Neuroprotective Strategies in Repair and Replacement of the Aortic Arch

Manetta, Frank; Mullan, Clancy; Catalano, Michael A.

doi:10.1055/s-0038-1649512

Cited by 20 publications

(10 citation statements)

References 176 publications

(206 reference statements)

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“…Experimental data suggests that their preconditioning and postconditioning mechanisms may cause the positive effects of volatile agents. The role of volatiles in pre-and postconditioning (pre-emptive and post-exposure treatment to increase the tolerance of neurons against subsequent lethal insult), reduction of inflammatory markers, improved postoperative neurocognitive function, and CBF is also well recognised [ 54 ].…”

Section: Neuroprotection Interventionsmentioning

confidence: 99%

“…While there is some clinical evidence for the role of magnesium sulphate in neuroprotection, the results of RCT studies are contradictory. It is often used due to its role in vasodilatation, stabilising electrochemical gradients, inhibiting glutamate at the NMDA receptor, and its ability to reduce intracellular calcium release [ 54 ]. Magnesium has shown effectiveness in improving short-term postoperative memory and cortical control over brain stem function after cardiac surgery [ 6 , 62 ].…”

Section: Neuroprotection Interventionsmentioning

confidence: 99%

“…There are comparisons made between the use of moderate hypothermia (20–28 °C) versus deep hypothermia (10–13 °C) [ 28 ], or profound hypothermia (<14 °C) against normothermia (36–38 °C) in cardiac surgery on CPB [ 54 ]. Hypothermic circulatory arrest (HCA) has several advantages during CPB.…”

Section: Neuroprotection Interventionsmentioning

confidence: 99%

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Contemporary Neuroprotection Strategies during Cardiac Surgery: State of the Art Review

Chakane

Mogane

Moutlana

et al. 2021

IJERPH

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Open-heart surgery is the leading cause of neuronal injury in the perioperative state, with some patients complicating with cerebrovascular accidents and delirium. Neurological fallout places an immense burden on the psychological well-being of the person affected, their family, and the healthcare system. Several randomised control trials (RCTs) have attempted to identify therapeutic and interventional strategies that reduce the morbidity and mortality rate in patients that experience perioperative neurological complications. However, there is still no consensus on the best strategy that yields improved patient outcomes, such that standardised neuroprotection protocols do not exist in a significant number of anaesthesia departments. This review aims to discuss contemporary evidence for preventing and managing risk factors for neuronal injury, mechanisms of injury, and neuroprotection interventions that lead to improved patient outcomes. Furthermore, a summary of existing RCTs and large observational studies are examined to determine which strategies are supported by science and which lack definitive evidence. We have established that the overall evidence for pharmacological neuroprotection is weak. Most neuroprotective strategies are based on animal studies, which cannot be fully extrapolated to the human population, and there is still no consensus on the optimal neuroprotective strategies for patients undergoing cardiac surgery. Large multicenter studies using universal standardised neurological fallout definitions are still required to evaluate the beneficial effects of the existing neuroprotective techniques.

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Section: Neuroprotection Interventionsmentioning

confidence: 99%

Section: Neuroprotection Interventionsmentioning

confidence: 99%

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Contemporary Neuroprotection Strategies during Cardiac Surgery: State of the Art Review

Chakane

Mogane

Moutlana

et al. 2021

IJERPH

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“…The European Society of Cardiology guidelines on aortic disease recommend the adoption of selective ACP to reduce the risk of stroke for surgical aortic procedures (class IIa, level B) [ 11 ]. However, this recommendation mainly relies on evidence from observational studies with only few randomized clinical trials available limited by small sample size [ 3 ]. The final consensus on which neuroprotective strategy should be preferred is still lacking, and significant variation in the clinical practice exists [ 8–10 ].…”

Section: Introductionmentioning

confidence: 99%

Neuroprotective strategies in acute aortic dissection: an analysis of the UK National Adult Cardiac Surgical Audit

