Cerebral protection strategies in aortic arch surgery: A network meta-analysis

Hameed, Irbaz; Rahouma, Mohamed; Khan, Faiza; Wingo, Matthew; Demetres, Michelle; Tam, Derrick Y.; Lau, Christopher; Iannacone, Erin; Palaniappan, Ashwin; Anderson, Heather; Fremes, Stephen E.; Girardi, Leonard N.; Gaudino, Mario

doi:10.1016/j.jtcvs.2019.02.045

Cited by 47 publications

(38 citation statements)

References 27 publications

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“…With increasing duration of cardiac arrest, the incidence of postoperative neurologic complications and mortality increases significantly 17 . Based on a recent clinical study, circulatory arrest longer than 40 minutes may lead to adverse impact on neurological outcomes 18 .…”

Section: Discussionmentioning

confidence: 99%

MHCA with SACP versus DHCA in Pediatric Aortic Arch Surgery: A Comparative Study

Xie

Huang

et al. 2020

Sci Rep

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The safety and efficacy of selective antegrade cerebral perfusion (SACP) in children undergoing aortic arch surgery are unclear. In this retrospective analysis, we compared moderate hypothermic circulatory arrest (MHCA; n = 61) plus SACP vs deep hypothermic circulatory arrest (DHCA; n = 53) in children undergoing aortic arch surgery during a period from January 2008 to December 2017. Demographic characteristics and the underlying anomalies were comparable between the two groups. The MHcA + SACP group had shorter cardiopulmonary bypass (CPB) time (146.9 ± 40.6 vs 189.6 ± 41.2 min for DHCA; p < 0.05) and higher nasopharyngeal temperature (26.0 ± 2.1 vs 18.9 ± 1.6 °C; p < 0.01). the MHcA + SACP group had lower rate of neurologic complications (3/61 vs 10/53 for DHCA; p < 0.05) but not complications in other organ systems. The MHCA + SACP group also had less 24-hour chest drainage (median, interquartile rage: 28.9, 12.6-150.0 vs 47.4, 15.2-145.0 ml/kg for DHCA; p < 0.05), shorter duration of postoperative mechanical ventilation (35.0, 15.4-80.3 vs 94.0, 42.0-144.0 h; p < 0.01), and shorter stay in intensive care unit (3.9, 3.0-7.0 vs 7.7, 5.0-15.0 d; p < 0.05). In regression analysis, in-hospital mortality was associated with longer CPB time. In conclusion, MHCA + SAcp is associated with better short-term outcomes in children receiving aortic arch surgery under CPB. Coarctation of the aorta (CoA) and interrupted aortic arch (IAA) are the most common congenital large vascular malformations 1. Surgery should be performed as early as possible. Minimally invasive surgery is recommended for simple CoA/IAA. Patients with other comorbid abnormalities, however, may require open surgery under cardiopulmonary bypass (CPB). Deep hypothermic circulatory arrest (DHCA) is routinely used in aortic arch surgeries that require CPB to minimize cerebral metabolism and to provide clean surgical field 2 , but may lead to hypothermia-induced coagulopathy, capillary leak syndrome, microvasculature endothelial dysfunction, elevated systemic inflammatory response and multiple organ dysfunctions 3. Meanwhile, the time of DHCA is limited by the temperature. Selective antegrade cerebral perfusion (SACP) is designed to supply regional cerebral perfusion through the circle of Willis, and allow longer CPB time than DHCA 4,5. More recently, SACP has been increasingly used with mild hypothermia or normothermia in aortic arch surgery 6. Several studies suggested that SACP in combination with mild hypothermia (core temperature at 30 °C) could provide sufficient cerebral protection in aortic arch surgery that typically lasted for at least 90 minutes 7,8. However, SACP at higher core temperatures has been associated with spinal cord injury and even cerebral thrombosis in some cases. As a result, the use of SACP with normothermia in young children remains controversial 9. In the current retrospective analysis, we used relatively larger number of cases to compare moderate hypothermic circulatory arrest (MHCA) in combination with SACP versus DHCA alone in ...

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Section: Discussionmentioning

confidence: 99%

MHCA with SACP versus DHCA in Pediatric Aortic Arch Surgery: A Comparative Study

Xie

Huang

et al. 2020

Sci Rep

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“…We read with great interest the recent comprehensive meta-analysis by Hameed and colleagues, 1 which provides valuable insight about currently used cerebral protection strategies during aortic arch repair procedures.…”

Section: Invasive and More Practical To The Editormentioning

confidence: 99%

Arch repair: Brachial artery cannulation is as effective, but less invasive and more practical

Vural

2019

The Journal of Thoracic and Cardiovascular Surgery

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“…In this issue of The Journal of Thoracic and Cardiovascular Surgery, Dr Vural writes to the Editors in response to a novel network meta-analysis of cerebral protection strategies during aortic arch surgery by Hameed and colleagues. 1 Dr Vural shifts the focus to alternative cannulation approaches for antegrade cerebral perfusion, specifically the potential advantages of brachial artery cannulation relative to axillary artery cannulation, which is the standard approach at most institutions. He cites his own institution's case series from 2002, 2 which demonstrated outcomes after brachial artery cannulation for antegrade cerebral perfusion in 104 patients.…”

Section: Reply: Alternative Arterial Cannulation In Aortic Arch Surgementioning

confidence: 99%

Reply: Alternative arterial cannulation in aortic arch surgery

Wojnarski

Vekstein

2019

The Journal of Thoracic and Cardiovascular Surgery

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Cerebral protection strategies in aortic arch surgery: A network meta-analysis

Cited by 47 publications

References 27 publications

MHCA with SACP versus DHCA in Pediatric Aortic Arch Surgery: A Comparative Study

MHCA with SACP versus DHCA in Pediatric Aortic Arch Surgery: A Comparative Study

Arch repair: Brachial artery cannulation is as effective, but less invasive and more practical

Reply: Alternative arterial cannulation in aortic arch surgery

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