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J Thorac Cardiovasc Surg 1995;109:591-593
© 1995 Mosby, Inc.

BRIEF COMMUNICATIONS

Ophthalmoscopic findings demonstrate reduced cerebral blood flow during retrograde cerebral perfusion

Naoki Yoshimura, MDa, Keiji Ataka, MDa, Masayoshi Okada, MDa, Chojiro Yamashita, MDa, Kayoko Yoshimura, MDb, Sadao Kobayashi, MDb


Kobe, Japan

Retrograde cerebral perfusion (RCP) via the superior vena cava has recently been discussed as an alternative method of cerebral protection during aortic arch operations. Go Go 1,2 This method may be simple and useful because it does not require cannulation and crossclamping of aortic arch vessels, and it may enhance the effect of cerebral protection in circulatory arrest. Go 3 However, it is not clear whether this procedure provides adequate oxygen supply for the brain. To resolve this problem, we have observed the optic fundus of a patient undergoing an aortic arch operation with RCP to evaluate the circulatory state of the brain during RCP.

A 78-year-old woman was admitted to our hospital because of hoarseness. Computed tomographic scanning and digital subtraction angiography revealed an aneurysm of the distal aortic arch. On December 7, 1993, graft replacement of the distal aortic arch was performed. Median sternotomy was carried out to expose the aortic arch and the aneurysm. A saccular aneurysm, 60 mm in diameter, was located at the origin of the left subclavian artery. After arterial cannulation at the ascending aorta and two separate venous cannulations via the right atrium, cardiopulmonary bypass (CPB) was established and core cooling was performed until a tympanic temperature of 18 ° C was reached. After a brief period of circulatory arrest, the bypass circuit of the CPB was opened and RCP through the superior vena caval cannula was initiated at a flow rate of 400 ml/min. Central venous pressure was maintained between 15 and 18 mm Hg during RCP. Resection of the distal arch aneurysm and creation of the distal and then the proximal anastomoses between the artificial vascular graft and the native aorta were performed during RCP. The left subclavian artery was reconstructed during the rewarming stage of CPB. Extracorporeal circulation time was 255 minutes and RCP time was 70 minutes. The patient awoke 7 hours after the operation and had no neurologic complications.

Fig. 1 shows the ophthalmoscopic findings during the operation. During CPB, the fundus looked normal. The optic disc was nearly circular with sharply outlined edges. The retinal vessels overlying the whole fundus were normally visible. No abnormalities, such as narrowing and irregularity in the arteries and veins, were observed. Arteries were physiologically narrower than the corresponding veins (Fig. 1, A). Both arteries and veins of the retina showed marked constrictions at 15 minutes after the initiation of RCP (Fig. 1, B). The veins were dilated to the normal size at 30 and 60 minutes after the initiation of RCP, although some branches still showed marked constrictions. The large arteries were reduced to thin threads, and the smaller arteries were invisible (Fig. 1, C and D). Blood flow became visible in the large arteries again 15 minutes after CPB was restarted (Fig. 1, E). After the patient was weaned from CPB, the retinal vessels showed complete recovery (Fig. 1, F). The optic disc did not show edematous swelling caused by the elevation of intracranial pressure Go 4 during the operation.








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  		Fig. 1. A, Optic fundus appeared normal during CPB. D, Optic disc; A, artery; V, vein. B, Arteries and veins showed marked constriction at 15 minutes after the initiation of RCP. C, Arteries were reduced to thin threads and the smaller arteries were invisible (arrows) 30 minutes after the initiation of RCP. Some branches of the veins showed marked constriction (arrowheads).D, At 60 minutes the optic fundus revealed almost same findings as those at 30 minutes after the initiation of RCP. E, Blood flow became visible in arteries (arrows) at 15 minutes after the initiation of antegrade reperfusion. F, Arteries and veins recovered completely after weaning from CPB.

 
Because the retina is the only place in the body where large arteries, arterioles, and veins can be directly observed, pathologic changes in the vessels can be visualized. It is widely accepted that alteration of the retinal circulation is similar to that of cerebral vessels because the ophthalmic artery branches directly from the internal carotid artery. Go 5 Therefore, the ophthalmic vessels may serve as an excellent guide to us in evaluating the state of the cerebral circulation during RCP. Although our patient was fully conscious and had no neurologic complication after the operation, a reduction in cerebral blood flow could be confirmed during RCP, especially in the arteries. These findings suggest that the oxygen supply to the brain by RCP is not enough to maintain good cerebral metabolism. Further studies should be done to clarify the adequacy of cerebral circulation during RCP.

Footnotes

From the Department of Surgery, Division II,a and the Department of Ophthalmology,b Kobe University School of Medicine, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe 650, Japan. Back

J THORACTFX CARDIOVASC SURG 1995; 109: 591-3 Back

References

  1. Safi HJ, Brien HW, Winter JN, et al. Brain protection via cerebral retrograde perfusion during aortic arch aneurysm repair. Ann Thorac Surg 1993;56:270-6.[Abstract]
  2. Takamoto S, Matsuda T, Harada M, Miyata S, Shimamura Y. Simple hypothermic retrograde cerebral perfusion during aortic arch replacement: a preliminary report on two successful cases. J THORAC CARDIOVASC SURG 1992;104:1106-9.[Abstract]
  3. Usui A, Oohara K, Liu T, et al. Determination of optimum retrograde cerebral perfusion condition. J THORAC CARDIOVASC SURG 1994;107:300-8.[Abstract/Free Full Text]
  4. Glaser JS. Papilledema of raised intracranial pressure. In: Tasman W, ed. Duane's clinical ophthalmology. Vol 2. Revised ed. Philadelphia: JB Lippincott, 1989:34-9.
  5. Behrendt T. Normal fundus. In: Tasman W, ed. Duane's clinical ophthalmology. Vol 3. Revised ed. Philadelphia: JB Lippincott, 1991:14-9.




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Chojiro Yamashita
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