Straight deep hypothermic circulatory arrest for aortic arch surgery: Going the way of the dinosaurs?
2017; Elsevier BV; Volume: 154; Issue: 6 Linguagem: Inglês
10.1016/j.jtcvs.2017.08.044
ISSN1097-685X
Autores Tópico(s)Congenital Heart Disease Studies
ResumoCentral MessageStraight deep hypothermic circulatory arrest for brain protection during aortic arch surgery is not the best option after 40 minutes of ischemia.See Article page 1831. Straight deep hypothermic circulatory arrest for brain protection during aortic arch surgery is not the best option after 40 minutes of ischemia. See Article page 1831. In this issue of the Journal, Damberg and colleagues1Damberg A. Carino D. Charilaou P. Peterss S. Tranquilli M. Ziganshin B.A. et al.Favorable late survival after aortic surgery under straight deep hypothermic circulatory arrest.J Thorac Cardiovasc Surg. 2017; 154: 1831-1839Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar report their experience with straight deep hypothermic circulatory arrest (DHCA) as the sole means of brain protection during operations on the aortic arch in 613 consecutive patients, focusing on late outcomes.1Damberg A. Carino D. Charilaou P. Peterss S. Tranquilli M. Ziganshin B.A. et al.Favorable late survival after aortic surgery under straight deep hypothermic circulatory arrest.J Thorac Cardiovasc Surg. 2017; 154: 1831-1839Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar The independent variables associated with increased 1-year mortality were acute type A aortic dissection, reoperative status, and the presence of descending thoracic aortic pathology. The independent variables associated with increased mortality beyond 1 year were increased age, postoperative complications (stroke, dialysis, pulmonary complications), and postoperative atrial fibrillation. The duration of DHCA did not emerge as a significant predictor of either 1-year or late mortality. Damberg and colleagues1Damberg A. Carino D. Charilaou P. Peterss S. Tranquilli M. Ziganshin B.A. et al.Favorable late survival after aortic surgery under straight deep hypothermic circulatory arrest.J Thorac Cardiovasc Surg. 2017; 154: 1831-1839Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar conclude that aortic arch surgery with DHCA can be performed with favorable early and late survivals and that the length of DHCA has only limited impact on these outcomes. Elefteriades and his colleagues at Yale are perhaps the most impassioned (and persistent) advocates of straight DHCA for operations involving the aortic arch, and they have used no other alternative or adjunctive strategy for brain protection since at least 2003. Their early outcomes, in terms of mortality and overt neurologic injury, are impressive (2.9% operative mortality, 2% stroke rate). The low prevalences of reoperations for bleeding, pulmonary complications, prolonged ventilation, and renal replacement therapy should provide reassurance to the users of this technique that when it is applied in a systematic fashion, the rates of mortality and morbidity are comparable to those achieved with other commonly used techniques, including moderate hypothermia with antegrade brain perfusion. Although Damberg and colleagues1Damberg A. Carino D. Charilaou P. Peterss S. Tranquilli M. Ziganshin B.A. et al.Favorable late survival after aortic surgery under straight deep hypothermic circulatory arrest.J Thorac Cardiovasc Surg. 2017; 154: 1831-1839Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar did not identify use of DHCA as an independent predictor of either 1-year or late mortality, there are concerns related to this finding regarding stroke and other indicators of neurologic injury. The stroke rate was 10.5% for patients with a DHCA time of 50 minutes or longer, versus 1.7% for those with a DHCA time shorter than 50 minutes, a 6-fold difference with a P value of .05. Temporary neurologic dysfunction and seizures, less sensitive but likely indicators of neurologic injury,2Ergin M.A. Uysal S. Reich D.L. Apaydin A. Lansman S.L. McCullough J.N. et al.Temporary neurological dysfunction after deep hypothermic circulatory arrest: a clinical marker of long-term functional deficit.Ann Thorac Surg. 1999; 67 (discussion 1891-4): 1887-1890Abstract Full Text