Objective To determine risk factors of delayed recovery of consciousness after aortic arch surgery underdeep hypothermic circulatory arrest （DHCA） and antegrade selective cerebral perfusion （ASCP）. Methods We retrospectively analyzed clinical data of 113 patients who underwent aortic arch surgery under DHCA＋ASCP in the Affiliated Drum Tower Hospital， Medical School of Nanjing University from October 2004 to April 2012. According to whether they regained consciousness within 24 hours after surgery， all the 113 patients were divided into normal group （73 patients including 55 males and 18 females with their average age of 48.1±10.9 years） and delayed recovery group （40 patients including 29 males and 11 females with their average age of 52.2±11.4 years）. Risk factors of delayed recovery of consciousness after surgery were evaluated by univariate analysis and multivariate logistic regression analysis. Results Nine patients （8.0%） died postoperatively， including 5 patients with multi-organ failure， 2 patients with heart failure， 1 patient with mediastinal infection， and 1 patient with pulmonary hemorrhage. There were 7 deaths （17.5%） in the delayed recovery group and 2 deaths （2.7%） in the normal group， and the in-hospital mortality of the delayed recovery group was significantly higher than that of the normal group （P=0.016）. A total of 94 patients （including 65 patients in the normal group and 29 patients in the delayed recovery group） were followed up for 4-95 months. Eight patients （including 5 patients in the normal group and 3 patients in the delayed recovery group） died during follow-up， including 2 patients with stroke， 3 patients with heart failure， 2 patients with pulmonary hemorrhage and 1 patient with unknown cause. Ten patients were lost during follow-up. Univariate analysis showed that age （P=0.042）， hypertension （P=0.017）， emergency surgery （P=0.001）， cardiopu- lmonary bypass （CPB） time （P=0.007）， aortic cross-clamp time （P=0.021）， and blood transfusion（P=0.012）were risk factors of delayed recovery of consciousness after aortic arch surgery. Multivariate logistic regression showed that emergency surgery （P=0.005） and CPB time＞240 minutes （P=0.000） were independent risk factors of delayed recovery of consciousness after aortic arch surgery. Conclusion Delayed recovery of consciousness after aortic arch surgery is attributed to a combination of many risk factors. Correct patient diagnosis， lesion site and involved scope should be made clear preoperatively in order to choose appropriate surgical strategies. During the surgery， strengthened brain protection， shortened operation time， improved surgical techniques， and perioperative stable circulation maintenance are all important measures to prevent delayed recovery of consciousness after aortic arch surgery.
Objective To summarize treatment experience and evaluate clinical outcomes of surgical therapy for Stanford type A aortic dissection （AD）. Methods Clinical data of 48 patients with Stanford type A AD who underwent surgical treatment in General Hospital of Lanzhou Military Region from October 2006 to March 2013 were retrospectively analyzed. There were 41 males and 7 females with their age of 26-72 （47.6±9.2） years. There were 43 patients with acute Stanford type A AD （interval between symptom onset and diagnosis＜14 days） and 5 patients with chronic AD. There were 19 patients with moderate to severe aortic insufficiency and 6 patients with Marfan symdrome but good aortic valve function，who all received Bentall procedure，total arch replacement and stented elephant trunk implantation. There were 8 patients with AD involving the aortic root but good aortic valve function who underwent modified David procedure，total arch replacement and stented elephant trunk implantation. There were 10 patients with AD involving the ascending aorta who received ascending aorta replacement，total arch replacement and stented elephant trunk implantation. There were 5 patients with AD involving partial aortic arch who underwent ascending aorta and hemiarch replacement. Patients were followed up in the 3rd，6th and 12th month after discharge then once every year. Follow-up evaluation included general patient conditions，blood pressure control，chest pain recurrence，mobility and computerized tomography arteriography （CTA）. ResultsCardiopulmonary bypass time was 121-500 （191.4±50.6） minutes，aortic cross-clamp time was 58-212 （112.3±31.7） minutes，and circulatory arrest and selective cerebral perfusion time was 26-56 （34.8±8.7） minutes. Postoperative mechanicalventilation time was 32-250 （76.2±35.6） hours，and ICU stay was 3-20 （7.1±3.4） days. Thoracic drainage within 24 hours postoperatively was 680-1 600 （1 092.5±236.3） ml. Seven patients （14.5%） died perioperatively including 2 patients with multiple organ dysfunction syndrome，2 patients with low cardiac output syndrome，1 patient with renal failure，1patient with delayed refractory hemorrhage，and 1 patient with coma. Twenty patients had other postoperative complicationsand were cured or improved after treatment. A total of 38 patients ［92.7% （38/41）］ were followed up for 3-48 （13.0±8.9） months，and 3 patients were lost during follow-up. During follow-up，there were 36 patients alive and 2 patients who died of other chronic diseases. There was no AD-related death during follow-up. None of the patients required reoperation for AD or false-lumen expansion. CTA at 6th month after discharge showed no anastomotic leakage，graft distortion or obstruction.Conclusion According to aortic intimal tear locations，ascending aorta diameter and AD involving scopes，appropriate surgical strategies，timing and organ protection are the key strategies to achieve optimal surgical results for Stanford type A AD. Combined axillary and femoral artery perfusion and increased lowest intraoperative temperature are good methods for satisfactory surgical outcomes of Stanford type A AD.
