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Ann Thorac Surg 2007;83:1055-1058
© 2007 The Society of Thoracic Surgeons

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Original Articles: Cardiovascular

Quick Proximal Arch Replacement With Moderate Hypothermic Circulatory Arrest

^a Division of Thoracic and Cardiovascular Surgery, Hannover Medical School, Hannover, Germany
^b Division of Radiology, Hannover Medical School, Hannover, Germany

Accepted for publication September 25, 2006.

^_* Address correspondence to Dr Kamiya, Department of Cardiac Surgery, University of Heidelberg, INF 110, 69120 Heidelberg, Germany (Email: hiroyuki.kamiya{at}med.uni-heidelberg.de).

	Abstract

Top Abstract Introduction Material and Methods Results Comment References

 
Background: The aim of this study is to evaluate the safety of proximal arch repair using only moderate hypothermic circulatory arrest (HCA) at a temperature of 25°C to 28°C without any adjunctive cerebral protection in comparison with those with moderate HCA and selective cerebral perfusion.

Methods: Thirty patients who underwent proximal arch repair using moderate HCA without selective cerebral perfusion (SCP) were retrospectively examined and defined as the SCP (–) group. As a control group, 31 patients who underwent moderate HCA and SCP within 10 minutes were included in this study and defined as the SCP (+) group.

Results: Mean circulatory arrest time was 9.4 ± 0.8 minutes and 7.5 ± 1.8 minutes (p = 0.0001) and mean nasopharyngeal temperature at the induction of the circulatory arrest was 26.0 ± 1.2°C and 26.8 ± 1.3°C (p = 0.014) in the SCP (+) group and SCP (–) group, respectively. Operative mortality was 3.2% in the SCP (+) group and 3.3% in the SCP (–), and neurologic complications were found in three (9.7%) patients in the SCP (+) group and two (6.7%) patients in the SCP (–) group (p = 0.69).

Conclusions: It was possible to perform proximal arch replacement in selected patients using moderate HCA without any adjunctive cerebral protection with excellent results, and no advantage of the use of SCP was found in patients who required short HCA for proximal arch replacement.

	Introduction

Top Abstract Introduction Material and Methods Results Comment References

 
Antegrade selective cerebral perfusion (SCP) with moderate hypothermic circulatory arrest (HCA) at a temperature of 25°C to 28°C has been the cerebral protection method of choice for repair of the aortic arch in our institute [1]. However, we have been using only moderate HCA without any adjunctive cerebral protection for patients with ascending aortic aneurysms extending into the proximal aortic arch if the distal anastomoses seem to be simple and easy. The aim of this study is to evaluate this surgical strategy in comparison with the surgical results of patients who underwent proximal arch repair with moderate HCA and SCP.

	Material and Methods

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Patients
Between October 2000 and December 2005, 862 adult patients underwent surgery for ascending aortic disease with or without a repair of the aortic arch. Of these, moderate HCA (temperature >24°C) with SCP was used in 512 patients (389 patients for proximal arch replacement and 123 patients for total arch replacement) and moderate HCA without SCP was used in 30 patients. These 30 patients were retrospectively examined and defined as the SCP (–) group. As a control group, 31 patients who underwent moderate HCA and SCP within 10 minutes were included in this study and defined as the SCP (+) group. All the studied patients underwent repair of the proximal arch through a median sternotomy and there was no patient who received total arch replacement. The review board of our institute approved the present study and waived the need for individual patient consent for this retrospective study.

Preoperative patient characteristics are presented in Table 1. There were no significant differences in preoperative patient characteristics between the groups. No patient received operation due to acute aortic dissection type A, and 27 patients in the SCP (+) group (87%) and 26 patients in the SCP (–) group (87%) received proximal arch replacement due to degenerative aneurysms.

During the circulatory arrest, distal anastomoses were performed with running suture. If needed, the arterial cannula was reinserted into the graft prosthesis. Then, CPB was resumed and the patient was rewarmed. In most cases, the rest of the manipulation of the proximal site and an anastomosis between prostheses were performed during the warming phase.

Definitions of Neurologic Complications
According to the report by Ergin and colleagues [2], we defined temporary neurologic dysfunction (TND) as the occurrence of at least one of the following symptoms: postoperative confusion, agitation, delirium, prolonged obtundation normally observed as drowsiness prolonged longer than 48 hours, or transient parkinsonism without obvious neurologic deficit. Stroke was defined as the presence of transient or permanent focal neurologic deficit that was confirmed by means of computed tomography as new deficits. When patients appeared to have neurologic complication, the patient was examined by a neurologist.

