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Publisher Copyright: © 2021 Annals of Cardiac Anaesthesia. Background: Cardiopulmonary bypass (CPB) may lead to tissue hypoxia, inflammatory response, and risk for acute kidney injury (AKI). We evaluated the prevalence of AKI and inflammatory response in neonates undergoing heart surgery requiring CPB with or without antegrade cerebral perfusion (ACP). Methods: Forty neonates were enrolled. The patients were divided into two groups depending on the use of ACP. AKI was classified based on the Kidney Disease: Improving Global Outcomes (KDIGO) criteria. Inflammatory response was measured using plasma concentrations of interleukins 6 (IL-6) and 10 (IL-10), white blood cell count (WBC), and C-reactive protein (CRP). Results: Eight patients (20%) experienced AKI: five (29%) in the ACP group and three (13%) in the non-ACP group (P = 0.25). Postoperative peak plasma creatinine and urine neutrophil gelatinase-associated lipocalin were significantly higher in the ACP group than in the non-ACP group [46.0 (35.0-60.5) vs 37.5 (33.0-42.5), P = 0.044 and 118.0 (55.4-223.7) vs 29.8 (8.1-109.2), P = 0.02, respectively]. Four patients in the ACP group and one in the non-ACP group required peritoneal dialysis (P = 0.003). Postoperative plasma IL-6, IL-10, and CRP increased significantly in both groups. There were no significant differences between the ACP and non-ACP groups in any of the inflammatory parameters measured. Conclusions: No significant difference in the AKI occurrence or inflammatory response related to CPB modality could be found. In our study population, inflammation was not the key factor leading to AKI. Due to the limited number of patients, these findings should be interpreted with caution.

The technique of antegrade cerebral perfusion has been adopted by many aortic surgery centers as the routine method of brain protection with some variations in its implementation. These variations stem from the issues with regard to the perfusion pressure, flow, temperature, pH management, hematocrit value, cannulation sites, and unilateral versus bilateral application. In this review, the prespecified issues were discussed and some recommendations about the implementation of antegrade cerebral perfusion were given.

INTRODUCTION: To determine the effects of wiilis polygon variations on long-term survival in patients with aortic aneurysm and/or aortic dissection operated with the Antegrade Selective Cerebral Perfusion (ASSP) technique METHODS: Twenty patients with ascending, arcus aneurysm and dissection who underwent antegrade selective cerebral perfusion via the right brachial artery were prospectively studied. Willis polygon variations were detected by cerebral multi-section computed tomographic angiography device. Cooling degrees, cross-clamping, low flow, total perfusion times, postoperative intensive care unit stay, neurologic examination, and hospitalization times were evaluated. RESULTS: Of the patients, 70% (14) were male and 30% (6) were female, with a mean age of 54.20+-10.58 (38-70). Five patients had Stanford type 1 aortic dissection and fifteen patients had ascending and/or aortic aortic aneurysms. The mean cardiopulmonary bypass times of the patients were 146+-32.9 (82-200) minutes, the cross-clamp times were 101+-31.6 (47-165) minutes, and the selective cerebral perfusion times were 26+-7.8 (16-45) minutes. Only one patient had paresthesia and loss of function in the right hand, and almost complete clinical improvement was observed on the second postoperative day. DISCUSSION AND CONCLUSION: With this study, we defined the willis polygon variations in the population. As we have determined; If there are three communicating arteries, the variations are not significant. Unless the patients are in the high-risk group, it is not necessary to evaluate the willis polygon variations before the procedure in patients who will undergo surgery with antegrade cerebral perfusion.

