Authors (including presenting author) :
Cheung THT(1), Yung EP(1)
Affiliation :
Perfusion Team, Department of Surgery, Prince of Wales Hospital
Introduction :
Selective cerebral perfusion(SCP) with moderate hypothermic circulatory arrest (MHCA; nasopharyngeal temperature of 25°C) has been proven to be a better perfusion strategy during aortic operation. Our cardiac surgery team had implemented this strategy as the primary cerebral protection strategy for circulatory arrest (CA) during aortic arch operation since 2009.
Results of aortic arch (AA) reconstructive surgery have improved over the past years; regardless hemi- or total arch replacement. This improvement majority is due to the use of antegrade cerebral perfusion (ACP) during systemic circulatory arrest (SCA) with hypothermia and surgical technique.
Objectives :
This study was taken to review the primary neurologic and mortality outcomes of the ACP and MHCA management strategies.
Methodology :
104 cases from January 2020 to September 2022 in PWH were reviewed. Inclusion criteria required subjects of acute type A aortic dissection with open repair requiring cardiopulmonary bypass and SCP during CA. Either unilateral or bilateral SCP cannulation methods were included. Exclusion criteria were cases with other primary cardiac disease which required surgery. Cases were reviewed for their length of bypass and CA during operation, post-operative complication, length of intubation and ICU stays, in-hospital time, and mortality rate. Data were then calculated and compared with previous years’ result.
Result & Outcome :
The average duration for cardiopulmonary bypass and HCA were 236.8±71.3mins and 50.5±25.1mins respectively and shown improvement compared with 2018-2019’s result. Average length of intubation was 1.3±2.2 days and average length of ICU stays was 2.2±2.2 days. Average in-hospital time after surgery was 16.3±12.4 days. 5 cases of postoperative stroke were reported, the incidence rate was 4.8% which was significantly lower than reported rates of 10% to 30% internationally. 7-day morality rate was 1.9% (n=2). 30-days mortality rate was 2.9% (n=3) which compare with 17% internationally. The one-year survival rate after surgery was 97%.
The outcomes of aortic arch surgery have improved significantly because of advancements in cardiac surgical techniques, perioperative brain monitoring, and management.
The following three interrelated factors are essential to brain protection: CA duration, cerebral temperature during CA, and cerebral perfusion. The shortest CA duration or no CA are always preferred, but the safest duration of circulatory arrest is hard to define. Hypothermia also plays an essential role in cerebral protection.
SCP and MHCA have emerged as safe and efficacy techniques for aortic arch operations.
