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Correspondence

Contemporary Conduct of Adult Deep Hypothermic Circulatory Arrest: Possible Roles of Retrograde Cerebral Perfusion, Anesthetic Preconditioning, and Aprotinin

Department of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104-4283

(Email: yiandoc{at}hotmail.com).

To the Editor:

I read with great interest the excellent article of Gega and colleagues [1] detailing their approach to adult aortic arch repair with straight deep hypothermic circulatory arrest (DHCA). Their results suggest the adequacy of straight DHCA without adjunctive perfusion, especially for arrest times of less than 40 minutes. There was, however, a fourfold increase in stroke risk when the DHCA time exceeded 40 minutes (13.1% vs 3.3% p < 0.01): 62.5% of these strokes were classified as embolic by an experienced neuroradiologist. Because the authors acknowledge in their discussion that retrograde cerebral perfusion is an adjunct for cerebral embolic washout, the following questions arise:

1 Was retrograde cerebral perfusion used in this series for embolic washout? If so, in what percentage of the patient cohort? Could this be a significant confounder?

2 If retrograde cerebral perfusion was not used at all, do the results of this series support the need for this perfusion technique to enhance embolic clearance? If so, would the authors suggest it be routine or only in selected cases with stroke predictors such as DHCA time exceeding 40 minutes or severe aortic atheroma, or both.

The second consideration is related to the conduct of cooling, because the authors do not specify in the article whether a neuroprotective volatile anesthetic such as desflurane was administered [2]. As a consequence, the following questions arise:

1 Was a volatile anesthetic administered during cooling in the DHCA protocol? If so, which agent(s) and what dose? What percentage of the study cohort?

2 If volatile anesthesia was administered during cooling, how might this have affected the outcome results? Major source of bias or not? Would the authors recommend the utility of a volatile anesthetic for neurologic preconditioning during the cooling phase of DHCA?

The third consideration is about the possible influence of aprotinin in this series, given the favorable effects on outcome after thoracic aortic surgery reported recently by the same group [3]. As a consequence, the following questions arise:

1 What percentage of the cohort was exposed to aprotinin? What was the dosing regimen?

2 Was aprotinin exposure considered in the reported multivariate analyses? If so, did it achieve statistical significance?

3 What is the current practice of the authors with respect to aprotinin utilization in aortic arch replacement with DHCA?

I congratulate the authors again on an outstanding contribution. I look forward to their feedback about these three considerations.

	Acknowledgments

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Financial support was provided by the Department of Anesthesiology and Critical Care at the University of Pennsylvania.

	References

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1. Gega A, Rizzo JA, Johnson MH, Tranquilli M, Farkas EA, Elefteriades JA. Straight deep hypothermic arrest: experience in 394 patients supports its effectiveness as a sole means of brain preservation Ann Thorac Surg 2007;84:759-767.[Abstract/Free Full Text]
2. Kurth CD, Priestley M, Watzman HM, McCann J, Golden J. Desflurane confers neurologic protection for deep hypothermic circulatory arrest in newborn pigs Anesthesiology 2001;95:959-964.[Medline]
3. Sedrakyan A, Wu A, Sedrakyan G, Diener-West M, Tranquilli M, Elefteriades J. Aprotinin use in thoracic aortic surgery: safety and outcomes J Thorac Cardiovasc Surg 2006;132:909-917.[Abstract/Free Full Text]

This article has been cited by other articles:

				J. G.T. Augoustides Invited Commentary Ann. Thorac. Surg., March 1, 2010; 89(3): 786 - 786. [Full Text] [PDF]

				J. A. Elefteriades, A. Gega, and J. A. Rizzo Reply Ann. Thorac. Surg., August 1, 2008; 86(2): 689 - 690. [Full Text] [PDF]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted 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): John G.T. Augoustides Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Augoustides, J. G.T. Search for Related Content PubMed PubMed Citation Articles by Augoustides, J. G.T. Related Collections Great vessels Related Article