Abstract： Objective To investigate the cerebral protective effects of hyperoxia management during deep hypothermia circulatory arrest（DHCA） rabbit by the blood gas indexes, superoxide dismutase（ SOD） activity and malondialdehyde （MDA） levels of brain, and ratio of water to brain. Methods A DHCA and antegrade selective cerebral perfusion （ASCP） rabbit model was established. Twenty-four 11-13 week-old male New Zealand rabbits（ weighing 2.7 to 3.4 kg） were assigned to three groups with a random number table: a sham operation group （Sham group）, an ASCP group （S group）, and an ASCP ＋ hyperoxia management group （SH group）. There were eight rabbits in each group. We recorded the intraoperative values for arterial oxygen pressure （PaO2）, arterial oxygen saturation （SaO2）, jugular venous oxygen pressure（PjvO2）, jugular venous oxygen saturation（ SjvO2） and blood lactate level. The brain SOD activity, MDA levels, and ratio of water to brain were measured after the operation. Results Before initiating circulatory arrest, before initiating reperfusion and five minutes of reperfusion, levels of PaO2 , PjvO2 , and SjvO2 in the SH group were significantly higher than those of the S group and Sham group. SOD activity in the SH group was not significantly different from that of the S group[（213.53±33.52） U/mg. prot vs. （193.02±27.67） U/mg. prot] and Sham group[（213.53±33.52） U/mg. prot vs.（244.38±35.02）U/mg. prot], but the SOD activity in the S group was lower than that in the Sham group（ P ＜ 0.05）. MDA levels in the SH group were lower than that in the S group[（1.42±0.30） nmol/mg. prot vs. （2.37±0.55） nmol/mg. prot, P ＜ 0.05]. Conclusion Our data show that hyperoxia management during DHCA＋ASCP improves rabbits’PjvO2 and SjvO2, maintains brain SOD activity, and decreases brain MDA levels, demonstrating the neuroprotective effects of hyperoxia mangagement.
Objective To evaluate the applicability of Transcranial Doppler (TCD) monitoring in brain protection in the process of aortic dissection surgical procedure. Methods From Feburary 2007 to November 2007, six patients with type I aortic dissection underwent surgical procedure in Xuanwu Hospital of Capital Medical University. All patients are male with their age ranged from 48 to 60 years. During the operation, right subclavian arterial cannulation technique was used to protect the brain, and TCD monitoring was adopted to guide cerebral perfusion. The function of nervous system after operation was observed, and the minimental state examination (MMSE) was used to assess the cognitive function of the patients. A twoyear followup was done to monitor patients’ aorta condition. Results The time of cardiopulmonary bypass (CPB) was 136 to 350 minutes. The time of selected cerebral perfusion was 20 to 65 minutes. The lowest cerebral blood flow was 31% of basic level according to TCD monitoring. All patients were successfully treated without neurological complication and cognitive dysfunction when discharged from hospital. MMSE score was 28 to 30 points. During the twoyear followup after operation, all aortic false lumen were closed and there was no dissection recurrence. Conclusion Monitoring blood change with TCD monitoring technique is safe and effective in evaluating brain protection by selective cerebral perfusion in aortic dissection surgical procedure.
Objective To investigate the efficacy and safety of the application of selective cerebral perfusion (SCP) technique in pediatric aortic arch reconstruction, so as to alleviate brain injury during operation. Methods From April 2007 to May 2008, 32 children aged from 8 days to 103 months (14.4±25.4 months) and weighed from 27 kg to 22.0 kg (6.7±4.4 kg) underwent aortic arch reconstruction with selective cerebral perfusion in Shanghai Children’s Medical Center. Twentytwo suffered from aortic coarctationwith intracardiac anomaly, and 10 suffered from interrupted aortic arch with intracardiac anomaly. The arterial cannulation was achieved by placing a flexible wire wound cannula in ascending aorta close to the root part of innominate artery. The rectal temperature was about 1820℃. Then the cannula was moved upward into innominate artery to perform SCP. Results The time of SCP was 17-121 mins（39.6±19.4 mins）, perfusion blood flow maintained in 15-40 ml/(kg·min)［29.7±6.1 ml/(kg·min）］. Four cases died of low cardiac output syndrome or arrhythmia, and no evidence of brain injury was observed. No obvious neurologic complication was observed in 28 survivls. No abnormal electroencephalogram was observed in 25 cases. The results of head Bsonography and brain magnetic resonance image (MRI) were normal in 5 neonates. Conclusion Selective cerebral perfusion is a simple, feasible, safe and effective technique in pediatric aortic arch reconstruction.
