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Hypothermic Circulatory Arrest for Thoracic Aortic Operations—Reply

Hypothermic Circulatory Arrest for Thoracic Aortic Operations—Reply In reply We are grateful for the kind comments by Dr Pocar and colleagues. In our comparison of 2 groups of patients, 20 underwent left heart bypass (LHB) and 39 had total circulatory arrest (TCA). Despite use of no adjunct, postoperative paraplegia decreased from 1 in 20 patients (5%) who underwent LHB to 1 in 39 patients (2.6%) who underwent TCA.1 Although this difference is not significant (P>.99), it does remain below the published series of patients who received spinal fluid drainage.2 There were no significant differences in stroke rate (P = .65) that occurred in 1 of 20 patients (5%) undergoing LHB vs 4 of 39 patients (10%) in the TCA group; however, we have observed a lower trend when the aorta is not manipulated, particularly around the aortic arch area during bypass. Subsequent to aortic arch anastomosis, it is crucial to switch arterial cannula to the graft not only to decrease TCA time, but also to prevent retrograde mobilization of atherosclerotic material to the brain. In the present reported series, there has been a wide range of TCA time with an average of about 40 minutes, however, in recent years our TCA time has developed a downward trend from the present practice time of about 20 to 25 minutes. The most notable benefit provided by TCA, in addition to spinal cord tolerance for ischemia, is the added protection of the kidneys and abdominal viscera.3 Some studies have not shown an improvement in renal protection with the use of TCA and have reported high early- and late-mortality rates with increased renal failure incidence.4 In our institution, use of TCA completely eliminated the incidence of postoperative renal failure. The difference was statistically significant among the 2 groups with a 0% rate of renal failure in patients undergoing TCA compared with a 15% rate of renal failure with LHB (P = .04). In summary, this single-institution comparison of results between hypothermic TCA and LHB techniques has produced useful information regarding safety and efficacy of TCA over LHB in the resection of the distal aortic arch, descending aorta, and thoracoabdominal aorta. We observed elimination of postoperative renal failure and significant reduction in 30-day postoperative mortality (P = .04). Correspondence: Dr Raissi, Division of Cardiothoracic Surgery, Cedars Sinai Medical Center, 8700 Beverly Blvd, Suite 6215, Los Angeles, CA 90048 (sharo.raissi@cshs.org). References 1. Soukiasian HJRaissi SSKleisli T et al. Total circulatory arrest for the replacement of the descending and thoracoabdominal aorta. Arch Surg 2005;140394- 398PubMedGoogle ScholarCrossref 2. Svensson LGKhitin LNadolny EM et al. Systemic Temperature and paralysis after thoracoabdominal and descending aortic operations. Arch Surg 2003;138175- 179PubMedGoogle ScholarCrossref 3. Kouchoukos NTMasetti PRokkas CK et al. Safety and efficacy of hypothermic cardiopulmonary bypass and circulatory arrest for operations on the descending thoracic and thoracoabdominal aorta. Ann Thorac Surg 2001;72699- 708PubMedGoogle ScholarCrossref 4. Safi HJHarlin SAMiller CC et al. Predictive factors for acute renal failure in thoracic and thoracoabdominal aortic aneurysm surgery. J Vasc Surg 1996;24338- 345PubMedGoogle ScholarCrossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Surgery American Medical Association

Hypothermic Circulatory Arrest for Thoracic Aortic Operations—Reply

Archives of Surgery , Volume 140 (10) – Oct 1, 2005

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Publisher
American Medical Association
Copyright
Copyright © 2005 American Medical Association. All Rights Reserved.
ISSN
0004-0010
eISSN
1538-3644
DOI
10.1001/archsurg.140.10.1010
Publisher site
See Article on Publisher Site

Abstract

In reply We are grateful for the kind comments by Dr Pocar and colleagues. In our comparison of 2 groups of patients, 20 underwent left heart bypass (LHB) and 39 had total circulatory arrest (TCA). Despite use of no adjunct, postoperative paraplegia decreased from 1 in 20 patients (5%) who underwent LHB to 1 in 39 patients (2.6%) who underwent TCA.1 Although this difference is not significant (P>.99), it does remain below the published series of patients who received spinal fluid drainage.2 There were no significant differences in stroke rate (P = .65) that occurred in 1 of 20 patients (5%) undergoing LHB vs 4 of 39 patients (10%) in the TCA group; however, we have observed a lower trend when the aorta is not manipulated, particularly around the aortic arch area during bypass. Subsequent to aortic arch anastomosis, it is crucial to switch arterial cannula to the graft not only to decrease TCA time, but also to prevent retrograde mobilization of atherosclerotic material to the brain. In the present reported series, there has been a wide range of TCA time with an average of about 40 minutes, however, in recent years our TCA time has developed a downward trend from the present practice time of about 20 to 25 minutes. The most notable benefit provided by TCA, in addition to spinal cord tolerance for ischemia, is the added protection of the kidneys and abdominal viscera.3 Some studies have not shown an improvement in renal protection with the use of TCA and have reported high early- and late-mortality rates with increased renal failure incidence.4 In our institution, use of TCA completely eliminated the incidence of postoperative renal failure. The difference was statistically significant among the 2 groups with a 0% rate of renal failure in patients undergoing TCA compared with a 15% rate of renal failure with LHB (P = .04). In summary, this single-institution comparison of results between hypothermic TCA and LHB techniques has produced useful information regarding safety and efficacy of TCA over LHB in the resection of the distal aortic arch, descending aorta, and thoracoabdominal aorta. We observed elimination of postoperative renal failure and significant reduction in 30-day postoperative mortality (P = .04). Correspondence: Dr Raissi, Division of Cardiothoracic Surgery, Cedars Sinai Medical Center, 8700 Beverly Blvd, Suite 6215, Los Angeles, CA 90048 (sharo.raissi@cshs.org). References 1. Soukiasian HJRaissi SSKleisli T et al. Total circulatory arrest for the replacement of the descending and thoracoabdominal aorta. Arch Surg 2005;140394- 398PubMedGoogle ScholarCrossref 2. Svensson LGKhitin LNadolny EM et al. Systemic Temperature and paralysis after thoracoabdominal and descending aortic operations. Arch Surg 2003;138175- 179PubMedGoogle ScholarCrossref 3. Kouchoukos NTMasetti PRokkas CK et al. Safety and efficacy of hypothermic cardiopulmonary bypass and circulatory arrest for operations on the descending thoracic and thoracoabdominal aorta. Ann Thorac Surg 2001;72699- 708PubMedGoogle ScholarCrossref 4. Safi HJHarlin SAMiller CC et al. Predictive factors for acute renal failure in thoracic and thoracoabdominal aortic aneurysm surgery. J Vasc Surg 1996;24338- 345PubMedGoogle ScholarCrossref

Journal

Archives of SurgeryAmerican Medical Association

Published: Oct 1, 2005

Keywords: hypothermia, natural,aortic surgery

References

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