS does not adequately reflect changes in SjO2 in patients with severe closed head injury. The reason for these disparities between SjO2 and TOI or rSO2 may be the difference in their sensitivity to hypothermia and their measurement area [17]. Assessment of SjO2 provides a global estimate of cerebral oxygen extraction during cardiopulmonary bypass, while that of TOI or rSO2 provides an estimate of only part of the anterior cerebral artery region [18]. However, TOI is evaluated noninvasively, and the difference between the right and left hemispheric values may be useful for detecting cerebral circulatory abnormality. Additionally, although correlation between TOI and SjO2 was poor under hypothermia in adults, all directional changes in these two variables were same.

However, cerebral oxygenation status may not always reflect the postoperative subtle neurological damage: for example, the minor changes that can be detected by magnetic resonance image. This represents a limitation of this study, and more detailed investigations need to be done in larger series to resolve this issue.

Multichannel near-infrared spectroscopic topography, which has been used to detect oxygenation changes in an extended cerebral area [19], is expected to contribute to a more precise monitoring of cerebral oxygenation during aortic arch operation in the future. To detect the heterogeneity of cerebral blood flow in high-risk patients such as patients with old cerebral infarction, multichannel measurement might be more useful because it can measure a wider cerebral area.

In conclusion, our method of SCP in TAR was nearly as safe as ordinary cardiac operation, as reflected by the evaluation of cerebral oxygenation using NIRS and SjO2.


   References
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 Abstract
 Introduction
 Material and methods
 Results
 Comment
 References
 

  1. Swain J.A., Macdonald T.J., Griffith P.K., et al. Low-flow hypothermic cardiopulmonary bypass protects the brain. J Thorac Cardiovasc Surg 1991;102:76-84.[Abstract]
  2. Sakurada T., Kazui T., Tanaka H., Komatsu S. Comparative experimental study of cerebral protection during aortic arch reconstruction. Ann Thorac Surg 1996;61:1348-1354.[Abstract/Free Full Text]
  3. Suzuki S., Takasaki S., Ozaki T., Kobayashi Y. A tissue oxygenation monitor using NIR spatially resolved spectroscopy. Proc SPIE-Int Soc Opt Eng 1999;3597:582-592.
  4. Kazui T., Washiyama N., Muhammad B.A.H., Terada H., Yamashita K., Takinami M. Improved results of atherosclerotic arch aneurysm using a refined technique. J Thorac Cardiovasc Surg 2001;121:491-499.[Abstract/Free Full Text]
  5. Kazui T., Washiyama N., Muhammad B.A.H., et al. Total arch replacement using aortic arch branched grafts with the aid of antegrade selective cerebral perfusion. Ann Thorac Surg 2000;70:3-8.[Abstract/Free Full Text]
  6. Kazui T., Washiyama N., Muhammad B.A.H., et al. Extended total arch replacement for acute type A aortic dissection: experience with seventy patients. J Thorac Cardiovasc Surg 2000;119:558-565.[Abstract/Free Full Text]
  7. Higami T., Kozawa S., Asadá T., et al. Retrograde cerebral perfusion versus selective cerebral perfusion as evaluated by cerebral oxygen saturation during aortic arch reconstruction. Ann Thorac Surg 1999;67:1091-1096.[Abstract/Free Full Text]
  8. Ogino H., Ueda Y., Sugita T., et al. Monitoring of regional cerebral oxygenation by near-infrared spectroscopy during continuous retrograde cerebral perfusion for aortic arch surgery. Eur J Cardiothorac Surg 1998;14:415-418.[Abstract/Free Full Text]
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