JTCS KCI
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

This Article
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
John G.T. Augoustides
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Augoustides, J. G.T.
Right arrow Search for Related Content
PubMed
Right arrow Articles by Augoustides, J. G.T.
Related Collections
Right arrow Cerebral protection
Right arrow Extracorporeal circulation
Right arrow Great vessels

J Thorac Cardiovasc Surg 2008;136:1105-1106
© 2008 The American Association for Thoracic Surgery

Letter to the Editor

Optimizing selective cerebral perfusion in adult aortic arch repair: Clinical relevance of the laboratory model

John G.T. Augoustides, MD, FASE

Associate Professor, Department of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, PA 19104-4283

To the Editor:

I read with great interest the excellent article by Halstead and colleagues1Go detailing in their porcine model of deep hypothermic circulatory arrest (DHCA) the neuroprotective effects of selective cerebral perfusion (SCP) via both carotid arteries at a mean of 50 mm Hg for a period of 90 minutes. In this laboratory model, the authors have clearly demonstrated the adverse cerebral effects associated with SCP at higher pressures and flow rates. The clinical relevance of this observation is illustrated in the study by Khaladji and colleagues,2Go in which they analyze outcomes after hypothermic circulatory arrest (71.1% hemiarch; 10.4% total arch) and bilateral cold selective SCP at a perfusion pressure of 40 to 60 mm Hg with flow rates of 400 to 650 mL/min.

However, Halstead and colleagues chose a long SCP time of 90 minutes, which is the time required for a total arch repair. In an earlier clinical study, these investigators3Go demonstrated their technique with a trifurcated graft with mean DHCA/SCP times of 31.1 ± 6.6 minutes and 65.3 ± 20.9 minutes, respectively, with SCP perfusion pressures of 50 to 70 mm Hg with flow rates of 800 to 1200 mL/min. Hence, this latest laboratory study is part of their ongoing quest to optimize their technique of total arch replacement with SCP, and it suggests a new range for bilateral SCP perfusion pressures and flow rate.

However, although this model is clinically relevant for hemiarch repairs,2Go how might it apply in the case of aortic arch repair with unilateral SCP?4Go Would lower SCP perfusion pressures be clinically superior, assuming a clinically competent circle of Willis? Or would the contralateral brain be at significant risk of ischemia, given the relevant incidence of clinical inadequacy in the circle of Willis for cerebral perfusion in DHCA with unilateral SCP?5Go Do the authors plan to evaluate unilateral SCP in their porcine DHCA model?

I congratulate the authors again on their important contribution. I look forward to their comments about these aspects of selective cerebral perfusion during adult aortic arch repair.

Footnotes

Financial support: Department of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania.

References

  1. Halstead JC, Meier M, Wurm M, Spielvogel D, Weisz D, Bodian C, et al. Optimizing selective cerebral perfusion: deleterious effects of high perfusion pressures. J Thorac Cardiovasc Surg 2008;135:784-791.[Abstract/Free Full Text]
  2. Khaladji N, Shrestha M, Meck S, Peterss S, Kamiya H, Kallenabch K, et al. Hypothermic circulatory arrest with selective antegrade cerebral perfusion in ascending aortic and aortic arch surgery: a risk factor analysis for adverse outcome in 501 patients. J Thorac Cardiovasc Surg 2008;135:908-914.[Abstract/Free Full Text]
  3. Spielvogel D, Halstead JC, Meier M, Kadir I, Lansman SL, Shahani R, et al. Aortic arch replacement using a trifurcated graft: simple, versatile and safe. Ann Thorac Surg 2005;80:90-95.[Abstract/Free Full Text]
  4. Kazui T. Which is more appropriate as a cerebral protection method—unilateral or bilateral perfusion. Eur J Cardiothorac Surg 2006;29:1039-1040.[Free Full Text]
  5. Papantchev V, Hristov S, Todorova D, Naydenov E, Paloff A, Nikolov D, et al. Some variations in the circle of Willis, important for cerebral protection in aortic surgery—a study in Eastern Europeans. Eur J Cardiothorac Surg 2007;31:982-989.[Abstract/Free Full Text]




This Article
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
John G.T. Augoustides
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Augoustides, J. G.T.
Right arrow Search for Related Content
PubMed
Right arrow Articles by Augoustides, J. G.T.
Related Collections
Right arrow Cerebral protection
Right arrow Extracorporeal circulation
Right arrow Great vessels

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
ANN THORAC SURG ASIAN CARDIOVASC THORAC ANN EUR J CARDIOTHORAC SURG
J THORAC CARDIOVASC SURG ICVTS ALL CTSNet JOURNALS