Aortic arch replacement with moderate hyperthomia and a modified 3-pump circuit

Dasarathan, Charumathi; Vaijyanath, Prashant; Sekhar, Lavanya; Cherian, Kotturathu Mammen

doi:10.1177/0267659110392441

Cited by 3 publications

(7 citation statements)

References 8 publications

(8 reference statements)

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“…However the lack of end organ dysfunction and apparent early correction of acidosis suggests a potential protective effect. Our results utilizing this modified perfusion strategy demonstrate similar benefits as those described by other groups: Matalanis et al, 13 Matsuyama et al, 12 Charumathi et al 14 The step-wise distal anastomosis technique and the cerebral and visceral protection demonstrated faster rewarming and decreased CPB times. 12 In their large series of 119 patients undergoing total arch replacement, Matsuyama et al utilized a separate lower body perfusion and demonstrated excellent clinical outcome and improved operative mortality from 10.4% to 3.4% when they started utilizing this technique.…”

Section: Discussionsupporting

confidence: 87%

Clinical and biochemical outcomes for additive mesenteric and lower body perfusion during hypothermic circulatory arrest for complex total aortic arch replacement surgery

et al. 2012

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Surgical repair of transverse aortic arch aneurysms frequently employ hypothermia and antegrade cerebral perfusion as protective strategies during circulatory arrest. However, prolonged mesenteric and lower limb ischemia can lead to significant lactic acidosis and end organ dysfunction, which remains a significant cause of post-operative morbidity and mortality. We report our experience with additive warm mesenteric and lower body perfusion (1-3 L/min, 30°C) in addition to continuous cerebral and myocardial perfusion in 5 patients who underwent total aortic arch replacement with trifurcated head vessel re-implantation and distal elephant trunk reconstruction. Concomitant surgical procedures included re-operations (2), aortic root operations (2), coronary artery bypass (2) and descending thoracic aortic replacement (1). Serum lactate levels demonstrated a rapid decline from a peak 9.9 ± 2.6 post circulatory arrest to 3.4 ± 2.0 in the intensive care unit (ICU). The lowest serum bicarbonate levels were 19.3 ± 3.5 mmol/L, intra-operatively, which normalized to 28.4 ± 2.4 mmol/L on return to the ICU. The lowest pH levels were 7.25 ± 0.10, corrected to 7.43 ± 0.04 on return to the ICU. Mean cardiopulmonary bypass and aortic cross-clamp times were 361 ± 104 and 253 ± 85 minutes, respectively. Mean cerebral and lower body circulatory arrest times were 0 (0) and 50 ± 35 minutes, respectively. The mean time required for systemic rewarming was 95 ± 66 minutes. There were no in-hospital mortalities and no patient experienced any neurological, mesenteric, renal or lower limb ischemic complications. Two patients required mechanical ventilation >24 hours, and one patient returned for reoperation for bleeding. Median intensive care unit and total hospital lengths of stay were 5 and 16 days, respectively. Our results suggest early serum lactate clearance, normalization of acidosis, and metabolic recovery when utilizing a simultaneous cerebral perfusion and warm body protection strategy for complex aortic arch surgery. This additive perfusion strategy may attenuate visceral and lower body ischemia that normally develops during periods of deep hypothermic circulatory arrest.

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Section: Discussionsupporting

confidence: 87%

Clinical and biochemical outcomes for additive mesenteric and lower body perfusion during hypothermic circulatory arrest for complex total aortic arch replacement surgery

et al. 2012

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“…Continuous ACP was maintained throughout the period of CPB at a temperature of 25 C. Flows varied between 1 and 3 lpm depending on whether flow was directed to the axillary artery and continued bihemispherically through the left common carotid artery at first and later the anastomosed graft using a mean perfusion pressure of 50-70 mmHg as a guide (2,14). A mild hypothermia (28-32 C) strategy avoids the effects of deep hypothermia and may help to decrease transfusion volume and reduce duration of intubation and intensive care unit stay (7,8). Others suggest that safety margins may be jeopardized with the mild hypothermia approach and a moderate hypothermia strategy may be better (7,8,15).…”

Section: Discussionmentioning

confidence: 99%

“…A mild hypothermia (28-32 C) strategy avoids the effects of deep hypothermia and may help to decrease transfusion volume and reduce duration of intubation and intensive care unit stay (7,8). Others suggest that safety margins may be jeopardized with the mild hypothermia approach and a moderate hypothermia strategy may be better (7,8,15). The optimal perfusion temperature and ACP flow rates have not yet been clearly defined in the literature (13,15).…”