Background: We designed a prospective randomized clinical study to compare unilateral and bilateral antegrade cerebral perfusion (ACP) under moderate hypethermia in open distal aortic hemiarch replacement in ascending aortic aneurysm. Methods: Forty-two patients were prospectively randomized into two groups; unilateral ACP to Group 1 and bilateral ACP to Group 2. Inclusion criteria were pathological aortic aneurysm in the ascending aorta and/or aortic arch, elective operation, normal preoperative carotid Doppler ultrasonography, and nonexistence of preoperative neurological event. Patients were evaluated with preoperative and postoperative biochemical blood analysis, magnetic resonance imaging (MRI), and neurological disorders. The primary endpoints were permanent neurological disorder and death. Results: There were 21 patients in each group. Mean age was 56.57 ± 10.06 years in Group 1 and 50.95 ± 15.64 years in Group 2 (p =.170). No significant difference was found according to demographic data. ACP times were significantly higher in bilateral ACP (Group 1: 12.62 ± 5.04 min, Group 2: 18.23 ± 9.04 min, p =.018) whereas cross-clamp time and cardiopulmonary bypass times were not (p =.693 and p =.584 sequentially). Transient neurological disorder was found in seven patients in Group 1 and in 4 patients in Group 2 (p =.484). Postoperative MRI revealed new milimetric ischemic zones in three patients in Group 1 but none in Group 2. No permanent neurological disorder or mortality was seen. Conclusion: The present randomized clinical prospective study could not prove the superiority of one of the technique in cerebral protection probably because, our overall ACP time was too short. © 2020 Wiley Periodicals LLC

Objective Our objective was to describe the technique and rationale for branch-first total aortic arch repair. Methods Branch-first total aortic arch repair involves serial clamping, reconstruction, and reperfusion of each of the arch branches using a specially designed trifurcation graft with a side port. During this sequence, perfusion to the heart and distal organs are preserved and continuous antegrade cerebral perfusion is permitted via the trifurcation graft. The diseased aorta is excised and replaced with a Dacron graft (W.L. Gore and Associates, Newark, Del) with a perfusion side port. The trifurcation graft is anastomosed to the new proximal ascending aorta. Results The branch-first technique permits total aortic arch repair without global cerebral circulatory arrest and excessive hypothermia. It shortens distal organ and cardiac ischemic time, and reduces the opportunity for air and particulate embolization during aortic repair. Conclusions Branch-first total aortic arch repair allows continuous antegrade cerebral perfusion and shortens distal organ and cardiac ischemic time, with unobstructed access to the full extent of the diseased aortic arch.

The total aortic arch replacement is one of the most technically demanding operations, the main risk of which is the intraoperative ischemic lesion of the brain. Despite progress, operating mortality associated with this operation, even at the most renowned specialized centers reaches 7.3%. An alternative to the classic “open” operation is aortic endoprosthesis, combined with the procedure of debranching. This approach allows diminishing trauma by reducing the duration of the cardiopulmonary bypass. The aim. To describe the rational approach for replacing the total aortic arch depending on the diameter of aneurysm, the condition of the arch vessels, and the acuteness of clinical condition.The main indications for the replacement of the aortic arch are the true atherosclerotic aneurysms, genetic connective tissue diseases (Marfan syndrome), syphilis. The total arch replacement recently becomes more frequent indication for acute type A aortic dissection. The newly introduced strategies of operation and perfusion for total aortic arch replacement are aimed to reduce the risk of neurological complications. This method is named “arch first technique” which gradually replaces the earlier technique, at which the first anastomosis is performed with a descending thoracic aorta. A more traditional method called the “descending aorta first” was selected. A mandatory element of both types of the operation is antegrade cerebral perfusion. The main advantage of this method is maintaining constant perfusion of the brain which significantly reduces the risk of its ischemic damage, avoids deep hypothermia and its negative impact on blood coagulation system. The technique of total arch replacement consists of the following elements: access, double arterial cannulation, the method of brain protection, formation of distal anastomosis with descending thoracic aorta, implantation of arch vessels into the prosthesis. Sequence of anastomosis depends on morphological and clinical peculiarities of the specific case. Changes in the strategy for “open” total aortic arch replacement in various aortic pathologies is discussed based on the author’s clinical experience and literature data. Conclusions. Total aortic arch replacement remains a traumatic and technically demanding operation, the main risks of which are hemorrhage and ischemic brain lesions. The method of arch replacement – “descending aorta first” includes double arterial cannulation, antegrade cerebral perfusion, deep hypothermia with complete blood flow stoppage for the lower half of the body and the use of multi-branch vascular prosthesis.

