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      Aortic Surgery without Infusion of Cardioplegic Solution at Total Circulatory Arrest

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          Abstract

          Background

          Minimal infusion of cardioplegic solution (CPS) during aortic surgery using total circulatory arrest (TCA) may reduce several potential side effects: clamping on a diseased aorta, insult of coronary ostia, and edema.

          Materials and Methods

          From 2006 to 2009, 72 patients underwent aortic surgery without infusion of cardioplegic solution at the initiation of circulatory arrest. The diagnoses were acute aortic dissection (44), aneurysm (22), and intramural hematoma (6).

          Results

          The duration of TCA, the lowest nasopharyngeal temperature, bypass time, and aortic clamp time was 45 minutes, 16.4℃, 162 minutes, and 100 minutes, respectively. The amount of CPS was 1,050 mL, and 15 patients underwent surgery without CPS. The average inotrope score was 113 points (range, 6.25 to 5,048.5 points) corresponding to the dopamine infusion of 5 mcg/kg/min for 1 day. Seven patients showed a level of creatine kinase-MB above 50 ng/mL, postoperatively, compared with the average of 12.75 ng/mL. The ischemic change was found on electrocardiogram in 5 patients, postoperatively. There was no cardiac morbidity requiring mechanical assist. The average of intensive care unit stay and postoperative hospital stay was 40 hours (range, 15 to 482 hours) and 11 days, respectively.

          Conclusion

          Minimal infusion of only retrograde CPS during rewarming without initial infusion at TCA in aortic surgery is feasible and can be used with acceptable results.

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          Most cited references26

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          Postoperative course and hemodynamic profile after the arterial switch operation in neonates and infants. A comparison of low-flow cardiopulmonary bypass and circulatory arrest.

          The neurological morbidity associated with prolonged periods of circulatory arrest has led some cardiac surgical teams to promote continuous low-flow cardiopulmonary bypass as an alternative strategy. The nonneurological postoperative effects of both techniques have been previously studied only in a limited fashion. We compared the hemodynamic profile (cardiac index and systemic and pulmonary vascular resistances), intraoperative and postoperative fluid balance, and perioperative course after deep hypothermia and support consisting predominantly of total circulatory arrest or low-flow cardiopulmonary bypass in a randomized, single-center trial. Eligibility criteria included a diagnosis of transposition of the great arteries and a planned arterial switch operation before the age of 3 months. Of the 171 patients, 129 (66 assigned to circulatory arrest and 63 to low-flow bypass) had an intact ventricular septum and 42 (21 assigned to circulatory arrest and 21 to low-flow bypass) had an associated ventricular septal defect. There were 3 (1.8%) hospital deaths. Patients assigned to low-flow bypass had significantly greater weight gain and positive fluid balance compared with patients assigned to circulatory arrest. Despite the increased weight gain in the infants assigned to low-flow bypass, the duration of mechanical ventilation, stay in the intensive care unit, and hospital stay were similar in both groups. Hemodynamic measurements were made in 122 patients. During the first postoperative night, the cardiac index decreased (32.1 +/- 15.4%, mean +/- SD), while pulmonary and systemic vascular resistance increased. The measured cardiac index was < 2.0 L.min-1.m-2 in 23.8% of the patients, with the lowest measurement typically occurring 9 to 12 hours after surgery. Perfusion strategy assignment was not associated with postoperative hemodynamics or other nonneurological postoperative events. After heart surgery in neonates and infants, both low-flow bypass and circulatory arrest perfusion strategies have comparable effects on the nonneurological postoperative course and hemodynamic profile.
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            Effect of mild hypothermia on ischemia-induced release of neurotransmitters and free fatty acids in rat brain.

