Perioperative Cerebral Protection For Type A Aortic Dissection

Background:Type A aortic dissection(TAAD)is a life-threatning cardiovascular condition with a high mortality in which urgent surgery is the most effective treatment.With the progress of science and technology and surgery,mortality rate of TAAD has reduced year by year.However,the choice of unilateral cerebral perfusion or bilateral cerebral perfusion remains to be determined.A number of cardiovascular centers have chosen unilateral cerebral perfusion as the routine perfusion method,however,the circle of willis is not intact in nearly half of the normal population.So there are still a lot of scholars insisting on bilateral cerebral perfusion,expecting to achieve a better clinical result.In addition,cerebral complications are still a challenge,especially in those patients complicating with brachiocephalic artery dissection and malperfusion.Because the lesions are complicated and are closely related to the brain function,the cerebral complications after surgery remain high.Neuroprotectants such as hormones,anti-inflammatory agents,free radical scavenger and calcium channel blockers have theoretical cerebral protective effect,however,there are no effective and available guide lines on timing,dosage and route of administration for TAAD.This project was funded by the new and high technology funding of the General Logistics Department of PLA(gxjs0312010): Hybrid treatment technology of aortic disease.The project intended to achieve a better cerebral protective effect by researching specific markers of blood,clinical and follow-up data and questionnaires,expecting to detect the contributory factors of brain damage and to develop an effective strategy for the perioperative cerebral protection of TAAD.1?Effect of improved bilateral antegrade selective cerebral perfusion on patients with type A aortic dissectionOBJECTIVE:To investigate the effect of improved bilateral antegrade selective cerebral perfusion on patients with TAAD.METHODS:One hundred and thirty patients with TAAD were grouped as bilateral antegrade selective cerebral perfusion group(BACP group,80cases)and unilateral antegrade selective cerebral perfusion group(UACP group,50 cases)from Jan 2013 through Jan 2016.The operative records from the two groups were compared in terms of operative time,cardiopulmonary bypass time,ACP time and cardiac arrest time;the postoperative clinical records were compared in terms of ICU time and the frequency of long ventilation over 7 days,reoperation for bleeding,postoperative renal failure needing ultrafiltration and hospital death;the brain injury records were compared in terms of pupil diameter right after ACP,recover time,frequency of permanent neurologic deficit(PND)and temporary neurologic deficit(TND)and CSS score before discharge;the data of cerebral complications and CSS score of complex TAAD patients.RESULTS:Compared with UACP group,patients in BACP group had shorter operative time,cardiopulmonary bypass time,ACP time and cardiac arrest time(P < 0.05).There was no statistical difference between the two groups in frequency of long ventilation,reoperation for bleeding and postoperative renal failure need for ultrafiltration;Compared with BACP group,patients in UACP group had longer ICU time and more frequency of hospital death.For brain injury,there was no difference between the two groups in PND;compared with UACP group,patients in BACP group had smaller pupil diameter right after ACP,shorter recovering time,less frequency of TND and lower CSS score before discharge.Compared with BACP group,complex TAAD patients of UACP group had higher frequency of PND and TND and higher CSS score,P <0.05.CONCLUSION:Improved bilateral antegrade selective cerebral perfusion on patients with TAAD can shorten operation related time and reduce early postoperative brain complications,and the patients had easier post anesthetic recovery and lower operative risk.In addition,compared with BACP group,bilateral antegrade selective cerebral perfusion produces has a better cerebral protection effect for complex patients with prolonged cardiopulmonary bypass time.2?Total arch replacement for type A aortic dissection complicated with brachiocephalic artery dissectionOBJECTIVE : To investigate the effect of total arch replacement for TAAD complicated with brachiocephalic artery dissection.METHODS:Sixty-eight patients with TAAD complicated with brachiocephalic artery dissection were analyzed from Jan 2010 through Jan 2016(Arch group),and another 60 patients with TAAD with normal brachiocephalic artery were grouped as