Objective We describe a novel and safe technique using a 12F–14F pediatric arterial cannula to establish unilateral, selective, antegrade cerebral perfusion (ACP) during open hemiarch reconstruction. Methods Between January 2015 and September 2018, 42 patients underwent elective aortic aneurysm repair requiring an open distal anastomosis and at least a hemiarch replacement via hypothermic circulatory arrest by 2 surgeons. All distal reconstructions were performed at moderate hypothermia (22°C–26°C) with direct cannulation of the innominate artery (IA) using a pediatric arterial cannula to allow ACP at 10–15 mL/kg/min. Data were collected by retrospective chart review. Results Thirty-one of the 42 patients (74%) were male. The mean patient age was 65 ± 13 years, and the mean body surface area was 2.1 ± 0.3 m2. Proximal repairs included a modified Bentall with a valve-graft composite (n = 17), valve-sparing root replacement (n = 2), and aortic valve replacement (n = 15). Perioperative mortality was 2% (n = 1), and the incidence of stroke was 0%. The mean lowest core body temperature reached during circulatory arrest was 23.8 ± 2.7°C with a mean ACP time of 21.8 ± 3.6 minutes. The mean aortic cross-clamp and cardiopulmonary bypass times were 160.6 ± 55.5 minutes and 204.7 ± 57.5 minutes, respectively. There were no cases of IA injury. Conclusions Direct IA cannulation with a pediatric arterial cannula is a safe and efficient method to allow ACP in aortic surgery requiring hypothermic circulatory arrest and may circumvent the potential complications of axillary cannulation., Graphical abstract Intraoperative view of the innominate artery (IA) and central aortic cannulation. The aortic aneurysm is cannulated in standard fashion, whereas the IA is cannulated with a 12F or 14F pediatric cannula.

Background During total aortic arch replacement surgery (TARS) for patients with acute type A aortic dissection, the organs in the lower body, such as the viscera and spinal cord, are at risk of ischemia even when antegrade cerebral perfusion (ACP) is performed. Combining ACP with retrograde inferior vena caval perfusion (RIVP) during TARS may improve outcomes by providing the lower body with oxygenated blood. Methods This study is designed as a multicenter, computer-generated, randomized controlled, assessor-blind, parallel-group study with a superiority framework in patients scheduled for TARS. A total of 636 patients will be randomized on a 1:1 basis to a moderate hypothermia circulatory arrest (MHCA) group, which will receive selective ACP with moderate hypothermia during TARS; or to an RIVP group, which will receive the combination of RIVP and selective ACP under moderate hypothermia during TARS. The primary outcome will be a composite of early mortality and major complications, including paraplegia, postoperative renal failure, severe liver dysfunction, and gastrointestinal complications. All patients will be analyzed according to the intention-to-treat protocol. Discussion This study aims to assess whether RIVP combined with ACP leads to superior outcomes than ACP alone for patients undergoing TARS under moderate hypothermia. This study seeks to provide high-quality evidence for RIVP to be used in patients with acute type A aortic dissection undergoing TARS. Trial registration Clinicaltrials.gov, ID: NCT03607786. Registered on 30 July 2018. Electronic supplementary material The online version of this article (10.1186/s13063-019-3319-2) contains supplementary material, which is available to authorized users.

ObjectivesAntegrade cerebral perfusion (ACP) under moderate hypothermic circulatory arrest is used during total aortic arch replacement surgery (TARS) in patients with acute type A aortic dissection, but it is associated with high mortality and morbidity. We hypothesized that combining ACP with retrograde inferior vena caval perfusion (RIVP) improves outcomes.MethodsThis pilot study was prospective, randomized, controlled and assessor-blinded. Patients scheduled for TARS were randomly treated with either ACP or RIVP + ACP. The primary outcome was a composite of mortality and major complications including paraplegia, postoperative renal failure, severe liver dysfunction, and gastrointestinal complications. Secondary outcomes included neurological complications, length of intubation and requirement of blood products.ResultsA total of 76 patients were recruited (n = 38 per group). Primary outcome occurred in 23 patients (61%) in the ACP group and 16 (42%) in the RIVP + ACP group (OR: 0.60, 95% CI: 0.21–1.62;p = 0.31). There was a lower incidence of transient neurological deficits in the RIVP + ACP group (26% vs. 58%, OR: 0.26; 95% CI: 0.10–0.67,p = 0.006;). The RIVP + ACP group underwent shorter intubation (25 vs 47 h,p = 0.022) and required fewer blood products (red cells, 3.8 units vs 6.5 units,p = 0.047; platelet: 2.0 units vs 2.0 units, p = 0.023) compared with the ACP group.ConclusionsRIVP + ACP may be associated with lower incidence of transient neurological deficits, shorter intubation and less blood transfusion requirement than ACP alone during TARS. Multi-center, randomized trials with larger samples are required to determine whether RIVP + ACP is associated with lower rates of mortality and major complications.Trial registration: Pilot study of a RCT registered in clinicaltrials.gov (NCT03607786), Registered 30 July, 2018—Retrospectively registered,https://clinicaltrials.gov/ct2/show/NCT03607786.