Section: Discussionmentioning

confidence: 99%

“…Therefore, lower body perfusion where temperature and perfusion can be independently controlled may potentially diminish metabolic debt. Visceral perfusion at a higher temperature (tepid or normothermic) has been reported to reduce postoperative bleeding and inflammatory reactions compared with moderate and deep hypothermic cardiopulmonary bypass (CPB) (6)(7)(8). An additional advantage of independent control of the upper and lower body flow includes the ability to change strategy based on unique surgical and patient needs (7).…”

Section: Perfusion Considerations Theory Of Independent Control Of Up...mentioning

confidence: 99%

“…Visceral perfusion at a higher temperature (tepid or normothermic) has been reported to reduce postoperative bleeding and inflammatory reactions compared with moderate and deep hypothermic cardiopulmonary bypass (CPB) (6)(7)(8). An additional advantage of independent control of the upper and lower body flow includes the ability to change strategy based on unique surgical and patient needs (7). If the repair is more complex than anticipated, one option may be to keep the upper and lower body at 25 C or lower if required.…”

Section: Perfusion Considerations Theory Of Independent Control Of Up...mentioning

confidence: 99%

See 2 more Smart Citations

Simultaneous Individually Controlled Upper and Lower Body Perfusion for Valve-Sparing Root and Total Aortic Arch Replacement: A Case Study

Fernandes¹,

Mayer²,

Adams³

et al. 2011

J Extra Corpor Technol

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Optimal perfusion strategies for extensive aortic resection in patients with mega-aortic syndromes include: tailored myocardial preservation, antegrade cerebral perfusion, controlled hypothermia and selective organ perfusion. Typically, the aortic arch resection and elephant trunk procedure are performed under hypothermic circulatory arrest with myocardial and cerebral protection. However, mesenteric and systemic ischemia occur during circulatory arrest and commonly rely upon deep hypothermia alone for metabolic protection. We hypothesized that simultaneously controlled mesenteric and systemic perfusion can attenuate some of the metabolic debt accrued during circulatory arrest, which may help improve perioperative outcomes. The perfusion strategy consisted of delivering a 1 to 3 liter per minute flow at 25°C to the head/upper body via right axillary graft and simultaneous perfusion to the lower body/mesenteric organs of 1 to 3 liters per minute at 30°C via a right femoral arterial graft. We describe our technique of simultaneous mesenteric, systemic, cerebral and myocardial perfusion, and protection utilized for a young male patient with Marfan’s syndrome, while undergoing a valve sparing root replacement, total arch replacement and elephant trunk reconstruction. This perfusion technique allowed us to deliver differential flow rates and temperatures to the upper and lower body (cold head/warm lower body perfusion) to minimize ischemic debt and quickly reverse metabolic derangements.

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A Safe and Flexible Cardiopulmonary Bypass Technique for Complex Aortic Surgery without the Requirement for Deep Hypothermic Circulatory Arrest

Machin,

Tams,

Bingham

et al. 2013

J Extra Corpor Technol

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This article describes an adaptable technique of full-body perfusion during complex aortic surgery, which was performed on six consecutive patients, at a nasopharyngeal temperature of 28–34°C for a mean duration of 5 hours. A modified perfusion system was used to provide upper and lower body perfusion through axillary and femoral artery cannulation. The option of selective antegrade cerebral perfusion was also available if required. A simple custom-made circuit and application of additional monitoring such as cerebral oximetry makes this technique a safe and flexible method of providing continuous whole-body perfusion at moderate hypothermia and above. We found that these patients all had no major coagulopathies after the procedure and demonstrated no observable neurological, renal, or gastrointestinal dysfunction on recovery.

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Aortic arch replacement with moderate hyperthomia and a modified 3-pump circuit

Cited by 3 publications

References 8 publications

Clinical and biochemical outcomes for additive mesenteric and lower body perfusion during hypothermic circulatory arrest for complex total aortic arch replacement surgery

Clinical and biochemical outcomes for additive mesenteric and lower body perfusion during hypothermic circulatory arrest for complex total aortic arch replacement surgery

Simultaneous Individually Controlled Upper and Lower Body Perfusion for Valve-Sparing Root and Total Aortic Arch Replacement: A Case Study

A Safe and Flexible Cardiopulmonary Bypass Technique for Complex Aortic Surgery without the Requirement for Deep Hypothermic Circulatory Arrest

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