Abstract： Objective To evaluate the clinical safety and neurological outcomes of right axillary artery cannulation with a side graft compared with a direct approachin aortic arch replacement for patients with acute Stanford type A aortic dissection. Methods Between July 2008 and July 2010， 280 consecutive patients with acute Stanford type A aortic dissection underwent right axillary artery cannulation for cardiopulmonary bypass （CPB） in total arch replacement and stented “elephant trunk” implantation in our hospital.These 280 patients were divided into two groups according to the method of axillary artery cannulation in operation:direct arterial cannulation was used in 215 patients（direct arterial cannulationgroup， DG group， mean age of 43.1±9.5 years）， while cannulation with a side graft was used in 65 patients（ indirect cannulation group， IG group， mean age of 44.7±8.3 years）. Clinical characteristics of both groups were similar except their axillary artery cannulation method. Patient outcomes were compared as to the prevalence of clinical complications， especially neurological deficits and postoperative morbidity. Results The overall hospital mortality was 3.6% （10/280）， 3.3% （7/215） in DG group and 4.6% （3/65） in IG group respectively.Right axillary artery cannulation was successfully performed in all cases without any occurrence of malperfusion. Postoperatively， 25 patients（8.9%）developed temporaryneurological deficits， 19 cases in DG group（8.8%）， and 6 cases in IG group （9.2%）， and all these patients were cured after treatment. The incidence of postoperative complications directly related to axillary artery cannulation was significantly lower in IG group than that in DG group（1 case vs. 19 cases， P=0.045）. There were no statistical differences in arterial perfusion peak flow， peak pressure，antegrade cerebral perfusion time， deep hypothermic circulatory arrest time， and CPB time between the two groups（P ＞ 0.05）. Conclusion Right axillary artery cannulation with a side graftcan significantly reduce the postoperative complications of axillary artery cannulation. It is a safe and effective method for patients undergoing surgery for acute Stanford type A aortic dissection.
Deep hypothermic circulatory arrest (DHCA) is an important assistant technique for complex cardiac surgery, which creates convenient operating conditions for surgery, and is also one of the measures to protect the brain during operation. However, the complications caused by this technique cannot be ignored, and it should be noticed that the occurrence of intestinal injury is relatively insidious, but brings great pain to patients and significantly reduces the quality of life after operation. Studies have shown that intestinal ischemia-reperfusion injury is induced by DHCA. It causes mast cells to activate and release many inflammatory mediators that destroy the intestinal mucosal epithelium barrier, and eventually lead to intestinal injury. This article reviewed the research progress of mast cells in the mechanism of DHCA-induced intestinal injury.
Objective To observe the influence of edaravone perfusion via the pulmonary artery on postoperative lung tissue and lung function during pulmonary ischemia in deep hypothermic circulatory arrest （DHCA）， and explore its possible mechanism. Methods A total of 24 healthy New Zealand white big-ear rabbits were randomly divided into three groups： （1） control group： DHCA model under cardiopulmonary bypass （CPB） was established； （2）low potassium dextran （LPD）group： LPD solution perfusion via the pulmonary artery after the establishment of DHCA； （3）edaravone group：LPD solution containing edaravone （5 mg/kg） perfusion via the pulmonary artery after the establishment of DHCA. Oxygenation index and lung compliance were observed at the time of baseline condition， recovery of ventilation， 1 hour and 2 hours after recovery of ventilation， and postoperative lung function of the three groups were compared. Malondialdehyde （MDA） and superoxide dismutase （SOD） in pulmonary venous blood were measured. All the rabbits were sacrificed after the operation. HE staining and immunohistochemistry were performed on the lung tissues to investigate lung structure changes and inflammatory reaction. Transmission electron microscopy was used to compare ultrastructural changes of lung.Results There were no statistical difference in oxygenation index， lung compliance， MDA and SOD among the 3 groups under the baseline condition （P＞0.05）. After recovery of ventilation， oxygenation index and lung compliance deteriorated to varying degrees in all 3 groups. Oxygenation index and lung compliance of the control group and LPD group at the time of recovery of ventilation， 1 hour and 2 hours after recovery of ventilation were significantly lower than those of edaravone group （oxygenation index：recovery of ventilation and in control group and edaravone group: 198.25±11.02 mm Hg vs. 244.87±13.05 mm Hg；lung compliance：one hour after recovery ventilation in control group and edaravone group：45.88±1.64 ml/cm H2O vs. 59.75±2.38 ml/cm H2O；P＜0.05）. After CPB removal， MDA levels were increased to varying degrees in all 3 groups. MDA levels of the control group and LPD group at the time of CPB removal， 1 hour and 2 hours after CPB removal were significantly higher than those of edaravone group （P＜0.05）. After CPB removal， SOD levels were decreased to varying degrees in all 3 groups. SOD levels of the control group and LPD group at the time of CPB removal， 1 hour and 2 hours after CPB removal were significantly lower than those of edaravone group （P＜0.05）. HE staining showed clear lung structure， less red blood cell leakage， less inflammatory cell infiltration， and less alveolar fluid accumulation in the edaravone group. Immunohistochemistry showed that integral light density of interleukin 6 （IL-6）in edaravone group was significantly lower than those of the LPD group and control group （14.44±1.75 vs. 20.18±2.22， P＜0.05）. Transmission electron microscopy showed integral basement membrane structure， clear blood gas barrier structure， significantly larger number of type II epithelial cells， abundant but not swollen mitochondria and lamellar bodies in the cytoplasm in the edaravone group， which were destroyed in varying degrees in the LPD group and control group. Conclusion Pulmonary artery perfusion of protective solution in low temperature can significantly reduce lung injury induced by DHCA and CPB. Protective solution containing edaravone in low temperature can better decrease lung injury and protect oxygenation.