Objectives Real-time noninvasive monitoring of cerebral blood flow (CBF) during surgery is key to reducing mortality rates associated with adult cardiac surgeries requiring hypothermic circulatory arrest (HCA). We explored a method to monitor cerebral blood flow during different brain protection techniques using diffuse correlation spectroscopy (DCS), a noninvasive optical technique which, combined with frequency-domain near-infrared spectroscopy (FDNIRS), also provides a measure of oxygen metabolism. Methods We used DCS in combination with FDNIRS to simultaneously measure hemoglobin oxygen saturation (SO2), an index of cerebral blood flow (CBFi), and an index of cerebral metabolic rate of oxygen (CMRO2i) in 12 patients undergoing cardiac surgery with HCA. Results Our measurements revealed that a negligible amount of blood is delivered to the cerebral cortex during HCA with retrograde cerebral perfusion, indistinguishable from HCA-only cases (median CBFi drops of 93% and 95%, respectively) with consequent similar decreases in SO2 (mean decrease of 0.6 ± 0.1% and 0.9 ± 0.2% per minute, respectively); CBFi and SO2 are mostly maintained with antegrade cerebral perfusion; the relationship of CMRO2i to temperature is given by CMRO2i = 0.052e0.079T. Conclusions FDNIRS-DCS is able to detect changes in CBFi, SO2, and CMRO2i with intervention and can become a valuable tool for optimizing cerebral protection during HCA., Graphical abstract Real-time noninvasive cerebral blood flow monitoring during cardiac surgery could help optimize neuroprotective measures and hence decrease rates of neurologic injury associated with hypothermic circulatory arrests (HCAs). We used combined frequency-domain near-infrared spectroscopy and diffuse correlation spectroscopy (FDNIRS-DCS) to measure hemoglobin oxygen saturation (SO2), cerebral blood flow index (CBFi), and cerebral metabolic rate of oxygen (CMRO2i) in 12 adults undergoing HCA (4 HCA-only, 3 retrograde cerebral perfusion [RCP], 5 antegrade cerebral perfusion [ACP]). We coacquired regional oxygen saturation (rSO2) from a hospital oximeter (INVOS), mean arterial blood pressure (MAP), and nasopharyngeal temperature. Our measurements revealed that during HCA with RCP CBFi drops to almost zero and overshoots above baseline when circulation is restarted, similar to the CBFi behavior found during HCA-only. As a consequence of the low perfusion, with RCP and HCA-only SO2 decreases during HCA; in contrast, both CBFi and SO2 are mostly maintained with ACP.

We present a case of antegrade cerebral perfusion based on a circuit with a centrifugal pump for general open-heart surgery to achieving cerebral protection during a challenging hybrid aortic arch repair.

We propose a technique to minimize the neurological and systemic risks involved in rerouting the blood flow toward the brain in a “single remaining vessel” configuration with a 90% stenosis by means of complete hypothermic cerebral protection associated with normothermic systemic blood flow with a “restitutio ad integrum” of the supra-aortic trunks flow. The perfusion of the brain and the arms was almost completely separated from the systemic perfusion by the deployment 1 year before of a thoracic endoprosthesis in association with complete chronic occlusion of the brachiocephalic trunk and a functioning carotid-subclavian bypass. The Free Flow of the prosthesis, which acted as a hook, moved the calcium toward the left carotid ostium, creating a 90% stenosis with intermittent acute cerebral hypoperfusion and amaurosis. We achieved an optimal result: The patient was discharged on postoperative day 7 with no neurological problems and with patency and direct blood flow in all the supra-aortic trunks.

