To valuate cerebral protection by retrograde cerebral perfusion (RCP) via superior vena cava,the study results for the last ten years have been reviewed.RCP is regarded as an assistant method in deep hypothermic circulatory arrest(DHCA) in that it provides partial brain blood flow,maintains a low brain temperature,optimizes cerebral metabolic function during DHCA by supplying oxygen and some nutrient and removal of catabolic products;it also reduces the incidence of cerebral embolization by flushing out air...
Objective To observe the influence of edaravone perfusion via the pulmonary artery on postoperative lung tissue and lung function during pulmonary ischemia in deep hypothermic circulatory arrest （DHCA）， and explore its possible mechanism. Methods A total of 24 healthy New Zealand white big-ear rabbits were randomly divided into three groups： （1） control group： DHCA model under cardiopulmonary bypass （CPB） was established； （2）low potassium dextran （LPD）group： LPD solution perfusion via the pulmonary artery after the establishment of DHCA； （3）edaravone group：LPD solution containing edaravone （5 mg/kg） perfusion via the pulmonary artery after the establishment of DHCA. Oxygenation index and lung compliance were observed at the time of baseline condition， recovery of ventilation， 1 hour and 2 hours after recovery of ventilation， and postoperative lung function of the three groups were compared. Malondialdehyde （MDA） and superoxide dismutase （SOD） in pulmonary venous blood were measured. All the rabbits were sacrificed after the operation. HE staining and immunohistochemistry were performed on the lung tissues to investigate lung structure changes and inflammatory reaction. Transmission electron microscopy was used to compare ultrastructural changes of lung.Results There were no statistical difference in oxygenation index， lung compliance， MDA and SOD among the 3 groups under the baseline condition （P＞0.05）. After recovery of ventilation， oxygenation index and lung compliance deteriorated to varying degrees in all 3 groups. Oxygenation index and lung compliance of the control group and LPD group at the time of recovery of ventilation， 1 hour and 2 hours after recovery of ventilation were significantly lower than those of edaravone group （oxygenation index：recovery of ventilation and in control group and edaravone group: 198.25±11.02 mm Hg vs. 244.87±13.05 mm Hg；lung compliance：one hour after recovery ventilation in control group and edaravone group：45.88±1.64 ml/cm H2O vs. 59.75±2.38 ml/cm H2O；P＜0.05）. After CPB removal， MDA levels were increased to varying degrees in all 3 groups. MDA levels of the control group and LPD group at the time of CPB removal， 1 hour and 2 hours after CPB removal were significantly higher than those of edaravone group （P＜0.05）. After CPB removal， SOD levels were decreased to varying degrees in all 3 groups. SOD levels of the control group and LPD group at the time of CPB removal， 1 hour and 2 hours after CPB removal were significantly lower than those of edaravone group （P＜0.05）. HE staining showed clear lung structure， less red blood cell leakage， less inflammatory cell infiltration， and less alveolar fluid accumulation in the edaravone group. Immunohistochemistry showed that integral light density of interleukin 6 （IL-6）in edaravone group was significantly lower than those of the LPD group and control group （14.44±1.75 vs. 20.18±2.22， P＜0.05）. Transmission electron microscopy showed integral basement membrane structure， clear blood gas barrier structure， significantly larger number of type II epithelial cells， abundant but not swollen mitochondria and lamellar bodies in the cytoplasm in the edaravone group， which were destroyed in varying degrees in the LPD group and control group. Conclusion Pulmonary artery perfusion of protective solution in low temperature can significantly reduce lung injury induced by DHCA and CPB. Protective solution containing edaravone in low temperature can better decrease lung injury and protect oxygenation.
Abstract： Objective To evaluate the clinical safety and neurological outcomes of right axillary artery cannulation with a side graft compared with a direct approachin aortic arch replacement for patients with acute Stanford type A aortic dissection. Methods Between July 2008 and July 2010， 280 consecutive patients with acute Stanford type A aortic dissection underwent right axillary artery cannulation for cardiopulmonary bypass （CPB） in total arch replacement and stented “elephant trunk” implantation in our hospital.These 280 patients were divided into two groups according to the method of axillary artery cannulation in operation:direct arterial cannulation was used in 215 patients（direct arterial cannulationgroup， DG group， mean age of 43.1±9.5 years）， while cannulation with a side graft was used in 65 patients（ indirect cannulation group， IG group， mean age of 44.7±8.3 years）. Clinical characteristics of both groups were similar except their axillary artery cannulation method. Patient outcomes were compared as to the prevalence of clinical complications， especially neurological deficits and postoperative morbidity. Results The overall hospital mortality was 3.6% （10/280）， 3.3% （7/215） in DG group and 4.6% （3/65） in IG group respectively.Right axillary artery cannulation was successfully performed in all cases without any occurrence of malperfusion. Postoperatively， 25 patients（8.9%）developed temporaryneurological deficits， 19 cases in DG group（8.8%）， and 6 cases in IG group （9.2%）， and all these patients were cured after treatment. The incidence of postoperative complications directly related to axillary artery cannulation was significantly lower in IG group than that in DG group（1 case vs. 19 cases， P=0.045）. There were no statistical differences in arterial perfusion peak flow， peak pressure，antegrade cerebral perfusion time， deep hypothermic circulatory arrest time， and CPB time between the two groups（P ＞ 0.05）. Conclusion Right axillary artery cannulation with a side graftcan significantly reduce the postoperative complications of axillary artery cannulation. It is a safe and effective method for patients undergoing surgery for acute Stanford type A aortic dissection.