Objective To determine risk factors of delayed recovery of consciousness after aortic arch surgery underdeep hypothermic circulatory arrest （DHCA） and antegrade selective cerebral perfusion （ASCP）. Methods We retrospectively analyzed clinical data of 113 patients who underwent aortic arch surgery under DHCA＋ASCP in the Affiliated Drum Tower Hospital， Medical School of Nanjing University from October 2004 to April 2012. According to whether they regained consciousness within 24 hours after surgery， all the 113 patients were divided into normal group （73 patients including 55 males and 18 females with their average age of 48.1±10.9 years） and delayed recovery group （40 patients including 29 males and 11 females with their average age of 52.2±11.4 years）. Risk factors of delayed recovery of consciousness after surgery were evaluated by univariate analysis and multivariate logistic regression analysis. Results Nine patients （8.0%） died postoperatively， including 5 patients with multi-organ failure， 2 patients with heart failure， 1 patient with mediastinal infection， and 1 patient with pulmonary hemorrhage. There were 7 deaths （17.5%） in the delayed recovery group and 2 deaths （2.7%） in the normal group， and the in-hospital mortality of the delayed recovery group was significantly higher than that of the normal group （P=0.016）. A total of 94 patients （including 65 patients in the normal group and 29 patients in the delayed recovery group） were followed up for 4-95 months. Eight patients （including 5 patients in the normal group and 3 patients in the delayed recovery group） died during follow-up， including 2 patients with stroke， 3 patients with heart failure， 2 patients with pulmonary hemorrhage and 1 patient with unknown cause. Ten patients were lost during follow-up. Univariate analysis showed that age （P=0.042）， hypertension （P=0.017）， emergency surgery （P=0.001）， cardiopu- lmonary bypass （CPB） time （P=0.007）， aortic cross-clamp time （P=0.021）， and blood transfusion（P=0.012）were risk factors of delayed recovery of consciousness after aortic arch surgery. Multivariate logistic regression showed that emergency surgery （P=0.005） and CPB time＞240 minutes （P=0.000） were independent risk factors of delayed recovery of consciousness after aortic arch surgery. Conclusion Delayed recovery of consciousness after aortic arch surgery is attributed to a combination of many risk factors. Correct patient diagnosis， lesion site and involved scope should be made clear preoperatively in order to choose appropriate surgical strategies. During the surgery， strengthened brain protection， shortened operation time， improved surgical techniques， and perioperative stable circulation maintenance are all important measures to prevent delayed recovery of consciousness after aortic arch surgery.
Abstract: Objective To observe the influence of various methods of cerebral protection during deep hypothermic circulatory arrest (DHCA ) on S-100 protein. Methods Eighteen dogs were randomly and equally divided into three groups: the deep hypothermic circulatory arrest (DHCA group ) , the DHCA with retrograde cerebral perfusion (DHCA + RCP group ) , and the DHCA with intermittent antegrade cerebral perfusion (DHCA + IACP group ). Upon interruption of cardiopulmonary bypass (CPB) , the nasopharyngeal temperature was slowly lowered to 18℃, before CPB was discontinued for 90 minutes, after 90 minutes, CPB was re-established and the body temperature was gradually restored to 36℃, then CPB was terminated. Before the circulatory arrest, 45min, 90min after the circulatory arrest and 15min, 30min after re-established of CPB, blood samples were drawn from the jugular veins fo r assay of S-100 protein. Upon completion of surgery, the dogs was sacrificed and the hippocampus was removed from the brain, properly processed for examination by transmission electron microscope for changes in the ultrastructure of the brain and nerve cells. Results There was no significant difference in the content of S-100 protein before circulatory arrest among all three groups (P gt; 0.05). After circulatory arrest, DHCA and DHCA +RCP group showed an significant increase in the content of S-100 protein (P lt; 0.01). There was no significant difference in the content of S-100 protein after circulatory arrest in DHCA + IACP group. Conclusion Cerebral ischemic injuries would occur if the period of DHCA is prolonged. RCP during DHCA would provide protection for the brain to some extent, but it is more likely to cause dropsy in the brain and nerve cells. On the other hand IACP during DHCA appears to provide better brain protection.
