Neuroprotection in Aortic Surgery[∗]

Operations on the aortic arch still remain a great challenge for cardiac surgeons and necessitate a period of cerebral blood flow interruption. lt is therefore imperative to protect the brain during this very sensitive time. Clinical as well as experimental studies have shown that the exact mechanism of neural injury seems to be multifactorial. Furthermore it is still uncertain, whether cerebral injury occurs during the interval of HCA or during reperfusion. Various strategies have been adopted in an effort to reduce neurological complications after aortic surgery. These included the use of hypothermic circulatory arrest, antegrade cerebral perfusion and retrograde cerebral perfusion. All these methods have both advantages and disadvantages. New surgical techniques such as cold reperfusion have shown promising results in animal experiments and need further clinical evaluation. One very promising pathway in preventing cerebral injury lies in pharmacological interventions.

Key words:

- Profound hypothermic cireulatory arrest - Retrograde cerebral perfusion - Antegrade cerebral perfusion - Cold reperfusion

1 Presented at the Annual meeting of the German Society for Thoracic and Cardiovascular Surgery in Leipzig . February 18 - 21, 2001

References

• 1 Rokkas C K, Helfrich L R, Lobner D C, Choi D W, Kouchoukos N T. Dextrorphan inhibits the release of excitatory amino acids during spinal cord ischemia.  AnnThorac Surg. 1994;  58 312-320
• 2 Rothman S M, Olney J W. Glutamate and the pathophysiology of hypoxic-ischemic brain damage.  Ann Neurol. 1986;  19 105-111
• 3 Choi D W, Maulucci-Gedde M, Kriegstein A R. Glutamate neurotoxicity in cortical cell culture.  J Neurosci. 1987;  7 357-368
• 4 McCullough J N, Zhang N, Reich D L, Juvonen T S, Klein J J, Spielvogel D, Ergin M A, Griepp R B. Cerebral metabolic suppression during hypothermic circulatory arrest in humans.  Ann Thorac Surg. 1999;  67 1895-1899
• 5 Ergin M A, Griepp R B. Progress in treatment in aneurysms of the aortic arch.  World J Surg. 1980;  4 535-539
• 6 Svensson L G, Crawford E S, Hess K R. et al . Deep hypothermia with circulatory arrest: determinants of stroke and early mortality in 656 patients.  J Thorac Cardiovasc Surg. 1993;  106 19-31
• 7 Bachet J, Guilmet D, Goudot B, Dreyfus G D, Delentdecker P, Brodaty D, Duboid C. Antegrade cerebral perfusion with cold blood: A 13 year experience.  Ann Thorac Surg. 1999;  67 1874-1878
• 8 Dossche K M, Schepens M A, Morshuis W J, Muysoms F E, Langemeijer J J, Vermeulen F E. Antegrade selective cerebral perfusion in operations on the proximal thoracic aorta.  AnnThorac Surg. 1999;  67 1904-1910
• 9 Deeb G M, Jenkins E, Boiling S F. et al . Retrograde cerebral perfusion during hypothermic circulatory arrest reduces neurologic morbidity.  J Thorac Cardiovasc Surg. 1995;  109 259-268
• 10 Raskin S A, Fuselier V W, Reeves-Viets J L, Coselli J S. Deep hypothermic circulatory arrest with and without retrograde cerebral perfusion.  Int Anesthesiol Clin. 1996;  34 177-193
• 11 Usui A, Abe T, Murase M. Early clinical results of retrograde cerebral perfusion for aortic arch operations in Japan.  Ann Thorac Surg. 1996;  62 94-104
• 12 Ueda Y, Okita Y, Aomi S, Koyanagi H, Takamoto S. Retrograde cerebral perfusion for aortic arch surgery: analysis for risk factors.  Ann Thorac Surg. 1999;  67 1879-1882
• 13 Ehrlich M P, Fang W C, Grabenwoger M, Kocher A, Ankersinit J, Laufer G, Grubhofer G, Wolner E, Havel M. Impact of retrograde cerebral perfusion on aortic arch aneurysm repair.  J Thoracic Cardiovasc Surg. 1999;  118 1026-1032
• 14 Boeckxstaens C J, Flameng W J. Retrograde cerebral perfusion does not perfuse the brain in nonhuman primates.  Ann Thorac Surg. 1995;  60 319-328
• 15 Ehrlich M P, Hagl C, McCullough J N, Zliang N, Shiang H, Bodian C, Griepp R B. Retrograde cerebral perfusion provides negligible flow through brain capillaries in the pig. J Thoracic Cardiovasc Surg (In press)
• 16 Astudillo R, van der Linden J, Ekroth R, Wesslen O, Hallhagen S, Scallan M. et al . Absent diastolic cerebral blood flow velocity after circulatory arrest but not after low flow in infants.  Ann Thorac Surg. 1993;  56 515-519
• 17 Jonassen A E, Quaegebeur J M, Young W L. Cerebral blood flow velocity in pediatric patients is reduced after cardiopulmonary bypass with profound hypothermia.  J Thorac Cardiovasc Surg. 1995;  110 934-943
• 18 Rodriguez R A, Austin E H, Audenaert S M. Post-bypass effects of delayed rewarming on cerebral blood flow velocities in infants after total circulatory arrest.  J Thorac Cardiovasc Surg. 1995;  110 1686-1691
• 19 Ehrlich M P, McCullough J N, Wolfe D, Zhang N, Shiang H, Weiss D, Bodian C, Griepp R B. Cerebral Effects of Cold Reperfusion after Hypothermia Circulatory Arrest. J Thorac Cardiovasc Surg (In press)
• 20 Olney J W, Ho O L, Rhee V. et al . Neurotoxic effects of glutamate.  N Engl J Med. 1973;  289 1374-1375
• 21 Choi D W. Glutamate neurotoxicity and diseases of the nervous system.  Neuron. 1988;  15 41-70
• 22 Tsengg E E, Brock M V, Kwoon C C. et al . Quantitative analyses of intracerebral excitatory amino acids and citrulline following hypothermic circulatory arrest.  Surg Forum. 1997;  48 297-299
• 23 Redmond J M, Gillinov A M, Zehr K J. et al . Glutamate excitotoxicity: A mechanism of neurologic injury associated with hypothermic circulatory arrest.  J Thorac Cardiovasc Surg. 1994;  107 776-787
• 24 Tsengg E E, Brock M V, Lange M S. et al . Neuronal nitric oxide synthase inhibition reduces neuronal apoptosis after hypothermic circulatory arrest.  Ann Thorac Saurg. 1997;  64 1639-1647

1 Presented at the Annual meeting of the German Society for Thoracic and Cardiovascular Surgery in Leipzig . February 18 - 21, 2001