Cerebral Protection In Aortic dissection
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1 Cerebral Protection In Aortic dissection Davide Pacini CARDIAC SURGERY DEPARTMENT - St. ORSOLA HOSPITAL UNIVERSITY OF BOLOGNA - ITALY
2 FINANCIAL DISCLOSURE: NONE
3 Cerebral protection in type A AoD
4 Antegrade Selective Cerebral Perfusion
5 Cerebral protection: the problem Isselbacher et al., Circulation Pre or post neurological injuryes
6 Cerebral perfusion open issues The unanswered issues Concept 1: How much the technique influences neurological outcomes Concept II: How much the dissection impairs cerebral functions
7 Are we sure everything is ok?? Cerebral protection in type A AoD
8 Cerebral perfusion open issues 1. Site of arterial cannulation 2. Unilateral vs bilateral 3. Management of cerebral malperfusion
9 Current practice in Europe Site of aa cannulation in acute setting Innominate aa Femoral Axillary De Paulis et al. EJCTS 2015
10 Issue 1: Site of arterial cannulation N= 1732 TYPE A AD Pz divided by time T1: T2: T3: Antegrade cerebral perfusion + Axillary artery cannulation Parikh et al. JTCVS April 2017
11 Supra-aortic vessels selection in acute AoD 1 Issue 1: Site of arterial cannulation Axillary aa Avoid manipolation of epiaortic vessels 2 Innominate aa Frequently involved in the dissection
12 Issue 1: Site of arterial cannulation 3 The common carotid artery Wider than axillary artery Arterial wall is stronger Rylski et al, EJCTS 2014
13 Current practice in Europe Type of cerebral perfusion in acute setting RETROGRADE DEEP HYPHOTERMIA UNILATERAL ASCP BILATERAL ASCP De Paulis et al. EJCTS 2015
14 Issue 2: Unilateral vs bilateral ASCP ICTS 2008 Author Year Patients 30 day Mortality Post op CVA Tasdemir (7.6%) 2 (1.9%) Karadeniz Küçüker (6.6%) 4 (2.3%) Panos (4%) 1 (4%) Budde (8%) 4 (7%) Bakhtiary (5%) 8 (7%)
15 Issue 2: Unilateral vs bilateral ASCP ICTS 2008 Author Year Patients 30 day Mortality Post op CVA Tasdemir (7.6%) 2 (1.9%) Karadeniz Küçüker (6.6%) 4 (2.3%) MEAN DURATION OF SACP = 32 min Panos (4%) 1 (4%) Budde (8%) 4 (7%) Bakhtiary (5%) 8 (7%)
16 Pathophysiology of the brain perfusion: Cerebral flow gradually declines during cerebral perfusion
17 Pathophysiology of the brain perfusion: Positron Emission Tomography (PET) Postop After 6 months The lack of left subclavian artery perfusion during cerebral perfusion led to temporary glucose hypometabolism in the occipital lobes Eur J Cardiothorac Surg. 2010;37:
18 Issue 2: Unilateral vs bilateral ASCP 82 uacp vs 121bACP : -Acute type A aortic dissection -Total arch replacement Similar CPB, x-clamp, circ arrest time, NP temperature Tong G, JTCVS 2017
19 Issue 2: Unilateral vs bilateral ASCP PND (p=0.091): 16.9% u-apc vs 8.4% b-apc 30-d mortality (p=0.075): 20.7% u-acp vs 11.6% b-acp Bilateral perfusion implied approximately 50% less mortality and neurologic morbidity rates than unilateral perfusion, but this did not reach statistical significance. Tong G, JTCVS 2017
20 Issue 2: Unilateral vs bilateral ASCP
21 Cerebral perfusion open issues 1. Site of arterial cannulation 2. Unilateral vs bilateral 3. Management of cerebral malperfusion Lack of evidence on effectiveness of specific perfusion strategies Cerebral perfusion Unilateral/Bilateral ACP Hyphotermic/moderate temperature Central/peripheral cannulation
22 Management of cerebral malperfusion: Early carotid perfusion Pre Post Additional aa line for CPB in connection with the II line in the femoral aa
23
24 IN SUMMARY Cerebral protection strategies evolved during the years with a clear advantage of ACP using the axillary artery as preferred site of arterial inflow Brain malperfusion caused by acute type A aortic dissection may not be always clinically evident but impairs outcomes regardless of the operative techniques Although definitive proof that bilateral ACP is superior to unilateral ACP is still lacking, it should be preferred especially when prolonged periods of ACP are anticipated
25 THANK YOU Davide Pacini CARDIAC SURGERY DEPARTMENT - ST. ORSOLA HOSPITAL UNIVERSITY OF BOLOGNA ITALY davide.pacini@unibo.it
26 : 303 patients, mean age 58.9 ± 13.6 years - Type A aortic dissection - 2 groups depending on presence of preoperative stroke Operative data Dumfarth et al. EJCTS 2018
27 n(%) Predictors for post Stroke OR P Value Preoperative malperfusion Preoperative CPR Bovine arch Dissection pattern of supra-aortic vessels Stroke No-stroke P Value Innominate artery dissected 30 (62.5) 144 (56.5) Right carotid artery 13 (27.1) 33 (12.9) Left carotid artery 5 (10.4) 14 (5.5) Dumfarth et al. EJCTS 2018
28 Management of cerebral malperfusion: Early Reperfusion Goldberg et al. Semin Thoracic Surg 2016
29 uacp vs. bacp Marfan, 19 years old - Chest pain and no neurological deficits - CT angiogram: acute type A aortic dissection - Echocardiography: tricuspid aortic valve with mild AI?
30 2- IN SUMMARY Brain malperfusion caused by acute type A aortic dissection may not be always clinically evident but impairs outcomes regardless of the operative techniques Although definitive proof that bilateral ACP is superior to unilateral ACP is still lacking, there is any obvious harm to use a complete brain protection especially when prolonged periods of ACP are anticipated
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