A Practical Approach to Cardiac Anesthesia (Practical Approach Series)

Relative to that reported in recent series of moderate hypothermia 5 , 7 , 18 , 19 , the significantly reduced operative mortality and morbidity presented here further supports the safety and efficacy of DHCA approaches. In addition, no adjunctive cerebral perfusion was utilized in the DHCA group, an adjunct we deem to be a key facet of an optimal neuroprotective strategy. An important caveat to consider when comparing the Penn results to those of the current study, however, is that all of the cases in the Penn series were elective. The operative mortality in that study, which included a very similar patient cohort to that in the present report, was 7.

The relatively high rate of postoperative renal failure in this latter study raises important concerns about the susceptibility to visceral ischemia and other end-organ dysfunction implicit in HCA performed with warmer temperatures. This effect becomes especially pronounced during more complex cases when aortic arch reconstruction times extend beyond thirty minutes Therefore, profound hypothermia may be an indispensable modality during such aortic cases where the anticipated duration of HCA may be prolonged, and preservation of end-organ viability beyond the brain is at a premium.

As demonstrated by the current results, proximal arch replacement under deep hypothermia can minimize ischemic insult to the periphery with resultant low rates of renal 1. To date, published data 5 , 7 , 12 , 19 do not support moderate hypothermia approaches utilizing selective ACP as providing an equal degree of protection to non-brain organs. On the contrary, in vivo studies in large animal models of moderate HCA have revealed that the spinal cord may be particularly susceptible to ischemic injury under such conditions with an alarmingly high incidence of irreversible paraplegia at 60 minutes The enhanced cytoprotective effects ascribed to deep versus moderate HCA may, at the molecular level, entail upregulation of the small-ubiquitin-like modifier SUMO conjugation pathway Further delineation of these molecular mechanisms are hopefully forthcoming, but these and other data already available provide a compelling argument for deep hypothermia as the preferred perfusion strategy for HCA.

Formal assessment for subtle neurocognitive deficits following DHCA was not performed in this study. Notwithstanding, the rates of permanent neurologic dysfunction such as stroke were relatively low and virtually nonexistent among electively performed cases 0. Proponents of moderate hypothermia have cited a higher incidence of postoperative delirium in procedures utilizing DHCA 18 , along with other more subtle indices of neurocognitive impairment 20 — An in-depth psychometric analysis of DHCA patients recently performed at Yale discounts these claims, however, documenting complete preservation of cognitive capacity, even among high-cognitive patients The authors acknowledge that even slight neurocognitive deficits following any cardiac operation have important prognostic implications Consequently, one criticism of the current study is the lack of comprehensive neurocognitive evaluation both in the perioperative period and in long-term follow-up.

Future studies will therefore need to incorporate such formal evaluations. Moreover, the current study was retrospective in design and did not include a comparison group, such as a patient cohort in whom moderate HCA was utilized. Prospective, randomized studies directly comparing deep and moderate HCA, in conjunction with selective cerebral perfusion techniques, would undoubtedly provide valuable and accurate insight into which circulatory management strategy maximizes neuroprotective effects while preserving peripheral organ function.

In summary, the use of deep hypothermia with adjunctive cerebral perfusion for circulatory arrest during proximal arch replacement affords excellent neurologic as well as non-neurologic outcomes. National Center for Biotechnology Information , U.

A Practical Approach to Cardiac Anesthesia

Author manuscript; available in PMC Aug 4. Brian Lima , M. Dave Bhattacharya , M. Chad Hughes , M. Author information Copyright and License information Disclaimer. The publisher's final edited version of this article is available at Am Surg. See other articles in PMC that cite the published article. Abstract Objective The use of selective cerebral perfusion with warmer temperatures during circulatory arrest has been increasingly utilized for arch replacement over concerns regarding the safety of deep hypothermic circulatory arrest DHCA.

Conclusions Deep hypothermia with adjunctive cerebral perfusion for circulatory arrest during proximal arch replacement affords excellent neurologic as well as non-neurologic outcomes. Introduction Preventing cerebral injury and other end-organ dysfunction during aortic arch surgery remains a formidable challenge, which has led to the evolution of a number of circulatory management strategies over recent decades 1 — Open in a separate window.

Table 1 Perfusion Data. DHCA, deep hypothermic circulatory arrest. AA, ascending aortic; AVR, aortic valve replacement. Results A summary of pertinent preoperative patient variables is provided in Table 3.