Control group.In arch group thirty-three patients had cerebral symptoms(SPT group)including 2 comas,6 syncope,and 25 cases complicated with somnolence,language barrier and sensory disturbance.The other 35 patients did not present with cerebral symptoms(NSPT group).All patients underwent total arch replacement.The records from SPT group and NSPT group were compared in terms of ACP time,the number of arch tear,PND,TND and hospital death and NIHSS score before discharged from hospital.The operative records from Arch group and Control group were compared in terms of operating time,cardiopulmonary bypass time,ACP time,cardiac arrest time,the numbercases of BACP or UACP,arch tear and moderate to severe aortic valve regurgitation(AR).The postoperative records from Arch group and Control group were compared in terms of ICU time,re-operation for bleeding,ventilation over 7 days,renal failure needing ultrafiltration,tracheotomy,pulmonary infection,PND,TND,hospital death,the data of preoperative cerebral symptoms?postoperative cerebral complications and prognosis of SPT group.RESULTS:All patients accepted total arch replacement successfully.There was no statistical difference between SPT group and NSPT group in ACP time.Compared with NSPT group,patients in SPT group had more frequency of arch tear,PND,TND,hospital death and NIHSS score(P < 0.05).Compared with Control group,patients in Arch group had longer operating time,cardiopulmonary bypass time,cardiac arrest time and more frequency of arch tear(P < 0.05).There was no difference between Arch group and Control group in frequency of re-operation for bleeding,tracheotomy,postoperative renal failure needing ultrafiltration and hospital death.Compared with Control group,patients in Arch group had longer ICU time,more frequency of long ventilation,pulmonary infection,PND and TND(P < 0.05).There was relationship a between preoperative cerebral symptoms and postoperative complications,and all the PND patients of SPT group had severe preoperative cerebral symptoms.CONCLUSION:Operation for TAAD complicated with brachiocephalic artery dissection is complex,and the incidence of postoperative cerebral complications is high.In addition,preoperative cerebral symptoms lead to poorer prognosis,and the level of postoperative complications has a relationship with the level of preoperative cerebral symptoms.3?Operative effect for type A aortic dissection with malperfusionOBJECTIVE:To investigate operative effect of type A aortic dissection with malperfusion(MPS).METHODS:One hundred and sixty patients with TAAD were retrospectively analyzed from Jan 2007 through Jan 2016,including 45 cases with MPS(MPS group)and 115 cases without MPS(NMPS group).In the MPS group,21 cases underwent surgical operation within 12 h after TAAD occurred(Early group)and 24 cases were operated later than 12 h(Delayed group).The records from Early group and Delayed group were compared in terms of frequency of postoperative renal failure needing ultrafiltration,tracheotomy,pulmonary infection,PND,TND and hospital death.The operative records from MPS group and NMPS group were compared in terms of operating time,cardiopulmonary bypass time,ACP time,cardiac arrest time,the number of BACP and UACP,moderate to severe AR and arch vessels involved.The postoperative records from MPS group and NMPS group were compared in terms of ICU time,frequency of re-operation for bleeding,ventilation over 7 days,renal failure needing ultrafiltration,tracheotomy,pulmonary infection,PND and TND and hospital death.RESULTS:There were no significant differences between Early group and Delayed group in frequency of tracheotomy.Compared with Early group,patients in Delayed group had more frequency of postoperative renal failure needing ultrafiltration,pulmonary infection,PND,TND and hospital death(P < 0.05).There were no significant statistical differences between MPS group and NMPS group in ACP time,the number of BACP or UACP,AR and arch vessels involved.Compared with MPS group,patients in NMPS group had shorter operating time,cardiopulmonary bypass time and cardiac arrest time(P < 0.05).There were no significant differences between MPS group and NMPS group in frequency of re-operation for bleeding;Compared with MPS group,patients in NMPS group had shorter ICU time and less frequency of long ventilation,postoperative renal failure needing ultrafiltration,tracheotomy,pulmonary infection,PND,TND and hospital death(P < 0.05).CONCLUSION:Operation for TAAD with MPS is complex,and the incidence of postoperative complications and mortality is high.Generally speaking,earlier