ObjectiveTo investigate the incidence of acute kidney injury (AKI) after deep hypothermic circulatory arrest (DHCA), to explore the risk factors and prognosis of postoperative AKI, and to establish a relatively accurate preoperative risk assessment strategy and prevention measures.MethodsThe clinical data of 252 patients who underwent deep hypothermic circulatory surgery in our hospital from January 2014 to October 2018 were retrospectively analyzed. There were 179 males and 73 females with an average age of 53.6±11.6 years. The patients were divided into an AKI group and a non-AKI group according to the AKI diagnostic criteria developed by kidney disease improving global outcomes (KDIGO). The data of the two groups were compared, and the risk factors related to AKI after DHCA were analyzed by single factor and multivariate logistic regression.ResultsAmong the 252 patients enrolled, the incidence of AKI was 69.0%. The postoperative hospital mortality rate was 7.9% (20/252). The univariate analysis showed that the patient's age and body mass index (BMI)≥28 kg/m2, left ventricular ejection fraction<55%, preoperative serum creatinine (Scr)≥110 μmol/L, preoperative estimated glomerular filtration rate (eGFR), Cleveland score and intraoperative cardiopulmonary bypass time, intraoperative infusion of red blood cells, intraoperative infusion of plasma, postoperative mechanical ventilation time≥40 h and other indicators were significantly different between the two groups (P<0.05); multivariate logistic regression analysis showed that there was significant difference between the two groups in age (OR=1.040, 95% CI 1.017–1.064, P=0.001), BMI≥28 kg/m2 (OR=2.335, 95%CI 1.093–4.990, P=0.029), eGFR<90 mL/(min·1.73 m2) (OR=2.044, 95%CI 1.082–3.863, P=0.028), preoperative Cleveland score (OR=1.300, 95%CI 1.054–1.604, P=0.014) and intraoperative cardiopulmonary bypass time (OR=1.009, 95%CI 1.002–1.017, P=0.014).ConclusionThe incidence of AKI is higher after DHCA. Patients with postoperative AKI have longer hospital stay and higher risk of hospitalization death. The age of patients, BMI≥28 kg/m2, eGFR<90 mL/(min·1.73) m2, Cleveland score, intraoperative extracorporeal circulation time are independent risk factors for AKI after DHCA.
Deep hypothermic circulatory arrest (DHCA) technology is the basic means of organ protection in complex aortic arch surgeries, congenital heart disease surgeries, pulmonary endarterectomy and other operations. The establishment of DHCA in rat model is helpful to explore the influence of DHCA and its pathophysiological pathways. However, there are some problems in this process, such as imperfect monitoring, inaccurate management and non-standard heparinization during the experimental period. It is necessary to review relevant literatures on DHCA rat model, in order to establish a DHCA rat model with standardized operation, clear standards and mature technology.
Abstract： Objective To investigate the cerebral protective effects of hyperoxia management during deep hypothermia circulatory arrest（DHCA） rabbit by the blood gas indexes, superoxide dismutase（ SOD） activity and malondialdehyde （MDA） levels of brain, and ratio of water to brain. Methods A DHCA and antegrade selective cerebral perfusion （ASCP） rabbit model was established. Twenty-four 11-13 week-old male New Zealand rabbits（ weighing 2.7 to 3.4 kg） were assigned to three groups with a random number table: a sham operation group （Sham group）, an ASCP group （S group）, and an ASCP ＋ hyperoxia management group （SH group）. There were eight rabbits in each group. We recorded the intraoperative values for arterial oxygen pressure （PaO2）, arterial oxygen saturation （SaO2）, jugular venous oxygen pressure（PjvO2）, jugular venous oxygen saturation（ SjvO2） and blood lactate level. The brain SOD activity, MDA levels, and ratio of water to brain were measured after the operation. Results Before initiating circulatory arrest, before initiating reperfusion and five minutes of reperfusion, levels of PaO2 , PjvO2 , and SjvO2 in the SH group were significantly higher than those of the S group and Sham group. SOD activity in the SH group was not significantly different from that of the S group[（213.53±33.52） U/mg. prot vs. （193.02±27.67） U/mg. prot] and Sham group[（213.53±33.52） U/mg. prot vs.（244.38±35.02）U/mg. prot], but the SOD activity in the S group was lower than that in the Sham group（ P ＜ 0.05）. MDA levels in the SH group were lower than that in the S group[（1.42±0.30） nmol/mg. prot vs. （2.37±0.55） nmol/mg. prot, P ＜ 0.05]. Conclusion Our data show that hyperoxia management during DHCA＋ASCP improves rabbits’PjvO2 and SjvO2, maintains brain SOD activity, and decreases brain MDA levels, demonstrating the neuroprotective effects of hyperoxia mangagement.
