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Zhen Chen - One of the best experts on this subject based on the ideXlab platform.

Yutaka Okita - One of the best experts on this subject based on the ideXlab platform.

  • a study of Brain Protection during total arch replacement comparing antegrade cerebral perfusion versus hypothermic circulatory arrest with or without retrograde cerebral perfusion analysis based on the japan adult cardiovascular surgery database
    The Journal of Thoracic and Cardiovascular Surgery, 2015
    Co-Authors: Yutaka Okita, Hiroaki Miyata, Noboru Motomura, Shinichi Takamoto
    Abstract:

    Objectives Antegrade cerebral perfusion and hypothermic circulatory arrest, with or without retrograde cerebral perfusion, are 2 major types of Brain Protection that are used during aortic arch surgery. We conducted a comparative study of these methods in patients undergoing total arch replacement to evaluate the clinical outcomes in Japan, based on the Japan Adult Cardiovascular Surgery Database. Methods A total of 16,218 patients underwent total arch replacement between 2009 and 2012. Patients with acute aortic dissection or ruptured aneurysm, or who underwent emergency surgery were excluded, leaving 8169 patients for analysis. For the Brain Protection method, 7038 patients had antegrade cerebral perfusion and 1141 patients had hypothermic circulatory arrest/retrograde cerebral perfusion. A nonmatched comparison was made between the 2 groups, and propensity score analysis was performed among 1141 patients. Results The matched paired analysis showed that the minimum rectal temperature was lower in the hypothermic circulatory arrest/retrograde cerebral perfusion group (21.2°C ± 3.7°C vs 24.2°C ± 3.2°C) and that the duration of cardiopulmonary bypass and cardiac ischemia was longer in the antegrade cerebral perfusion group. There were no significant differences between the antegrade cerebral perfusion and hypothermic circulatory arrest/retrograde cerebral perfusion groups with regard to 30-day mortality (3.2% vs 4.0%), hospital mortality (6.0% vs 7.1%), incidence of stroke (6.7% vs 8.6%), or transient neurologic disorder (4.1% vs 4.4%). There was no difference in a composite outcome of hospital death, bleeding, prolonged ventilation, need for dialysis, stroke, and infection (antegrade cerebral perfusion 28.4% vs hypothermic circulatory arrest 30.1%). However, hypothermic circulatory arrest/retrograde cerebral perfusion resulted in a significantly higher rate of prolonged stay in the intensive care unit (>8 days: 24.2% vs 15.6%). Conclusions Hypothermic circulatory arrest/retrograde cerebral perfusion and antegrade cerebral perfusion provide comparable clinical outcomes with regard to mortality and stroke rates, but hypothermic circulatory arrest/retrograde cerebral perfusion resulted in a higher incidence of prolonged intensive care unit stay. Antegrade cerebral perfusion might be preferred as the Brain Protection method for complicated aortic arch procedures.

  • Brain Protection in Surgery for Acute Type A Aortic Dissection
    Controversies in Aortic Dissection and Aneurysmal Disease, 2014
    Co-Authors: Yutaka Okita, Kenji Okada, Atsushi Omura, Hiroya Kano, Tomonori Shirasaka, Hitoshi Minami, Takeshi Inoue, Toshihito Sakamoto, Shunsuke Miyahara, Katsuhiro Yamanka
    Abstract:

    From October 2000 to August 2012, 232 consecutive patients with acute type A aortic dissection had surgery (mean age: 66.3 ± 13.0, 21–96). All patients had surgery on an emergency or urgent basis. Thirty-four were in shock status and five required percutaneous assisted circulation. A cardiac tamponade was detected in 53 patients and a moderate or severe aortic regurgitation in 34 patients. Forty-six (19.8 %) had neurological symptom consisting with coma in 4, stroke in 12, TIA in 28, and paraplegia in 2. Fourteen patients had coronary malperfusion, 11 had visceral malperfusion, and 33 had leg malperfusion. The extent of the aortic replacement was ascending aorta in 4, hemiarch in 141, total arch in 84, total arch to descending aorta in 2, and TEVAR in 1. Aortic valve resuspension or valve repair was performed in 207, root replacement with valve sparing in 22, and Bentall procedure in 4. Brain Protection was achieved by deep hypothermic circulatory arrest with or without retrograde cerebral perfusion in 78, and antegrade selective cerebral perfusion in 150. The overall hospital mortality was 13.4 % (31/232). Newly developed permanent neurological deficits occurred in 2.7 % (5/186) of patients and transient neurological dysfunction (TND) occurred in 1.6 % (3/186). There was no difference in incidence of hospital death, stroke and TND between the DHCA and ACP group also between the patients who had a hemiarch or a total arch replacement.