Background: For type A aortic dissection (TAAD), antegrade cerebral perfusion (ACP) was proposed as a more physiological method than retrograde cerebral perfusion (RCP) for intra-operative brain protection, but it is still debatable whether antegrade cerebral perfusion (ACP) or retrograde cerebral perfusion (RCP) is related to the better clinical outcome. The present study was undertaken to compare the results in our patients receiving surgery for TAAD with ACP or RCP. The primary aim of this study was focused on the incidence of and the factors associated with surgical mortality, post-operative neurological outcomes and long-term survival. Methods: From February 2001 to March 2019, there were 223 consecutive patients with TAAD treated surgically at our hospital. The median age at presentation was 56 years (range 29–88 years) and 70 patients (31.4%) over 65 years of age. There were 168 patients treated with RCP and 55 patients treated with ACP. The primary endpoints were surgical mortality and neurological outcome. Propensity score matching was used to compare the treatment results of surgeries with RCP or ACP. The long-term survival was also analyzed. Results: The overall in-hospital mortality rate and the overall 30-day mortality rate were 15.6% and 14.3% respectively. For the patients without pre-operative shock (n = 184), the in-hospital mortality rate was 10.3% and the 30-day mortality rate was 8.7% and higher long-term survival rates (88.3% for 5 years, 86.5% for 10 years, 86.5% for 15 years) were documented for this patient group. There was no significant difference on the surgical mortality between the ACP group and the RCP group. In the entire cohort, there were 23 patients (10.3%) who suffered from post-operative neurological deficits (PND) and there were less PND for the patients with RCP than the patients with ACP (7.7% vs 18.1%, p = 0.027). After propensity score matching, there was still higher incidence of PND in the ACP group than in the RCP group but without statistical significance (18.5% vs 11.1%, p = 0.279). Conclusions: Aortic surgery carries high risk for the patients with TAAD and PND is not an unusual post-operative morbidity. In our series, pre-operative shock, pre-operative CPR, CRI, past history with CAD are related to higher surgical mortality. The younger patients (

OBJECTIVES The risk of brain injury following surgery for type A aortic dissection (TAAD) remains substantial and no consensus has still been reached on which neuroprotective technique should be preferred. We aimed to investigate the association between neuroprotective strategies and clinical outcomes following TAAD repair. METHODS Using the UK National Adult Cardiac Surgical Audit, we identified 1929 patients undergoing surgery for TAAD (2011–2018). Deep hypothermic circulatory arrest (DHCA) only, unilateral (uACP), bilateral antegrade cerebral perfusion (bACP) and retrograde cerebral perfusion were used in 830, 117, 760 and 222 patients, respectively. The primary end point was a composite of death and/or cerebrovascular accident (CVA). Generalized linear mixed model was used to adjust the effect of neuroprotective strategies for other confounders. RESULTS The use of bACP was associated with longer circulatory arrest (CA) compared to other strategies. There was a trend towards lower incidence of death and/or CVA using uACP only for shorter CA. In particular, primary end point rate was 27.7% overall and 26.5%, 12.5%, 28.0% and 22.9% for CA, Management of type A acute aortic dissection (TAAD) remains a challenge.

Antegrade selective cerebral perfusion has become the preferred choice for brain protection during aortic arch surgery. To perform antegrade selective cerebral perfusion, cannulas have been introduced directly into the ostia of the supra-aortic vessels (SAV) after institution of hypothermic circulatory arrest and opening the aortic arch. We describe a different surgical technique with a new type of cannula for antegrade selective cerebral perfusion. This cannula, called AV (Andrea Venturini) cannula, has been designed to be introduced in the SAV directly using a standard guidewire technique (Seldinger's technique). The AV cannula can also be introduced from the ostia of the SAV if preferred. The AV cannula can be introduced before the institution of hypothermic circulatory arrest and before opening the aortic arch. One great advantage of this technique is that the ostia of the SAV remain free from a cannula, allowing the operator easier access and a faster anastomosis or reimplantation.