ObjectiveTo investigate the incidence of acute kidney injury (AKI) after deep hypothermic circulatory arrest (DHCA), to explore the risk factors and prognosis of postoperative AKI, and to establish a relatively accurate preoperative risk assessment strategy and prevention measures.MethodsThe clinical data of 252 patients who underwent deep hypothermic circulatory surgery in our hospital from January 2014 to October 2018 were retrospectively analyzed. There were 179 males and 73 females with an average age of 53.6±11.6 years. The patients were divided into an AKI group and a non-AKI group according to the AKI diagnostic criteria developed by kidney disease improving global outcomes (KDIGO). The data of the two groups were compared, and the risk factors related to AKI after DHCA were analyzed by single factor and multivariate logistic regression.ResultsAmong the 252 patients enrolled, the incidence of AKI was 69.0%. The postoperative hospital mortality rate was 7.9% (20/252). The univariate analysis showed that the patient's age and body mass index (BMI)≥28 kg/m2, left ventricular ejection fraction<55%, preoperative serum creatinine (Scr)≥110 μmol/L, preoperative estimated glomerular filtration rate (eGFR), Cleveland score and intraoperative cardiopulmonary bypass time, intraoperative infusion of red blood cells, intraoperative infusion of plasma, postoperative mechanical ventilation time≥40 h and other indicators were significantly different between the two groups (P<0.05); multivariate logistic regression analysis showed that there was significant difference between the two groups in age (OR=1.040, 95% CI 1.017–1.064, P=0.001), BMI≥28 kg/m2 (OR=2.335, 95%CI 1.093–4.990, P=0.029), eGFR<90 mL/(min·1.73 m2) (OR=2.044, 95%CI 1.082–3.863, P=0.028), preoperative Cleveland score (OR=1.300, 95%CI 1.054–1.604, P=0.014) and intraoperative cardiopulmonary bypass time (OR=1.009, 95%CI 1.002–1.017, P=0.014).ConclusionThe incidence of AKI is higher after DHCA. Patients with postoperative AKI have longer hospital stay and higher risk of hospitalization death. The age of patients, BMI≥28 kg/m2, eGFR<90 mL/(min·1.73) m2, Cleveland score, intraoperative extracorporeal circulation time are independent risk factors for AKI after DHCA.
ObjectiveTo investigate the results of emergent aortic arch replacement using moderate hypothermic circulatory arrest and unilateral antegrade cerebral perfusion (MHCA+UACP).MethodsWe retrospectively analyzed the clinical data of 146 patients who underwent emergent aortic arch replacement using MHCA+UACP in our institution from January 2008 to June 2018. There were 111 males and 35 females aged 60.3±7.2 years. According to different surgical approaches, patients were divided into two groups: a total arch replacement (TAR) group (n=104) and a semi arch replacement (SAR) group (n=42). Right axillary artery was cannulated for cardiopulmonary bypass (CPB) and cerebral perfusion. Core temperature at the onset of MHCA was 23.4±1.4 ℃. UACP was initiated at 18-22 ℃ with the flow of 5-10 ml/(kg·min). Flow was adjusted to maintain cerebral perfusion pressure of 50–60 mm Hg.ResultsCPB time was 235.0±42.0 min. Aortic clamp time was 154.0±29.0 min. Circulatory arrest (CA) time was 48.1±13.0 min. The CPB time and CA time of the TAR group were longer than those of SAR group. Overall mortality rate was 9.6%. Complications included permanent neurological dysfunction (PND), temporary neurological dysfunction (TND), acute kidney injury (AKI) requiring dialysis and delayed extubation (mechanical ventilation time >72 hours). Overall incidence of PND and TND was 2.7% and 6.8%, respectively. The incidence of AKI requiring dialysis was 4.1%. The incidence of delayed extubation was 21.9%. No difference of mortality rate or incidence of complications was found between the two groups. The average follow-up was 63.0±33.1 months. The 5-year survival rate was 72.6% in the TAR group and 85.5% in the SAR group.ConclusionEmergent aortic arch replacement using MHCA+UACP can be accomplished with excellent results.
Deep hypothermic circulatory arrest (DHCA) technology is the basic means of organ protection in complex aortic arch surgeries, congenital heart disease surgeries, pulmonary endarterectomy and other operations. The establishment of DHCA in rat model is helpful to explore the influence of DHCA and its pathophysiological pathways. However, there are some problems in this process, such as imperfect monitoring, inaccurate management and non-standard heparinization during the experimental period. It is necessary to review relevant literatures on DHCA rat model, in order to establish a DHCA rat model with standardized operation, clear standards and mature technology.