  • prospective comparative study of Brain Protection in total aortic arch replacement deep hypothermic circulatory arrest with retrograde cerebral perfusion or selective antegrade cerebral perfusion
    The Annals of Thoracic Surgery, 2001
    Co-Authors: Yutaka Okita, Kenji Minatoya, Osamu Tagusari, Motomi Ando, Kazuyuki Nagatsuka, Soichiro Kitamura
    Abstract:

    Abstract Background . The purpose of this study was to compare the results of total aortic arch replacement using two different methods of Brain Protection, particularly with respect to neurologic outcome. Methods . From June 1997, 60 consecutive patients who underwent total arch replacement through a midsternotomy were alternately allocated to one of two methods of Brain Protection: deep hypothermic circulatory arrest with retrograde cerebral perfusion (RCP: 30 patients) or with selective antegrade cerebral perfusion (SCP: 30 patients). Preoperative and postoperative (3 weeks) Brain CT scan, neurological examination, and cognitive function tests were performed. Serum 100b protein was assayed before and after the cardiopulmonary bypass, as well as 24 hours and 48 hours after the operation. Results . Hospital mortality occurred in 2 patients in the RCP group (6.6%) and 2 in the SCP group (6.6%). New strokes occurred in 1 (3.3%) of the RCP group and in 2 (6.6%) of the SCP group ( p = 0.6). The incidence of transient Brain dysfunction was significantly higher in the RCP group than in the SCP group (10, 33.3% vs 4, 13.3%, p = 0.05). Except in patients with strokes, S-100b values showed no significant differences in the two groups (RCP: SCP, prebypass 0.01 ± 0.04: 0.05 ± 0.16, postbypass 2.17 ± 0.94: 1.97 ± 1.00, 24 hours 0.61 ± 0.36: 0.60 ± 0.37, 48 hours 0.36 ± 0.45: 0.46 ± 0.40 μg/L, p = 0.7). There were no intergroup differences in the scores of memory decline (RCP 0.74 ± 0.99; SCP 0.55 ± 1.19, p = 0.6), orientation (RCP 1.11 ± 1.29; SCP 0.50 ± 0.76, p = 0.08), or intellectual function (RCP 1.21 ± 1.27; SCP 1.05 ± 1.15, p = 0.7). Conclusions . Both methods of Brain Protection for patients undergoing total arch replacement resulted in acceptable levels of mortality and morbidity. However, the prevalence of transient Brain dysfunction was significantly higher in patients with the RCP.

Steven L Giannotta - One of the best experts on this subject based on the ideXlab platform.

  • temporary occlusion of the middle cerebral artery in intracranial aneurysm surgery time limitation and advantage of Brain Protection
    Journal of Neurosurgery, 1997
    Co-Authors: Sean D Lavine, Lena S Masri, Michael J Levy, Steven L Giannotta
    Abstract:

    The risk of focal infarction secondary to the induced reversible arrest of local arterial flow during microsurgical dissection of middle cerebral artery (MCA) aneurysms was evaluated further to define the optimal approach to temporary arterial occlusion. To compare the effectiveness of potential Brain-Protection anesthetics, a group of patients treated with the intravenous agents propofol, etomidate, and pentobarbital, administered individually or in combination, was compared to a group treated with the inhalational agent isoflurane. Forty-nine consecutive MCA aneurysm surgeries involving the temporary clipping of the parent vessel were retrospectively reviewed. Thirty-eight patients received intravenous Brain-Protection (IVBP) anesthesia. Groups of patients with and without infarctions, and receiving and not receiving IVBP anesthesia, were compared based on the duration and nature of temporary arterial occlusion. Postoperative radiographic evidence of new infarction was used as the threshold for failure of occlusion tolerance. The overall infarction rate was 22.4% (11 of 49 patients), including 15.8% (six of 38 patients) in the IVBP group versus 45.5% (five of 11 patients) in the group that did not receive Brain Protection (NBP). In the NBP group, the mean duration of temporary occlusion was 3.9 +/- 2.2 minutes for patients without infarction versus 12.2 +/- 4.3 minutes for patients with focal infarction (p < 0.01). In contrast, the mean duration was 13.6 +/- 10.6 minutes for patients without infarction and 18.5 +/- 9.9 minutes for patients with infarction in the IVBP group. All patients (four of four) in the NBP group who underwent occlusion lasting 10 minutes or longer suffered an infarction versus five of 23 patients in the IVBP group (p < 0.0001). Patients with multiple aneurysms were found to be at increased risk of developing focal infarction, whereas those treated with intermittent temporary clip application were at decreased risk. It is concluded that patients in whom focal iatrogenic ischemia is induced during MCA aneurysm clip ligation have a significant advantage compared with those receiving isoflurane when they are given pentobarbital as the primary neuroprotective agent or when they receive propofol or etomidate titrated to achieve electroencephalographic burst suppression, particularly if more than 10 minutes of occlusion time is required. It is also concluded that 10 minutes is a general guideline for safe, temporary occlusion of the MCA. The use of intermittent temporary arterial occlusion and its use in patients with multiple aneurysms need further evaluation before specific recommendations can be made.