Amaç: Bu çalışma, antegrad serebral perfüzyon ve distal ılımlı hipotermik sirkülatuararrest tekniğinin endotel fonksiyonuna ilişkin biyobelirteçler üzerine etkisini standart kalp cerrahisi ile karşılaştırmayı amaçlamaktadır.Materyal-Metod: Asendan aort anevrizması için 28 ° C' da selektif antegrad serebral perfüzyon ve orta derecede hipotermik alt vücut dolaşım durması uygulanan 36 hasta (standart çalışma grubu), konvansiyonel kardiyopulmoner bypass ile standart kalp ameliyatı uygulanan (kontrol grubu) 36 hasta prospektif olarak karşılaştırıldı. Vena kava inferiordan elde edilen kan örneklerinde nitrik oksit, asimetrik dimetilarginin, hidrojen sülfit ve toplam antioksidan kapasite durumu ve laktat seviyeleri incelenmiştir. Klinik sonuçlar ve biyokimyasal parametreler değerlendirildi.Bulgular: Endotel fonksiyonuyla ilgili biyobelirteçler, asimetrik dimetilarjinin dışındaki gruplar arasında benzer bulundu. Asimetrik dimetilarjinin düzeyleri düşüktü, laktat düzeyleri ise kontrol grubuna göre anlamlı derecede yüksek bulundu. Kontrol gruptaki koroner arter hastalarının baskınlığını nedeniyle çıkan sonuçlarda kafa karıştırıcı bir faktör olarak düşünülerek koroner arter hastaları analiz dışında bırakıldığında, asimetrik dimetilarjinin düzeylerinin, iki alt grup arasında benzer olduğu bulundu.Sonuç: Çalışma grubundaki düşük plazma asimetrik dimetilarjinin seviyeleri, endotelyal nitrik oksit sentezinde koruyucu bir role sahip olabilir. Koroner arter hastalığı olan hastalar her iki gruptan da dışlandığında, endotel fonksiyonuna bağlı biyobelirteçler her iki grupta da benzerdi. Bu sebeple antegrad serebral perfüzyon ve distal ılımlı hipotermik sirkülatuar arrest tekniğinin kısa dönemde endotel fonksiyonlarını etkilemediğini düşünmekteyiz. Aim: This study aims to compare biomarkers related to endothelial function during selective antegrade cerebral perfusion with moderate hypothermic lower body circulatory arrest with that of standard cardiac surgery.Material and Methods: Thirty-six consecutive patients who underwent selective antegrade cerebral perfusion with moderately hypothermic lower body circulatory arrest at 28°C (study group) for aneurysms of the ascending aorta were prospectively compared with 36 patients who underwent standard cardiac surgery (control group) with conventional cardiopulmonary bypass. Nitric oxide, asymmetric dimethylarginine, hydrogen sulfide and total antioxidant capacity status and lactate levels in blood specimens obtained from the vena cava inferior were studied. Clinical results and biochemical parameters were evaluated.Results: Biomarkers related to endothelial function were found to be similar between the groups except for asymmetric dimethylarginine. The asymmetric dimethylarginine levels were lower, while lactate levels were significantly higher compared to the control group. When the patients with coronary artery disease were excluded from the analysis to rule out the predominance of coronary artery disease patients in one group as a confounding factor, the asymmetric dimethylarginine levels were found to be similar between the two subgroups.Conclusion: Low plasma levels of asymmetric dimethylarginine in the study group may have a protective role in endothelial nitric oxide synthesis. When patients with coronary artery disease were excluded from both group, biomarkers related to endothelial function were similar in both groups. We consider that endothelial functions are not affected adversely during short periods of moderately hypothermic lower body circulatory arrest.

