Poster Houston

SAFETY OF ANTEGRADE CEREBRAL UNILATERAL PERFUSION IN AORTIC ARCH SURGERY C.Cavozza, P.Scoti, A.Audo, D. Mercogliano, M. Serra, P. Spitaleri, G. Camporini, C. Manca, D. Ricci, G. Parodi, L. De Silva, A. Pergolo and D. Medici Cardiac Surgery and Cardiac Anesthesia, Azienda Ospedaliera Alessandria, Italty ,[object Object],[object Object],Male 72 ,[object Object],36 Elective 36 Emergency 72 Emergency Elective ? And the brain? Surgical Procedures Direct or side-graft Innominate artery cannulation Chronic type A Aortic Dissection Annuloectasia involving ascending hemiarch Ascending aortic aneurysm involving ascending hemiarch ,[object Object],Bentall with ascending hemiarch replacement 5 Asacending aorta and hemiarch replacement 4 5* Bentall with total arch replacement and TSA reimplantation 3 8 11 David with partial arch replacement 5 Cabrol with total arch replacement and TSA reimplantation 3 Ascending aorta with total arch replacement and TSA reimplantation with Elephant trunk 2 Elective Surgical Procedures Emergency Surgical Procedures Type A Standford aortic dissection or De Bakey I/II Redo Bentall with Ascending hemiarch replacement 16 Ascending aorta and ascending hemiarch replacement 51 6 Wheat and hemiarch replacement 3 Ascending aorta and total arch replacement and TSA reimplantation with elephant trunk 2 SITES OF ARTERIAL CANNULATION DURING CPB Brain Perfusion during circulatory arrest 24 patients 14 patients Patients were cooled to 26° C of rectal temperature . Rigth antegrade perfusion started at flow rate of 10-15 cc/Kg/min with an brain inflow temperature of 25° C When arch and Femoral artery are cannulated a Coronary sinus catheter is inserted into innominate artery for brain perfusion To asses brain perfusion we used infrared spectroscopy scalp capillary saturation by a dual sensor for NIRS Attached to the patient's forehead to monitor the tissur oxygenation index (TOI) in the bilateral frontal lobe. Anesthesia was maintaned by continous intravenous propofol, remifentanyl and cis-atracurium infusion. The Bispectral index (BIS) was monitored with BIS monitor to mantain the depth of anesthesia. The BIS index was maintained from 35 to 45 at the beginning and from 0 to 20 during circulatory arrest ( Bust Soppression), to reduce cerebral oxigen demand (CMRO2) NIRS ,[object Object],Bilateral brain perfusion CPB time/min ,[object Object],[object Object],Transient Neurologic deficit ,[object Object],106 2 191 +/- 53 ,[object Object],8%* ,[object Object],[object Object],When left saturation decreased to abnormal values, Bilateral Cerebral Perfusion is mandatory The best surgical approach for cerebral protection, during open distal anastomosys, is still a matter of controversy. In our experience unilateral brain perfusion on hypothermia in most of cases is adeguate for allowing safe and better surgical view in surgery of aortic arch. When left cerebral saturation decreases respect baseline values , bilateral cerebral perfusion is mandatory to obtain good outcome. 32 patients Side-Graft Axillary artery cannulation 38 patients In all cases the innominate and the left carotid arteries were snared ,while the left subclavian artery was occluded by Swan Ganz catheter Side-graft femoral artery cannulation Arch cannulation This approach, based on our experience, help correct decrease in cerebral saruration values. Ideally baseline values should be obtained when the patients is awake, resting comfortable with O2 supplementation. We define abnormal rSO2 (regional SO2 saturation) as a 20% left reduction from baseline values or an absolute decrease of 50% 1: induction of anesthesia; 2: onset of CPB; 3:cooling on CPB; 4: unilateral right cerebral perfusion; 5: profound left saturation; 6: perfusion via left carotid cannula * In this patient we performed also bilateral pulmonary thromboendoarterectomy * operative mortality was defined as death during first 30 days after the operation .The overall mortalityi ncludes : three intraoperative exsanguination, two low cardiac output and four for multiorgan failure ** Temporary neurologic dysfunction was defined as presence of reversible postoperative motor deficit,confusion, agitation, or transient delirium. The computed tomography scan had to be normal and all symptoms resolved before discharge . ***Four patients sustained perioperative permanent neurologic damage(hemiplegia, paraparesis, multiple cerebral infarction) Bilateral antegrade selective cerebral perfusion By Kazui Baylor college of Medicine Houston, Texas 1-2 may, 2009 7 th Current trends in Aortic and Cardiothoracic Surgery Conclusions RESULTS Neuromonitoring Clinical Data OBJECTIVE BACKGROUND Materials & Methods Since De Bakey's first successful repair of aortic arch aneurysm in 1957, understanding of the aortic arch pathology, neuroprotective strategies, neuromonitoring and surgical technique have markedly improved. Adeguate brain protection is essential and commonly performed in our Institution by either antegrade selective perfusion of the brachiocefalic arteries, retrograde cerebral perfusion or an interval of profound hyphotermic circulatory arrest. . We present our experience for open distal aortic surgery with antegrade unilateral brain perfusion by means of cannulation of the right axillary or innominate artery .

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