Objective To summarize the efficacy of aortic arch 1 zone clamping technique in the procedure of ascending aortic aneurysm involving the proximal aortic arch. Methods The clinical data of patients with ascending aortic aneurysm involving the proximal aortic arch who underwent surgical treatment with aortic arch 1 zone clamping technique in our hospital from 2017 to 2019 were retrospectively analyzed. ResultsA total of 35 patients were enrolled, including 21 males and 14 females, with an average age of 63.9±10.8 years. According to different lesions, the proximal aorta underwent Bentall/Carbrol procedure in 8 patients, Wheat in 4 patients, David in 3 patients, and ascending aorta replacement in 20 patients. Distal lesions were completely resected under aortic arch 1 zone clamping technique, and anastomotic reconstruction was performed under hypothermic cardiopulmonary bypass. Distal anastomosis was performed with interrupted suture in 7 patients, and continuous suture with intermittent reinforcement of the posterior wall in 28 patients. All patients successfully completed the procedure. The average cardiopulmonary bypass time was 121.5±28.2 min, the aortic clamping time was 78.1±21.3 min, and the distal anastomosis time was 15.2±3.6 min. One patient underwent a second thoracotomy for hemostasis, and the remaining patients were drained 330.6±108.1 mL on the first day following the procedure. The postoperative mechanical ventilation time of 2 patients exceeded 24 hours, and the main complications were pulmonary infection in 1 patient and acute renal injury in 2 patients. Transient delirium occurred in 2 patients and no transient or permanent neurological dysfunction occurred. The average follow-up time was 2.6±1.1 years. The maximum diameter of the ascending aorta after operation was 30.4±0.9 mm, the diameter of zone 1 aortic arch was 39.8±3.1 mm, and the diameter of the distal aortic arch was 32.3±4.3 mm. There was no lesion in the artificial blood vessels of all patients, and no aneurysms occurred at the proximal or distal anastomosis. No reoperation or intervention was needed for the aorta. ConclusionThe aortic arch 1 zone clamping technique can simplify the procedure of ascending aortic aneurysm involving the proximal aortic arch, reduce or avoid the use of deep hypothermic circulatory arrest, reduce the surgical trauma, and has good short-term and medium-term efficacy.
Abstract： Objective To determine the risk factors for acute kidney injury (AKI) after thoracic aortic arch replacement surgery under deep hypothermic circulatory arrest (DHCA). Methods We retrospectively analyzed the clinical data of 139 patients who underwent thoracic aortic arch replacement surgery under DHCA between January 2004 and December 2008 in Beijing Anzhen Hospital Affiliated to Capital University of Medical Sciences. The patients were divided into two gro-ups according to whether AKI occurred after thoracic aortic arch replacement surgery. In the AKI gro-up (n=48), there were 39 males and 9 females with an age of 57.67±9.56 years. In the normal renal function gro-up (n=91), there were 69 males and 22 females with an age of 41.30±13.37 years. We observed the clinical data of the patients in both gro-ups, including left ventricular ejecting fraction (LVEF) before operation, diameter of the left ventricle, diameter of the ascending aorta, renal function, cardiopulmonary bypass time, aortic crossclamp time, and DHCA time. The risk factors for AKI and death after operation were evaluated by univariate analysis and stepwise logistic regression analysis. Results Among all the patients, AKI occurred in 48 (34.53%), 17 (12.23%) of whom underwent continuous renal replacement therapy (CRRT). Respiratory failure occurred in 27 patients (19.42%). Twentynine patients (20.86%) had cerebral complications, including temporary cerebral dysfunction in 26 patients and permanent cerebral dysfunction in 3 patients. In all the patients, 14 (10.07%) died, including 4 patients of heart failure, 9 patients of multiple organ failure, and 1 patient of cerebral infarction. There were 3 (3.30%)deaths in the normal renal function gro-up and 11 (22.92%) deaths in the AKI gro-up with a significant difference of mortality rate between the two gro-ups (P=0.011). A total of 118 patients were followed -up and 7 were lost. The follow-up time was from 5 to 56 months with an average time of 42 months. During the follow-up period, 7 patients died, including 3 patients of heart failure, 2 patients of cerebral apoplexy, and 2 patients of unknown reasons. The logistic regression analysis revealed that creatinine level was greater than 13260 μmol/L before operation (OR=1.042, P=0.021) and respiratory failure (OR=2.057, P=0.002) were independent determinants for AKI after the operation. Conclusion AKI is the most common complication of thoracic aortic arch replacement surgery under DHCA, and is the risk factor of mortality after the surgery. It is important to enhance perioperative protection of the renal function.