Objective To summarize the methods and experiences of surgical treatment of aortic arch diseases with four branches aortic graft under deep hypothermia circulatory arrest （DHCA） and antegrade selective cerebral perfusion （ASCP）. Methods In 2004 from September to December, surgical treatment of 12 patients with 7 aortic aneurysm（4 cases with ascending aorta and aortic arch aneurysm, 3 cases with aneurysm of aortic isthmus） and 5 aortic dissection（DeBakey Ⅰ 1 case, DeBakey Ⅱ 3 cases, DeBakey Ⅲ 1 case） were collected in Gunma Prefectural Cardiovascular Center. All operations were carried out under DHCA and ASCP, and four branches aortic graft were used to replace the aortic arch. The Bentall procedure, total and partial arch replacement and elephant trunk technique were undertaken in different patients. Results Total 12 patients recovered from the great vessel diseases smoothly without severe cerebral and other systematic complications, the time of operation was 5.5±1.7 h, the period of DHCA was 42.2±12.9min, 4 cases with no blood transfusion, the time of hospitalization was 22.3±7.2d. Conclusion ASCP is a safe. and effective method of cerebral protection during circulation arrest, and four branches aortic graft may shorten the time of DHCA and simplify the procedure of aortic arch replacement.
Objective To monitor the distribution of blood perfusion during aortic arch aneurysm surgery under double arterial lines with single pump. Methods We retrospectively analyzed the clinical data of 37 patients underwent aortic arch repair or reconstruction between September 2012 and April 2014. There were 9 females and 28 males at mean age of 48.1±10.8 years ranging from 19.0-72.0 years.We took double arterial lines with single pump for cardiopulmonary bypass (CPB) during the operation and we monitored the perfusion tube flow of both the upper and lower body by blood flow detector. Cerebral blood perfusion was measured by transcranial cerebral Doppler and near-infrared spectroscopy cerebral oxygen saturation (rSO2). Results The mean CPB time of all 37 patients was 195.8±40.5 minutes ranging from 136.0-277.0 minutes and the mean duration time of selective antegrade cerebral perfusion (SCAP) was 21.6±5.6 minutes ranging from 5.0-35.0 minutes. During cooling and rewarming phases, the part of blood flow through axillary artery cannulation ranged from 31.5% to 40.8% of the whole body perfusion. The blood flow of SACP was increased to 15.0 ml / (kg·min) in 2 patients with significantly lower rSO2 and middle cerebral artery blood flow during SACP, and they had an uneventful recovery process after surgery. There were another 2 patients recorded abnormal situation of rSO2 without interventions. One patient died and the other one recovered with compications of spinal cord. Conclusions The technique of double arterial lines with single pump is reasonable and effective. The cerebral perfusion monitoring is helpful to detect abnormal perfusion during aortic arch aneurysm surgery.
Objective To evaluate the safety and effectiveness of modified total arch replacement by retrospectively analyzing the clinical outcome of surgical patients with Stanford type A aortic dissection (AAD). Methods From June 2015 to December 2016, 39 consecutive patients with AAD were recruited to this study. This modified technique was preformed under general anesthesia and a 30℃ hypothermia circulatory arrest (HCA) with continual bilateral antegrade cerebral perfusion. Different surgical approaches were applied according to the aortic root condition: Bentall procedure (4 patients), David procedure (2 patients), aortic valve plasty and ascending aortic replacement (25 patients) and Cabrol procedure (8 patients). Concomitant procedures included mitral valve plasty (1 patient) and tricuspid valve plasty (1 patient). Results The average cardiopulmonary bypass (CPB), aortic occlusion time (ACC), HCA and operation time was 218.5±42.2 min, 134.2±32.4 min, 4.9±2.3 min and 415.5±80.5 min respectively. Four patients required dialysis and 2 patients developed temporary neurological deficit. No permanent neurological deficit, postoperative paraplegia or in-hospital death occurred. Computed tomography examination was performed on all patients before discharge and 3 months after discharge. The follow-up result showed that 37 patients developed complete thrombosis in the false lumen and 2 patients developed partial thrombosis. Conclusion Modified total arch replacement is a safe and effective approach for AAD. It can greatly avoid postoperative complications and provide satisfactory short-term outcomes.