ObjectiveTo establish a novel animal model of deep hypothermic circulatory arrest (DHCT) in rabbits without thoracotomy, and investigate acute kidney injury (AKI) induced by DHCT and early novel biomarkers of AKI. MethodsForty-two New Zealand big ear rabbits (3.5-4.0 kg, male or female) were randomly divided into 2 groups with 21 rabbits in each group. Cardiopulmonary bypass (CPB) was established via the right carotid artery and jugular vein in both groups. In Group A, CPB continued when the rectal temperature was maintained at 28℃. In group B, DHCT started when the rectal temperature reached 16℃ to 18℃ and lasted for 60 minutes before CPB was resumed and rewarming was started. The rectal temperature was restored to 35℃ within 30 minutes, then CPB was maintained for 30 minutes. CPB time was same in both groups. Preoperatively and 6 hours, 24 hours and 48 hours after the operation, venous blood samples were taken to examine serum creatinine (Cr) and β-trace protein (β-TP), and urine samples were taken to examine neutrophil gelatinase-associated lipocalin (NGAL). Four rabbits were sacrificed at respective above time points to measure renal malondialdehyde (MDA) content. Hematoxylin-Eosin (HE) staining, TUNEL assay and transmission electron microscopy were used to examine morphological changes of renal tubular epithelial cells (TECs). ResultsFour rabbits died in group A and five rabbits died in Group B during the experiment.(1)Blood Cr:There was no statistical difference between different time points in Group A (P > 0.05). In Group B, serum Cr at 24 hours after the operation was significantly higher than other time points, and also significantly higher than that of group A (P < 0.05).(2)Blood β-TP and urinary NGAL:There was no statistical difference between different time points in Group A (P > 0.05). In Group B, blood β-TP and urinary NGAL at the time of 6 hours, 24 hours and 48 hours postoperatively were significantly higher than preoperative levels (P < 0.05). Blood β-TP and urinary NGAL at the time of 24 hours postoperatively were significantly higher than other time points (P < 0.05). Blood β-TP and urinary NGAL at the time of 6 hours, 24 hours and 48 hours postoperatively were significantly higher than those of group A (P < 0.05).(3)Renal MDA content of Group B at the time of 24 hours postoperatively was significantly higher than other time points as well as that of Group A (P < 0.05).(4) HE staining showed serious pathological injuries of renal TECs at the time of 24 hours postoperatively in Group B. There was no significant pathological injury of renal TECs at the time of 24 hours postoperatively in Group A. (5)TUNEL-positive rate of group B at the time of 24 hours postoperatively was significantly higher than other time points as well as that of group A (P < 0.05).(6)Transmission electron microscope showed serious pathological injuries of renal TECs organelles at the time of 24 hours postoperatively in Group B. There was no significant pathological injury of renal TECs organelles in Group A. ConclusionsThis DHCT rabbit model without thoracotomy is a simple, convenient, and economical animal model with long-term animal survival for the study of DHCT-induced organ injury. AKI is most serious at the time of 24 hours after DHCA. Blood β-TP and urinary NGAL can be used as early biomarkers of DHCT-induced AKI.