operation produces better effects.4?The study of neuroprotective drugs1)?The protective effects of ulinastatin on organs in patients with type A aortic dissection after total arch replacementOBJECTIVE: To investigate the protective effects of ulinastatin on organs in patients with TAAD after total arch replacement.METHODS:Sixty-six patients with TAAD for total arch replacement in our center were analysed from Jan 2014 through Mar 2016.According to different perioperative drug regimens,66 patients were grouped as UTI group and CTL group.The operative records from UTI group and CTL group were compared in terms of operating time,cardiopulmonary bypass time,ACP time,cardiac arrest time,the lowest rectal temperature and frequency of bilateral antegrade selective cerebral perfusion(BACP)and unilateral antegrade selective cerebral perfusion.The 1st day,3rd day and 5th day postoperative blood records from UTI group and CTL group were compared in terms of lactate(LAC),serum creatinine(CR),blood urea nitrogen(BUN),total bilirubin(TBIL),alanine aminotransferase(AST)and oxygen index(OI).The postoperative clinic records from UTI group and CTL group were compared in terms of ICU time and frequency of re-operation for bleeding,ventilation over 7 days,postoperative renal failure needing ultrafiltration,tracheotomy,pulmonary infection,PND,TND and hospital death.RESULTS:There were no significant statistical differences between UTI group and CTL group in operating time,cardiopulmonary bypass time,ACP time and cardiac arrest time,the lowest rectal temperature and frequency of BACP and UACP(P> 0.05).Compared with CTL group,patients in UTI group had lower LAC in the first postoperative day,higher OI in the 1st,3rd,5th postoperative day(P < 0.05).There was no statistical difference between UTI group and CTL group in CR,BUN,TBIL and AST(P> 0.05).The postoperative clinic records from UTI group and CTL group had no difference in the frequency of re-operation for bleeding,postoperative renal failure needing ultrafiltration,tracheotomy,PND and TND and hospital death.Compared with CTL group,patients in UTI group had shorter ICU time,less frequency of long ventilation and pulmonary infection(P < 0.05).CONCLUSION:Ulinastatin produces protective effects on pulmonary function.However,the clinical protective effects on liver and kidney is not obvious.2)?The protective effects of edaravone and ulinastatin on brain in patients with type A aortic dissection after total arch replacementOBJECTIVE:To investigate the protective effects of edaravone and ulinastatin on brain in patients with TAAD after total arch.METHODS:One hundred and twenty patients with TAAD for total arch replacement in our center were randomly analyzed from Jan 2014 through Jan 2016.According to different perioperative drug regimens,120 patients were grouped as EU group?E group?U group and CTL group.The operative records from all groups were compared in terms of operating time,cardiopulmonary bypass time,ACP time and cardiac arrest time,the lowest rectal temperature,frequency of BACP and UACP.S-100 and neuron specific enolase(NSE)from four groups were detected at the time points of beginning of surgery(T0),opening of the aorta clamp(T1),right after cardiopulmonary bypass(T2),after surgery for ICU(T3),24 h postoperation(T4)and day-3 postoperation(T5).The postoperative clinic records from all groups were compared in terms of recovery time,ICU time,CSS score before discharge,PND,TND and hospital death.RESULTS:There was no statistical difference among the four groups in operating time,cardiopulmonary bypass time,ACP time and cardiac arrest time,the lowest rectal temperature and frequency of BACP and UACP(P> 0.05).Compared with CTL group,patients in EU group had lower counting of NSE in T1 to T5,patients in E group had lower counting of NSE in T3,patients in U group had lower counting of NSE in T1 and T3(P < 0.05).Compared with CTL group,patients in EU group had lower counting of S-100 in T1 to T5,patients in E group had lower counting of S-100 in T1 to T4,patients in U group had lower counting of S-100 in T4(P < 0.05).The postoperative clinic records from the four groups had no significant difference in hospital time and the frequency of PND,TND,CSS score over 16 and hospital death(P> 0.05).Compared with CTL group,patients in EU group and U group had shorter ventilation time.CONCLUSION:Edaravone and ulinastatin makes protective effects on brain.They cut down specific brain injury markers of blood in patients with TAAD after total arch replacement.However,further research is needed to prove the clinical significance.