Statistical Analysis
Results are expressed as mean ± standard deviation. Statistical analysis was performed using the Student t test for continuous variables or the ² test (Fisher exact test if n < 5) for categorical variables. A p value less than 0.05 was considered significant. All statistical analyses were performed using SPSS 10.0 software (SPSS Inc, Chicago, IL).

	Results

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All perioperative data and postoperative adverse events are listed in Table 2. All the patients received replacement of the ascending aorta and the proximal aortic arch. As concomitant procedures, aortic valve-root procedures (including aortic valve replacement, root replacement with a composite graft, and aortic root reimplantation) were performed in 27 (82%) patients in the SCP (+) group and 22 (73%) patients in the SCP (–) group (p = 0.21), and coronary artery bypass grafting was performed in seven (23%) patients in the SCP (+) group and six (20%) patients in the SCP (–) group (p = 0.81). In the SCP (–) group, two patients underwent other concomitant procedures; closure of atrial septal defect type I with mitral valve repair and replacement of infrarenal abdominal aorta.

Operative mortality was 3.2% in the SCP (+) group and 3.3% in the SCP (–) group One patient in the SCP (+) group died due to multiorgan failure on the tenth postoperative day and one patient in the SCP (–) group died suddenly on the third postoperative day at the general ward, presumably due to a cardiac event.

Neurologic complications were found in three (9.7%) patients in the SCP (+) group and two (6.7%) patients in the SCP (–) group (p = 0.69). One patient each in both groups suffered from temporary delirium, and one patient in the SCP (–) group suffered from postoperative confusion. Those were diagnosed by neurologists and classified as TND (3.2% in the SCP [+] group versus 6.7% in the SCP [–] group; p = 0.61). One patient suffered from aphasia and another patient suffered from paralysis of the right arm in the SCP (+) group. In both patients, new deficits were confirmed by means of computed tomography and classified as stroke. Thus, stroke was identified in two (6.4%) patients in the SCP (+) group whereas no patient in the SCP (–) group suffered from stroke (p = 0.49). Reexploration for bleeding was needed in one (3.2%) patient in the SCP (+) group and also in one (3.3%) patient in the SCP (–) group (p = 0.98). One patient in the SCP (–) group suffered from acute abdomen due to perforation of the sigmoid colon one week after the operation and underwent resection of the colon. There were no differences in durations of intensive care unit and hospital stay between the groups.

	Comment

Top Abstract Introduction Material and Methods Results Comment References

 
In this series, it was possible to perform proximal arch replacement in selected patients using moderate HCA at a mean 26.8 ± 1.3°C for a mean 7.5 ± 1.8 minutes without any adjunctive cerebral protection with excellent results. In the present study, no advantage of the use of SCP was found in the patients who required short HCA for proximal arch replacement.

It has been considered that 35 to 40 minutes of HCA at 20°C is relatively safe, but there is increasing evidence that the safe interval is probably a lot shorter [1]. To secure a larger safety margin, SCP is at present used as an adjunctive cerebral protection in many institutes [3–6]. However, there is no standard guideline as to what temperature should be achieved before the extracorporeal circulation can be stopped followed by the initiation of SCP, and each institute has its own protocol. In recent years, the trend has gone from deep temperatures, under 20°C as advocated by the Mount Sinai group [3], toward higher temperatures up to 25°C [4–6]. In our institute, SCP with moderate HCA at a temperature of 25°C to 28°C is the cerebral protection method of choice at present.

However, it is unclear whether SCP is useful also for very short durations of HCA because manipulations to establish SCP itself require a few minutes, cannulation tubes disturb quick anastomosis, and cannulation into the arch vessels can cause embolic events. Considering such facts, we have been performing proximal arch replacement using moderate HCA without SCP in patients with ascending aortic aneurysms extending into the proximal aortic arch if the distal anastomoses seem to be simple and easy. In this series, proximal arch replacement could be performed with a mean 7.5 ± 1.8 minutes under the condition of bloodless operative field achieved through HCA without being disturbed by cannulation tubes, and the results suggest that this strategy is technically possible.