Background Many studies have shown the benefits of deep hypothermia on cerebral protection during arch surgery; however this has a deleterious effect on endothelial function, coagulation & renal functions. Our aim from this study was to show that we could achieve cerebral protection by using selective antegrade cerebral perfusion (SACP) and mild hypothermia, hence avoiding the side effects of deep hypothermia. Methods In this retrospective analytical study, the computerised database was interrogated retrospectively to identify all patients who underwent full arch or hemi-arch replacement with the utilisation of open distal anastomosis technique. The cases retrieved were operated on between August 2003 and September 2013, in the Lancashire cardiac center, Blackpool Victoria Hospital. The main indication of surgery was based on size criteria. A total of 73 patients were identified for inclusion in the study. All patients had SACP along with a period of lower body circulatory arrest at mild systemic hypothermia. 22 patients including 9 (40.9%) men underwent full arch replacement (Group A) and 51 had hemi-arch replacement which included 43 (66.7%) men (Group B). Results The arch group (Group A) had no neurological complications. In the hemi-arch group (Group B), 2 patients (3.9%) had cerebrovascular events but there were no cases of paraplegia. Temporary hemofiltration was required in 1 patient (4.5%) in Group I and 2 patients (3.9%) in Group II. Further, 2 patients (9.1%) in the arch group and 3(6%) in the hemi-arch group had renal dysfunction not needing dialysis. Mean ICU stay was 2 days (±6.5 days) in the arch group and 1 day (±13.9 days) in the hemi-arch group. Overall there were 4 in-hospital deaths including 2 (9.1%) in the arch group and 2 (3.9%) in the hemi-arch group. There was no significant statistical difference between the two groups. Conclusion The study showed outcomes comparable to other previous larger studies and adds to the available evidence in favour of this approach.

Aortic arch open surgery continues to represent a formidable challenge for heart surgeons. In fact, the interruption of physiological brain perfusion is a major detrimental effect during the systemic circulatory arrest resulting in a series of neurological complications. In order to protect the brain from these injuries, three techniques have been proposed and widely utilized as a means of protecting the brain: deep hypothermic circulatory arrest (DHCA), retrograde cerebral perfusion (RCP) and antegrade cerebral perfusion (ACP). The basis for all the techniques is the protection afforded by hypothermia with the consequent metabolic suppression.

ResumenObjetivosLa reparación de la coartación aórtica con/sin hipoplasia de arco en neonatos/lactantes es controvertida. Los abordajes quirúrgicos mediante toracotomía o esternotomía, respectivamente, evitan o requieren circulación extracorpórea. Presentamos nuestros resultados, analizando si existen diferencias significativas entre ambas técnicas.MétodosEstudio retrospectivo; 132 lactantes con anatomía de corazón biventricular y cirugía del arco aórtico durante el período 2004-2014: 65-esternotomías y 67 toracotomías. En las esternotomías usamos rutinariamente perfusión cerebral selectiva (PCS). La parada circulatoria es excepcional.ResultadosGrupos no homogéneos: el abordaje esternal asocia más cardiopatía, más hipoplasia de arco y mayor complejidad. Técnicas quirúrgicas: por esternotomía 83% pacientes recibieron anastomosis término-lateral y por toracotomía 87% anastomosis termino-terminal. Mortalidad hospitalaria: 10,7% esternotomía y 4,5% toracotomía (ns). Morbilidad hospitalaria: sin diferencias en complicaciones neurológicas ni en recoartación precoz, pero las esternotomías tienen más lesión del nervio recurrente laríngeo y mayores estancias hospitalarias que las toracotomías (p