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Table 3 Preoperative Patient Characteristics. Table 4 Postoperative Outcomes. Discussion Central to the debate over the temperature nadir of HCA is the contention that deep hypothermia potentiates bleeding risk, is directly injurious to the brain and other organ systems, and therefore poses significant perioperative morbidity and mortality.

Study Limitations The authors acknowledge that even slight neurocognitive deficits following any cardiac operation have important prognostic implications Conclusions In summary, the use of deep hypothermia with adjunctive cerebral perfusion for circulatory arrest during proximal arch replacement affords excellent neurologic as well as non-neurologic outcomes. Antegrade cerebral perfusion with cold blood: Total excision of the aortic arch for aneurysm. Treatment of aneurysm of transverse aortic arch. J Thorac Cardiovasc Surg. Prosthetic replacement of the aortic arch.

Selective antegrade cerebral perfusion via right axillary artery cannulation reduces morbidity and mortality after proximal aortic surgery. Nonneurologic morbidity and profound hypothermia in aortic surgery. The safety of moderate hypothermic lower body circulatory arrest with selective cerebral perfusion: A propensity score analysis. Total arch replacement using aortic arch branched grafts with the aid of antegrade selective cerebral perfusion.

Aortic arch replacement using selective cerebral perfusion.

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Hypothermic circulatory arrest with selective antegrade cerebral perfusion in ascending aortic and aortic arch surgery: A risk factor analysis for adverse outcome in patients. Kouchoukos NT, Masetti P. Total aortic arch replacement with a branched graft and limited circulatory arrest of the brain. Retrograde and antegrade cerebral perfusion: Results in short elective arch reconstructive times. Early and long-term outcome of total arch replacement using selective cerebral perfusion. Technical advances in total aortic arch replacement.

Deep hypothermia with circulatory arrest.

Determinants of stroke and early mortality in patients. What is the best method for brain protection in surgery of the aortic arch? Safety of moderate hypothermia and antegrade cerebral perfusion during systemic circulatory arrest. Moderate hypothermia and unilateral selective antegrade cerebral perfusion: A contemporary cerebral protection strategy for aortic arch surgery. Neurologic complications after deep hypothermic circulatory arrest: Types, predictors, and timing. Tex Heart Inst J. Neuropsychologic outcome after deep hypothermic circulatory arrest in adults.

Surgery of the thoracic aorta using deep hypothermic total circulatory arrest. Are there neurological consequences other than frank cerebral defects? Eur J Cardiothorac Surg. Individualized thoracic aortic replacement for the aortopathy of bicuspid aortic valve disease. Journal of Heart Valve Disease.

A practical approach to neurophysiologic intraoperative monitoring. Demos Medical Publishing; Deep hypothermic circulatory arrest: Effects of cooling on electroencephalogram and evoked potentials. Practice guidelines for perioperative blood transfusion and adjuvant therapies: Following the module, participants will have a demonstrable understanding of the background and practical implications of Informed Consent..

This understanding is intended to be a foundation for action about translating principles into practice and give participants the confidence to take a proactive role in improving processes and standards within their own work area. We are pleased to invite you to our second Primary Care industry-themed webinar "Robust Feasibility" that will take place on Friday 1st February at This two day course is primarily aimed at research delivery staff that have contact with research participants e.

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Those in post for more than 12 months may attend as a refresher. This course is aimed at improving best practice in the consent process for clinical research. The objective of this two-day course is to provide attendees with a foundation of knowledge to enable them to develop their practice as a research practitioner.

It offers the opportunity to gain an understanding of the management and running of clinical studies. Attendees will be able to apply relevant knowledge and skills gained from the course to their working environment and will be able to build upon their experience as a research practitioner. Anyone involved in grant submissions or the set up and co-ordination of clinical trials is welcome to attend. This event will provide an opportunity to share best practice, ideas for research and showcase involvement in research by Ageing and Care Home communities.

It is for health care professionals who support the ageing specialty and those involved with Care Homes and Villages, along with Researchers who have an interest in these areas. Free registration and lunch provided. CPD points will be applied for.

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This half-day workshop is designed to provide the opportunity to explore the consent process in more depth covering Good Clinical Practice GCP. This event is a comprehensive review of current best practice and ASH highlights by international and national experts. Communication and Consent within the Paediatric Research Setting. This course aims to provide a foundation of knowledge around the process of getting involved in commercially sponsored and funded research to enable you to develop your site to get involved in commercial research.