Full Text PDF PubMed Scopus (213) Google Scholar, 3Krähenbühl E.S. Immer F.F. Stalder M. Englberger L. Eckstein F.S. Carrel T.P. Temporary neurological dysfunction after surgery of the thoracic aorta: a predictor of poor outcome and impaired quality of life.Eur J Cardiothorac Surg. 2008; 33: 1025-1029Crossref PubMed Scopus (34) Google Scholar occurred in 5.1% and 1% of the patients, respectively, but they were not analyzed further. It should also be noted that among the patients in whom the duration of DHCA was 40 minutes or longer, the operative mortality was 4.5%, 4 times higher than the mortality for the patients with a DHCA time of less than 40 minutes (1.1%), although the difference did not reach statistical significance. Although there is no consensus, there is agreement among most aortic surgeons, including the same Yale group,4Ziganshin B.A. Rajbanshi B.G. Tranquilli M. Fang H. Rizzo J.A. Elefteriades J.A. Straight deep hypothermic circulatory arrest for cerebral protection during aortic arch surgery: safe and effective.J Thorac Cardiovasc Surg. 2014; 148 (discussion 898-900): 888-898Abstract Full Text Full Text PDF PubMed Scopus (85) Google Scholar that 40 minutes is the upper limit of safety when using DHCA. It is therefore concerning that, with the availability of other strategies for neuroprotection during extensive operations on the aortic arch (namely antegrade brain perfusion) and with knowledge of the adverse effects on neurologic function with the longer arrest times that were observed in this study, Damberg and colleagues1Damberg A. Carino D. Charilaou P. Peterss S. Tranquilli M. Ziganshin B.A. et al.Favorable late survival after aortic surgery under straight deep hypothermic circulatory arrest.J Thorac Cardiovasc Surg. 2017; 154: 1831-1839Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar did not initiate brain perfusion either initially, when a prolonged and complicated procedure was anticipated, or when the DHCA time approached 40 minutes. That said, Damberg and colleagues1Damberg A. Carino D. Charilaou P. Peterss S. Tranquilli M. Ziganshin B.A. et al.Favorable late survival after aortic surgery under straight deep hypothermic circulatory arrest.J Thorac Cardiovasc Surg. 2017; 154: 1831-1839Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar have provided solid evidence that DHCA is a safe and effective method of brain protection for procedures involving the aortic arch if the duration of circulatory arrest does not exceed 40 minutes. It continues to be the method of choice for many surgeons who perform partial arch procedures, myself included, and it is likely to remain so.5Ziganshin B.A. Which method of cerebral protection do you prefer to use for aortic arch surgery?.Aorta (Stamford). 2013; 1: 69-70Crossref PubMed Scopus (10) Google Scholar Will straight deep hypothermic circulatory arrest for aortic arch operations eventually go the way of the dinosaurs in favor of other techniques with antegrade brain perfusion? Not any time soon. Favorable late survival after aortic surgery under straight deep hypothermic circulatory arrestThe Journal of Thoracic and Cardiovascular SurgeryVol. 154Issue 6PreviewSurgical and cerebral protection strategies in aortic arch surgery remain under debate. Perioperative results using deep hypothermic circulatory arrest (DHCA) have been associated with favorable short-term mortality and stroke rates. The present study focuses on late survival in patients undergoing aortic surgery using DHCA. Full-Text PDF Open ArchiveTechnique of circulatory arrest makes a differenceThe Journal of Thoracic and Cardiovascular SurgeryVol. 156Issue 1PreviewI enjoyed the recent article by Damberg and colleagues1 and the accompanying editorial commentary by Kouchoukos2 regarding the ongoing differences of opinion regarding the application of deep hypothermic circulatory arrest during aortic surgery in adults. The same controversy continues among congenital surgeons. However, I was surprised to see both in the article by Damberg and colleagues1 as well as the editorial commentary by Kouchoukos that the only technical detail of circulatory arrest that was discussed was its duration. Full-Text PDF Open Archive
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