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8. Evolving selective cerebral perfusion for aortic arch operations: high flow rate with moderate hypothermic circulatory arrest
Kenji Minatoya, Hitoshi Ogino, Hitoshi Matsuda, Hiroaki Sasaki, Toshikatsu Yagihara, Soichiro Kitamura; Osaka, Japan
Objective: Although hypothermic circulatory arrest (HCA) combined with selective cerebral perfusion (SCP) is a safe strategy for aortic arch operations, the optimal temperature of hypothermia and the optimal flow rate of SCP are not clearly understood. We have gradually elevated the temperature of HCA from 20 degrees to 28 degrees for aortic arch operations since 2002. This study explored the impact of different temperatures during HCA with SCP on neurological complications.
Methods: Since January 2002, 192 patients underwent aortic arch replacement (mean age 70.6±9.3, 120 male) with hypothermic CA with SCP through median sternotomy. Eighty-one patients were cooled down to 20 degrees (group A), 81 were cooled down to 25 degrees (group B), and 30 were cooled down to 28 degrees (group C). Brachiocephalic and left common carotid arteries were perfused separately during the SCP in all cases. Left subclavian artery was additionally perfused in group C. Twenty-two operations in group A, 17 in group B and 6 in group C were performed emergently (P=0.58). The flow rate of SCP was maintained around 10 ml/kg/min in group A and B, and around 15 ml/kg/min in group C to keep blood pressure at temporal artery over 60mmHg.
Results:The early mortality rate was 1.2% (1of 81) in group A, 1.2% (1of 81) in group B and 0 in group C (P=0.30). Two patients (2.5%) had postoperative stroke in group A, 4 (4.9%) in group B, and 2 (6.7%) in group C (P=0.56). Seven patients (8.6%) had postoperative transient neurological dysfunction in group A, 6 (7.4%) in group B, and 1 (3.3%) in group C (P=0.63). No patients had postoperative paraplegia in all groups. The average durations of circulatory arrest were 64±21 min in group A, 49±14 min in group B, and 48±13 min in group C (P<0.0001). The average durations of SCP were 145±67 min in group A, 116±48 min in group B, and 119±62 min in group C (P=0.0047). The average flow rate of SCP were 8.8±1.9 ml/kg/min in group A, 10.4±3.1 ml/kg/min in group B, and 17.0±2.8 ml/kg/min in group C (P<0.0001).
Conclusions: Postoperative neurological events were not amplified according to the higher temperature. The temperature during HCA could be raised up to 28 degrees safely by means of high flow rate of SCP. The use of moderate HCA with SCP during aortic arch replacements allows radical reconstruction of aortic arch without time restrains and could avoid the necessity for deep hypothermia.
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