            We have demonstrated previously that mild intraischemic hypothermia confers a marked protective effect on the final histopathological outcome. The present study was carried out to evaluate whether this protective effect involves changes in the degree of local cerebral blood flow reductions, tissue accumulation of free fatty acids, or alterations in the extracellular release of glutamate and dopamine. Rats whose intraischemic brain temperature was maintained at 36 degrees C, 33 degrees C, or 30 degrees C were subjected to 20 minutes of ischemia by four-vessel occlusion combined with systemic hypotension. Levels of local cerebral blood flow, as measured autoradiographically, were reduced uniformly in all experimental animals at the end of ischemia by gas chromatography after tissue extraction and separation by thin layer chromatography. A massive ischemia-induced accumulation of individual free fatty acids was observed in animal groups whose intraischemic brain temperature was maintained at either 36 degrees C or 30 degrees C. Extracellular neurotransmitter levels were measured by microdialysis; the perfusate was collected before, during, and after ischemia. In rats whose intraischemic brain temperature was maintained at 36 degrees C, dopamine and glutamate increased significantly during ischemia and the early period of recirculation (by 500-fold and sevenfold, respectively). In animals whose brain temperature was maintained at 33 degrees C and 30 degrees C, the release of glutamate was completely inhibited, and the release of dopamine was significantly attenuated (by 60%). These results suggest that mild intraischemic hypothermia does not affect the ischemia-induced local cerebral blood flow reduction or free fatty acid accumulation.(ABSTRACT TRUNCATED AT 250 WORDS)
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              Prosthetic replacement of the aortic arch.

              Four patients are reported in whom the aortic arch and variable portions of the ascending and descending aorta were replaced with a prosthesis. In three patients the preoperative diagnosis was dissecting aneurysm of the aortic arch and in one an arteriosclerotic aneurysm of the aortic arch was present. A combination of surface cooling and cardiopulmonary bypass was utilized to produce total body hypothermia. Arch replacement was carried out during a period of total circulatory arrest. Cardiopulmonary bypass was then utilized to warm the patient and resuscitate the heart. The average duration of cerebral ischemia was 43 minutes and the average duration of myocardial ischemia was 74 minutes. The average lowest esophageal temperature was 14 degrees C., and the average lowest rectal temperature was 18 degrees C. Three patients are alive and well 4 to 13 months following surgery. One patient died 4 days postoperatively of pulmonary insufficiency. This experience indicates that by utilizing total body hypothermia and circulatory arrest aortic arch replacement can be carried out with an acceptable mortality rate. Corrective surgery could be offered to patients with life-threatening enlarging aneurysms of the aortic arch.
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                Author and article information

                Journal
                Korean J Thorac Cardiovasc Surg
                Korean J Thorac Cardiovasc Surg
                KJTCS
                The Korean Journal of Thoracic and Cardiovascular Surgery
                Korean Society for Thoracic and Cardiovascular Surgery
                2233-601X
                2093-6516
                February 2013
                06 February 2013
                : 46
                : 1
                : 27-32
                Affiliations
                [1 ]Department of Thoracic and Cardiovascular Surgery, Kosin University Gospel Hospital, Kosin University College of Medicine, Korea.
                [2 ]Department of Thoracic and Cardiovascular Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Korea.
                Author notes
                Corresponding author: Hae Young Lee, Department of Thoracic and Cardiovascular Surgery, Kosin University Gospel Hospital, Kosin University College of Medicine, 262 Gamcheon-ro, Seo-gu, Busan 602-702, Korea. (Tel) 82-51-990-6466, (Fax) 82-51-990-3066, anso54@ 123456empal.com
                Article
                10.5090/kjtcs.2013.46.1.27
                3573162
                23422926
                cd5cf85a-1d1f-4e75-8fc9-1aa9b6991ab1
                © The Korean Society for Thoracic and Cardiovascular Surgery. 2013. All right reserved.

                This is an open access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                : 16 July 2012
                : 29 October 2012
                : 20 November 2012
                Categories
                Clinical Research

                Surgery
                aorta,aortic, surgery,heart arrest, induced,myocardial protection
                Surgery
                aorta, aortic, surgery, heart arrest, induced, myocardial protection

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