  • temporary occlusion of the middle cerebral artery in intracranial aneurysm surgery time limitation and advantage of Brain Protection
    Neurosurgical Focus, 1997
    Co-Authors: Sean D Lavine, Lena S Masri, Michael J Levy, Steven L Giannotta
    Abstract:

    The risk of focal infarction secondary to the induced reversible arrest of local arterial flow during microsurgical dissection of middle cerebral artery (MCA) aneurysms was evaluated further to define the optimal approach to temporary arterial occlusion. To compare the effectiveness of Brain-Protection anesthetics, a group of patients treated with the intravenous agents, propofol, etomidate, and pentobarbital, administered individually or in combination, was compared to a group treated with the inhalational agent isoflurane. Forty-nine consecutive MCA aneurysm surgeries involving the temporary clipping of the parent vessel were retrospectively reviewed. Thirty-eight patients received intravenous Brain-Protection (IVBP) anesthesia. Groups of patients with and without infarctions, and receiving and not receiving IVBP, were compared based on the duration and nature of temporary arterial occlusion. Postoperative radiographic evidence of new infarction was used as the threshold for failure of occlusion tolerance. The overall infarction rate was 22.4% (11 of 49 patients), including 15.8% (six of 38 patients) in the IVBP group versus 45.5% (five of 11 patients) in the isoflurane (ISO) group. In the ISO group, the mean duration of temporary occlusion was 3.9 +/- 2.2 minutes for patients without infarction versus 12.2 +/- 4.3 minutes for patients with focal infarction (p < 0.01). In contrast, the mean duration was 13.6 +/- 10.6 minutes for patients without infarction and 18.5 +/- 9.9 minutes for patients with infarction in the IVBP group. All patients in the ISO group who underwent occlusion lasting 10 minutes or longer suffered an infarction versus five of 23 patients in the IVBP group. Patients with multiple aneurysms were found to be at increased risk of developing focal infarction, whereas those treated with intermittent temporary clip application were at a decreased risk. It is concluded that patients in whom focal iatrogenic ischemia is induced during MCA aneurysm clip ligation have a significant advantage compared with those receiving ISO when they are given pentobarbital as the primary neuroprotective agent or when they receive propofol or etomidate titrated to achieve electroencephalographic burst suppression, particularly if more than 10 minutes of occlusion time is required. It is also concluded that 10 minutes is a general guideline for safe, temporary occlusion of the MCA. The use of intermittent temporary arterial occlusion and patients with multiple aneurysms need further evaluation before specific recommendations can be made.

Lars G Svensson - One of the best experts on this subject based on the ideXlab platform.

  • Brain Protection via cerebral retrograde perfusion during aortic arch aneurysm repair
    The Annals of Thoracic Surgery, 1993
    Co-Authors: Hazim J Safi, Heather W Brien, Jeffrey N Winter, Angela C Thomas, Robert L Maulsby, Harold K Doerr, Lars G Svensson
    Abstract:

    Abstract Eleven patients underwent resection and graft replacement of ascending and aortic arch aneurysms. Retrograde cerebral perfusion was used during the procedures to minimize cerebral ischemia. Retrograde cerebral perfusion (15 ° to 24 °C) was administered through the superior vena cava. The mean cerebral ischemic time was 35 minutes (range, 11 to 71 minutes). Throughout retrograde cerebral perfusion, blood samples were drawn from the innominate and left carotid arteries at 1, 5, and every 10 minutes thereafter for analysis of arterial oxygen content, total creatine kinase level, and creatine kinase BB fraction. All patients survived. All except 1 awoke neurologically intact. In this patient, electroencephalogram and transcranial Doppler studies conducted before circulatory arrest were consistent with embolic phenomena. There was no significant difference between the current group's intraoperative electroencephalograms and those of a similar historical group. Postoperative complications included transient renal failure, myasthenia gravis, cholecystitis, premature atrial contractions, atrial fibrillation, and vocal cord paralysis. The creatine kinase BB fraction range was 1.8 to 13.4. The increase of total creatine kinase level was due to MM fraction. Retrograde cerebral perfusion during circulatory arrest is a valuable adjunct for protecting the Brain. The creatine kinase BB band was not a good marker to detect Brain injury. With continued use of this technique and accumulation of a larger series, we may better define the role of retrograde cerebral perfusion in Brain Protection.