Benedetto

Dimagli

Cooper

et al. 2021

European Journal of Cardio-Thoracic Surgery

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OBJECTIVES The risk of brain injury following surgery for type A aortic dissection (TAAD) remains substantial and no consensus has still been reached on which neuroprotective technique should be preferred. We aimed to investigate the association between neuroprotective strategies and clinical outcomes following TAAD repair. METHODS Using the UK National Adult Cardiac Surgical Audit, we identified 1929 patients undergoing surgery for TAAD (2011–2018). Deep hypothermic circulatory arrest (DHCA) only, unilateral (uACP), bilateral antegrade cerebral perfusion (bACP) and retrograde cerebral perfusion were used in 830, 117, 760 and 222 patients, respectively. The primary end point was a composite of death and/or cerebrovascular accident (CVA). Generalized linear mixed model was used to adjust the effect of neuroprotective strategies for other confounders. RESULTS The use of bACP was associated with longer circulatory arrest (CA) compared to other strategies. There was a trend towards lower incidence of death and/or CVA using uACP only for shorter CA. In particular, primary end point rate was 27.7% overall and 26.5%, 12.5%, 28.0% and 22.9% for CA <30 min and 28.6%, 30.4%, 33.3% and 33.0% for CA ≥30 min with DHCA only, uACP, bACP and retrograde cerebral perfusion, respectively. The use of DHCA only was associated with five-fold [odds ratio (OR) 5.35, 95% confidence interval (CI) 1.36–21.02] and two-fold (OR 1.77, 95% CI 1.01–3.09) increased risk of death and/or CVA compared to uACP and bACP, respectively, but the effect of uACP was significantly associated with CA duration (hazard ratio 0.97, 95% CI 0.94–0.99; P = 0.04). CONCLUSIONS In TAAD repair, the use of uACP and bACP was associated with a lower adjusted risk of death and/or CVA when compared to DHCA. uACP can offer some advantage but only for a shorter CA duration.

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“…Circulatory arrest is required to allow for a bloodless operative field, while hypothermia provides the brain and end-organ protection by significantly reducing the global metabolic demand. 5 6 With a temporary interruption of cerebral and systemic perfusion, aortic surgery under hypothermic circulatory arrest (HCA) may be the only available model of reversible clinical death.…”

Section: Introductionmentioning

confidence: 99%

Does Hypothermic Circulatory Arrest for Aortic Surgery Trigger Near-Death Experience? Incidence of Near-Death Experiences after Aortic Surgeries Performed under Hypothermic Circulatory Arrest

et al. 2021

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Background Understanding near-death experiences (NDE) could provide a new insight into the analysis of human consciousness and the neurocognitive processes happening upon the approach of death. With a temporary interruption of systemic perfusion, aortic surgery under hypothermic circulatory arrest (HCA) may be the only available model of reversible clinical death. We present, herein, the results of an observational study designed to assess the incidence of NDE after aortic surgery. Methods We performed a prospective study including consecutive patients who underwent thoracic aortic surgery between July 2018 and September 2019 at our institution. Procedures without HCA were included to constitute a control group. The primary outcome was the incidence of NDE assessed with the Greyson NDE scale during the immediate postoperative course, via a standardized interview of the patients in the surgical ward. Results One hundred and one patients were included. Twenty-one patients (20.8%) underwent nonelective interventions for aortic dissection. Ninety-one patients had hemiarch replacement (90.1%). Sixty-seven (66.3%) interventions were performed with HCA, with an average circulatory arrest duration of 26.9 ± 25.5 minutes, and a mean body temperature of 23.7 ± 3.8°C. None of the patients reported any recollection from their period of unconsciousness. There was no NDE experiencer in the study cohort. Conclusion Several confounding factors regarding anesthesia, or NDE evaluation, might have impaired the chance of NDE recollections, and might have contributed to this negative result. Whether HCA may trigger NDE remains unknown.

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Neuroprotective Strategies in Repair and Replacement of the Aortic Arch

Cited by 20 publications

References 176 publications

Contemporary Neuroprotection Strategies during Cardiac Surgery: State of the Art Review

Contemporary Neuroprotection Strategies during Cardiac Surgery: State of the Art Review

Neuroprotective strategies in acute aortic dissection: an analysis of the UK National Adult Cardiac Surgical Audit

Does Hypothermic Circulatory Arrest for Aortic Surgery Trigger Near-Death Experience? Incidence of Near-Death Experiences after Aortic Surgeries Performed under Hypothermic Circulatory Arrest

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