In the present study, neurologic complications were found in two (6.7%) patients in the SCP (–) group and in three patients (9.7%) in the SCP (+) group. This result could be interpreted that there was no advantage to the use of SCP on the neurologic outcome in the selected patients who required proximal arch replacement in our study cohort. Moreover, no patient in the SCP (–) group suffered from stroke, whereas it was identified in two patients in the SCP (+) group, although the difference was not statistically significant. We consider that this result may be due to the absence of cannulation tubes needed for SCP.

Patient selection is extremely important for this technique. In our institute, only three surgeons (A.H., M.K., and M.S.) have used this method (moderate hypothermia without SCP) and the surgical decision was made according to the surgeon’s visual impression of the aneurysms. Thus, there have been no strict selection criteria for this surgical method; however, here those could be discussed based on this study.

The most important prerequisite for the application of this method is to use the technique only in patients with simple morphology of the aortic arch, in whom it can be clearly expected, prior to introducing HCA, that the proximal arch replacement could be performed quickly and easily. From this perspective, degenerative aneurysm of the ascending aorta extending to the arch (as shown in Fig 1) may be a preferable indication for this procedure. In this series, most of the patients in both groups had degenerative aneurysm (87% in both groups). Presumably those degenerative aneurysms could occur second to the aortic valve disease, as shown by the fact that approximately 80% of all patients (87% in the SCP [+] group and 73% in the SCP [–] group) received concomitant aortic valve procedures. In well-selected patients in this series, especially in patients with degenerative aneurysm, the distal anastomosis could be done within 10 minutes. This result suggests that proximal arch replacement with moderate hypothermic circulatory arrest without SCP could be one of the methods of choice in such a patient cohort. Although four patients with other pathologies (atherosclerotic aneurysm in one patient and chronic aortic dissection in three patients) were treated without SCP in this series, we consider that patients with those aortic pathologies are not optimal candidates for this method because unexpected morphology of the aortic inner wall has sometimes been seen in such patients in our usual clinical settings.

View larger version (54K): [in this window] [in a new window]   Fig 1. A three-dimensional computer tomography of a patient in the SCP (+) group. A degenerative aneurysm of the ascending aorta (5.5 cm) extended to the arch.

In conclusion, it was possible to perform proximal arch replacement in selected patients using moderate HCA at a mean 26.8 ± 1.3°C for a mean 7.5 ± 1.8 minutes without any adjunctive cerebral protection with excellent results, and, in the present study, no advantage of the use of SCP was found in patients who required short HCA for proximal arch replacement. This technique enables quick and safe proximal arch replacement, but patient selection is extremely important when applying this strategy.

	References

Top Abstract Introduction Material and Methods Results Comment References

 

1. Hagl C, Khaladj N, Karck M, et al. Hypothermic circulatory arrest during ascending and aortic arch surgery: the theoretical impact of different cerebral perfusion techniques and other methods of cerebral protection Eur J Cardiothorac Surg 2003;24:371-378.[Abstract/Free Full Text]
2. Ergin MA, Galla JD, Lansman L, Quintana C, Bodian C, Griepp RB. Hypothermic circulatory arrest in operations on the thoracic aortaDeterminants of operative mortality and neurologic outcome. J Thorac Cardiovasc Surg 1994;107:788-797.[Abstract/Free Full Text]
3. Hagl C, Ergin MA, Galla JD, et al. Neurologic outcome after ascending aorta-aortic arch operations: effect of brain protection technique in high-risk patients J Thorac Cardiovasc Surg 2001;121:1107-1121.[Abstract/Free Full Text]
4. Kazui T, Yamashita K, Washiyama N, et al. Usefulness of antegrade selective cerebral perfusion during aortic arch operations Ann Thorac Surg 2002;74:S1806-S1809.[Abstract/Free Full Text]
5. Di Eusanio M, Wesselink RM, Morshuis WJ, Dossche KM, Schepens MA. Deep hypothermic circulatory arrest and antegrade selective cerebral perfusion during ascending aorta-hemiarch replacement: a retrospective comparative study J Thorac Cardiovasc Surg 2003;125:849-854.[Abstract/Free Full Text]
6. Bachet J, Guilmet D, Goudot B, et al. Antegrade cerebral perfusion with cold blood: a 13-year experience Ann Thorac Surg 1999;67:1874-1878.[Abstract/Free Full Text]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Hiroyuki Kamiya Christian Hagl Klaus Kallenbach Nawid Khaladj Axel Haverich Matthias Karck Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Kamiya, H. Articles by Karck, M. Search for Related Content PubMed PubMed Citation Articles by Kamiya, H. Articles by Karck, M. Related Collections Great vessels