Amac: Bu yazida yenidogan ve infantlarda aortik arkus ve intrakardiyak tamir ile birlikte, selektif antegrad serebral perfuzyon ile yapilan cerrahi deneyimimiz bildirildi. Ca­lis­ma­pla­ni:­Mart 2007 Nisan 2012 tarihleri arasinda arkus aort ve intrakardiyak tamiri uygulanan 27 ardisik hastanin (18 erkek, 9 kiz; ort. yas 9.9+1.7 gun, dagilim 1-26 gun) tibbi verileri retrospektif olarak incelendi. Ameliyat sirasi risk faktorleri ve ameliyat sonrasi 30 gunluk mortalite arasindaki iliski incelendi. Bul gu lar: Hastalarin ortalama vucut agirligi 3.2±0.9 kg idi. On iki hastada major kardiyak defekt vardi ve bunlar trunkus arteriozus (Vaan Pragh tip 4) (n=2), buyuk arterlerin transpozisyonu (n=5), cift cikisli sag ventrikulde Taussing Bing anomalisi (n=2) ve aortopulmoner pencere defekti (n=3) idi. Bobrek yetmezligi ve diyaliz ile mortalite arasinda istatistiksel olarak anlamli bir iliski bulundu [Ki kare, sirasiyla 27 (p=0.000) ve 20.66 (p=0.000)]. So­nuc:­ Yenidoganlarda ve infantlarda, intrakardiyak cerrahi tamir ile es zamanli arkus aort tamiri, tek asamali selektif antegrad serebral perfuzyon ile yapilabilir. Anah tar soz cuk ler: Antegrad serebral perfuzyon; arkus aort intrakardiyak cerrahi; yenidogan bebek. Background:­ In this article, we aimed to report our surgical experiences with selective antegrade cerebral perfusion combined with the aortic arch and intracardiac surgery in neonates and infants. Methods: Medical data of 27 consecutive patients (18 boys, 9 girls; mean age 9.9+1.7 days; range 1 to 26 days) who undergoing aortic arch and intracardiac repair between March 2007 and April 2012 were retrospectively analyzed. The link between perioperative risk factors and 30-day mortality following surgery were investigated. Results:­The mean body weight of patients were 3.2±0.9 kg. Major associated cardiac defects were present in 12 and included truncus arteriosus (Vaan Pragh type 4) (n=2), transposition of the great arteries (n=5), double outlet right ventricle with Taussing Bing anomaly (n=2), and aortopulmonary window defect (n=3). Renal insufficiency and dialysis were statistically significantly associated with mortality [Chi square 27 (p=0.000) and 20.66 (p=0.000), respectively]. Conclusion:­ Aortic arch repair with simultaneous intracardiac surgical repair can be done with selective antegrade cerebral perfusion at a single stage in neonates and infants.

Objective: We retrospectively performed a comparative analysis of temperature measurement sites during surgical repair of the thoracic aorta. Methods: Between January 2004 and May 2006, 22 patients (mean age: 63±12 years) underwent operations on the thoracic aorta with arterial cannulation of the aortic arch concavity and selective antegrade cerebral perfusion (ACP) during deep hypothermic circulatory arrest (HCA). Indications for surgical intervention were acute type A dissection in 14 (64%) patients, degenerative aneurysm in 6 (27%), aortic infiltration of thymic carcinoma in 1 (4.5%) and intra-aortic stent refixation in 1 (4.5%). Rectal, tympanic and bladder temperatures were evaluated to identify the best reference to arterial blood temperature during HCA and ACP. Results: There were no operative deaths and the 30-day mortality rate was 13% (three patients). Permanent neurological deficits were not observed and transient changes occurred in two patients (9%). During re-warming, there was strong correlation between tympanic and arterial blood temperatures (r= 0.9541, pConclusion: We conclude that tympanic temperature measurements correlate with arterial blood temperature monitoring during aortic surgery with HCA and ACP and, therefore, should replace bladder and rectal measurements.

Introduction Neurological injury remains the major cause of morbidity and mortality following open aortic arch repair. Systemic hypothermia along with antegrade cerebral perfusion (ACP) is the accepted cerebral protection approach, with axillary artery cannulation being the most common technique used to establish ACP. More recently, innominate artery cannulation has been shown to be a safe and efficacious method for establishing ACP. Inasmuch as there is a lack of high-quality data comparing axillary and innominate artery ACP, we have designed a randomised, multi-centre clinical trial to compare both cerebral perfusion strategies with regards to brain morphological injury using diffusion-weighted MRI (DW-MRI). Methods and analysis 110 patients undergoing elective aortic surgery with repair of the proximal arch requiring an open distal anastamosis will be randomised to either the innominate artery or the axillary artery cannulation strategy for establishing unilateral ACP during systemic circulatory arrest with moderate levels of hypothermia. The primary safety endpoint of this trial is the proportion of patients with new radiologically significant ischaemic lesions found on postoperative DW-MRI compared with preoperative DW-MRI. The primary efficacy endpoint of this trial is the difference in total operative time between the innominate artery and the axillary artery cannulation group. Ethics and dissemination The study protocol and consent forms have been approved by the participating local research ethics boards. Publication of the study results is anticipated in 2018 or 2019. If this study shows that the innominate artery cannulation technique is non-inferior to the axillary artery cannulation technique with regards to brain morphological injury, it will establish the innominate artery cannulation technique as a safe and potentially more efficient method of antegrade cerebral perfusion in aortic surgery. Trial registration number NCT02554032.