Abstract： Objective To determine the risk factors for acute kidney injury (AKI) after thoracic aortic arch replacement surgery under deep hypothermic circulatory arrest (DHCA). Methods We retrospectively analyzed the clinical data of 139 patients who underwent thoracic aortic arch replacement surgery under DHCA between January 2004 and December 2008 in Beijing Anzhen Hospital Affiliated to Capital University of Medical Sciences. The patients were divided into two gro-ups according to whether AKI occurred after thoracic aortic arch replacement surgery. In the AKI gro-up (n=48), there were 39 males and 9 females with an age of 57.67±9.56 years. In the normal renal function gro-up (n=91), there were 69 males and 22 females with an age of 41.30±13.37 years. We observed the clinical data of the patients in both gro-ups, including left ventricular ejecting fraction (LVEF) before operation, diameter of the left ventricle, diameter of the ascending aorta, renal function, cardiopulmonary bypass time, aortic crossclamp time, and DHCA time. The risk factors for AKI and death after operation were evaluated by univariate analysis and stepwise logistic regression analysis. Results Among all the patients, AKI occurred in 48 (34.53%), 17 (12.23%) of whom underwent continuous renal replacement therapy (CRRT). Respiratory failure occurred in 27 patients (19.42%). Twentynine patients (20.86%) had cerebral complications, including temporary cerebral dysfunction in 26 patients and permanent cerebral dysfunction in 3 patients. In all the patients, 14 (10.07%) died, including 4 patients of heart failure, 9 patients of multiple organ failure, and 1 patient of cerebral infarction. There were 3 (3.30%)deaths in the normal renal function gro-up and 11 (22.92%) deaths in the AKI gro-up with a significant difference of mortality rate between the two gro-ups (P=0.011). A total of 118 patients were followed -up and 7 were lost. The follow-up time was from 5 to 56 months with an average time of 42 months. During the follow-up period, 7 patients died, including 3 patients of heart failure, 2 patients of cerebral apoplexy, and 2 patients of unknown reasons. The logistic regression analysis revealed that creatinine level was greater than 13260 μmol/L before operation (OR=1.042, P=0.021) and respiratory failure (OR=2.057, P=0.002) were independent determinants for AKI after the operation. Conclusion AKI is the most common complication of thoracic aortic arch replacement surgery under DHCA, and is the risk factor of mortality after the surgery. It is important to enhance perioperative protection of the renal function.
Objective To determine risk factors of delayed recovery of consciousness after aortic arch surgery underdeep hypothermic circulatory arrest （DHCA） and antegrade selective cerebral perfusion （ASCP）. Methods We retrospectively analyzed clinical data of 113 patients who underwent aortic arch surgery under DHCA＋ASCP in the Affiliated Drum Tower Hospital， Medical School of Nanjing University from October 2004 to April 2012. According to whether they regained consciousness within 24 hours after surgery， all the 113 patients were divided into normal group （73 patients including 55 males and 18 females with their average age of 48.1±10.9 years） and delayed recovery group （40 patients including 29 males and 11 females with their average age of 52.2±11.4 years）. Risk factors of delayed recovery of consciousness after surgery were evaluated by univariate analysis and multivariate logistic regression analysis. Results Nine patients （8.0%） died postoperatively， including 5 patients with multi-organ failure， 2 patients with heart failure， 1 patient with mediastinal infection， and 1 patient with pulmonary hemorrhage. There were 7 deaths （17.5%） in the delayed recovery group and 2 deaths （2.7%） in the normal group， and the in-hospital mortality of the delayed recovery group was significantly higher than that of the normal group （P=0.016）. A total of 94 patients （including 65 patients in the normal group and 29 patients in the delayed recovery group） were followed up for 4-95 months. Eight patients （including 5 patients in the normal group and 3 patients in the delayed recovery group） died during follow-up， including 2 patients with stroke， 3 patients with heart failure， 2 patients with pulmonary hemorrhage and 1 patient with unknown cause. Ten patients were lost during follow-up. Univariate analysis showed that age （P=0.042）， hypertension （P=0.017）， emergency surgery （P=0.001）， cardiopu- lmonary bypass （CPB） time （P=0.007）， aortic cross-clamp time （P=0.021）， and blood transfusion（P=0.012）were risk factors of delayed recovery of consciousness after aortic arch surgery. Multivariate logistic regression showed that emergency surgery （P=0.005） and CPB time＞240 minutes （P=0.000） were independent risk factors of delayed recovery of consciousness after aortic arch surgery. Conclusion Delayed recovery of consciousness after aortic arch surgery is attributed to a combination of many risk factors. Correct patient diagnosis， lesion site and involved scope should be made clear preoperatively in order to choose appropriate surgical strategies. During the surgery， strengthened brain protection， shortened operation time， improved surgical techniques， and perioperative stable circulation maintenance are all important measures to prevent delayed recovery of consciousness after aortic arch surgery.
Objective To compare the changes between deep hypothermic circulatory arrest (DHCA) with deep hypothermic low flow (DHLF) cardiopulmonary bypass (CPB) on pulmonary surfactant (PS) activity in infants with congenital heart disease. Methods Twenty infants with ventricular septum defect and pulmonary hypertension were assigned to either DHCA group or DHLF group according to the CPB methods respectively. Measurements of saturated phosphatidylcholine /total phospholipids (SatPC /TPL), saturated phosphatidylcholine/ total protein (SatPC/TP) and static pulmonary compliance were performed before institution of CPB, 5 minutes after cessation of CPB and 2 hours. Results The length of ICU stay in DHLA group was significantly longer ( P lt;0 05) than that in DHCA group. SatPC/TPL, SatPC/TP and static pulmonary compliance in DHLF group were significantly lower compared with DHCA group ( P lt;0.01). Conclusion DHLF could lower the PS activity level significantly as compared with DHCA in infants with congenital heart disease.