  • Brain Protection via cerebral retrograde perfusion during aortic arch aneurysm repair.
    The Annals of thoracic surgery, 1993
    Co-Authors: Hazim J Safi, Heather W Brien, Jeffrey N Winter, Angela C Thomas, Robert L Maulsby, Harold K Doerr, Lars G Svensson
    Abstract:

    Eleven patients underwent resection and graft replacement of ascending and aortic arch aneurysms. Retrograde cerebral perfusion was used during the procedures to minimize cerebral ischemia. Retrograde cerebral perfusion (15 degrees to 24 degrees C) was administered through the superior vena cava. The mean cerebral ischemic time was .35 minutes (range, 11 to 71 minutes). Throughout retrograde cerebral perfusion, blood samples were drawn from the innominate and left carotid arteries at 1, 5, and every 10 minutes thereafter for analysis of arterial oxygen content, total creatine kinase level, and creatine kinase BB fraction. All patients survived. All except 1 awoke neurologically intact. In this patient, electroencephalogram and transcranial Doppler studies conducted before circulatory arrest were consistent with embolic phenomena. There was no significant difference between the current group's intraoperative electroencephalograms and those of a similar historical group. Postoperative complications included transient renal failure, myasthenia gravis, cholecystitis, premature atrial contractions, atrial fibrillation, and vocal cord paralysis. The creatine kinase BB fraction range was 1.8 to 13.4. The increase of total creatine kinase level was due to MM fraction. Retrograde cerebral perfusion during circulatory arrest is a valuable adjunct for protecting the Brain. The creatine kinase BB band was not a good marker to detect Brain injury. With continued use of this technique and accumulation of a larger series, we may better define the role of retrograde cerebral perfusion in Brain Protection.

Naoki Washiyama - One of the best experts on this subject based on the ideXlab platform.

  • Brain Protection using antegrade selective cerebral perfusion: a multicenter study
    The Annals of thoracic surgery, 2003
    Co-Authors: Marco Di Eusanio, Teruhisa Kazui, Marc A.a.m. Schepens, Wim J. Morshuis, Karl M. Dossche, Roberto Di Bartolomeo, Davide Pacini, Angelo Pierangeli, Kazuhiro Ohkura, Naoki Washiyama
    Abstract:

    Abstract Background To evaluate the results of antegrade selective cerebral perfusion as a method of Brain Protection during surgery of the thoracic aorta and to determine predictors of hospital mortality and adverse neurologic outcome. Methods Between October 1995 and March 2002, 588 patients underwent aortic surgery with the aid of antegrade selective cerebral perfusion. There were 334 men (56.8%); the mean age was 63.7 ± 11.8 years. One hundred sixty-two patients (27.6%) underwent urgent operation. The separated graft technique was employed to reimplant the arch vessels in 230 patients (65.3%) of the 352 requiring aortic arch replacement. Associated procedures were performed in 254 patients (43.2%). One hundred twelve patients underwent elephant trunk procedure. The mean cerebral perfusion time was 67 ± 37 minutes. Results The overall hospital mortality rate was 8.7%. A logistic regression analysis revealed urgent operation, recent central neurologic event, tamponade, unplanned coronary artery revascularization and pump time to be independent predictors of hospital mortality ( p p p Conclusions In our experience the utilization of antegrade selective cerebral perfusion resulted in encouraging results in terms of hospital mortality and Brain complications. Neither the extent of the replacement nor the duration of the cerebral perfusion had an impact on hospital mortality and neurologic outcome.

  • Selections of aortic reconstruction procedures and Brain Protection methods during aortic arch repairs; including mid-term survival and freedom from cerebral infarction
    Kyobu geka. The Japanese journal of thoracic surgery, 2002
    Co-Authors: Naoki Washiyama, Teruhisa Kazui, K Yamashita, Terada H, T Suzuki, K Ohkura, A H M Bashar
    Abstract:

    Aortic reconstruction procedures and Brain Protection methods are very important among operative factors that have direct influence on surgical results. We nowadays use hypothermic circulatory arrest (HCA) with or without retrograde cerebral perfusion (RCP) as Brain Protection methods during hemiarch replacement (HAR) and selective cerebral perfusion (SCP) during total arch replacement (TAR) using 4-branched arch graft. The purpose of this study was to verify the appropriateness of this strategy. From April 1997 to August 2001, we performed 120 TAR assisted by SCP and 30 HAR assisted by HCA with or without RCP. Incidences of in-hospital death and postoperative neurological dysfunction were compared between the 2 groups. In-hospital deaths were 4 (3.3%) and 1 (3.3%), permanent neurological dysfunction were 3 (2.5%) and 1 (3.3%), temporary neurological dysfunction were 4 (3.3%) and 1 (3.3%), 3-year survival were 92 +/- 3% and 97 +/- 3% and cerebral infarctions after discharge were 2 and 0 in TAR and HAR, respectively. Appropriate selections of aortic reconstruction procedures and Brain Protection methods lead to good operative results in aortic arch repairs.