Current trends in cannulation and neuroprotection during surgery of the aortic arch in Europe†‡

OBJECTIVES To conduct a survey across European cardiac centres to evaluate the methods used for cerebral protection during aortic surgery involving the aortic arch. METHODS All European centres were contacted and surgeons were requested to fill out a short, comprehensive questionnaire on an internet-based platform. One-third of more than 400 contacted centres completed the survey correctly. RESULTS The most preferred site for arterial cannulation is the subclavian-axillary, both in acute and chronic presentation. The femoral artery is still frequently used in the acute condition, while the ascending aorta is a frequent second choice in the case of chronic presentation. Bilateral antegrade brain perfusion is chosen by the majority of centres (2/3 of cases), while retrograde perfusion or circulatory arrest is very seldom used and almost exclusively in acute clinical presentation. The same pumping system of the cardio pulmonary bypass is most of the time used for selective cerebral perfusion, and the perfusate temperature is usually maintained between 22 and 26°C. One-third of the centres use lower temperatures. Perfusate flow and pressure are fairly consistent among centres in the range of 10-15 ml/kg and 60 mmHg, respectively. In 60% of cases, barbiturates are added for cerebral protection, while visceral perfusion still receives little attention. Regarding cerebral monitoring, there is a general tendency to use near-infrared spectroscopy associated with bilateral radial pressure measurement. CONCLUSIONS These data represent a snapshot of the strategies used for cerebral protection during major aortic surgery in current practice, and may serve as a reference for standardization and refinement of different approache

Long-term surgical results in sudden death syndrome associated with cardiac dysfunction after myocardial infarction.

To evaluate the surgical results in patients with inducible ventricular tachyarrhythmias due to coronary disease and left ventricular dysfunction, the authors reviewed their experience in 170 patients who had survived one or more cardiac arrests after myocardial infarction and were unresponsive to drug therapy based on electrophysiologic studies (EPS). There were nine operative deaths (5%). Based on intraoperative EPS, surgical remodeling of left ventricular dysfunction (aneurysm resection, infarct debulking, and septal reinforcement) with map-guided cryoablation and coronary artery bypass graft was performed in 34 patients (group A), and left ventricular remodeling and coronary artery bypass graft without guided endocardial resection was performed in 25 patients (group B). Forty-three patients (group C) had coronary artery bypass graft with implantation of an automatic implantable cardioverter defibrillator (AICD). Group D (68 patients) received AICD only. After operation, based on EPS results, four patients in group A (12%) and three patients in Group B (15%) required AICD implantation. Overall survival at 6 years was 65%, 48%, 85%, and 58% in patient groups A, B, C, and D, respectively (p = not significant). During follow-up in group A patients, none died suddenly and none needed AICD. In group B, two patients required AICD 3 and 5 years later, and five patients died suddenly. The incidence of sudden death was 2.3%/patient/year and 3.5%/patient/year after AICD implantation (groups C and D). At 6 years, cardiac-event-free survival was 80% and 70% for groups A and B and 38% and 24% for groups C and D, respectively (p less than 0.001). Patients receiving map-guided ablative procedures had significantly improved cardiac-event-free survival rates

The dynamics of platelet thrombus formation rate, thrombus retention time, and rate of embolization on a control and heparin bonded polyurethane angio-catheter

The dynamics of platelet deposition and embolization from control and heparin bonded polyurethane catheters (CPC and HBPC) was evaluated with In-111 labeled autologous platelets (IN-PLT) and a computerized gamma camera (CGC). Ten non-heparinized dogs (18-25 kg) were catheterized in both femoral arteries with 10 cm of CPC and HBPC (5 Fr., Cordis) 24 hr after injection of 300-420 microCi of In-PLT, and imaged for 3 hr with the computerized gamma camera. The regional platelet deposition curves (RPDC) indicated multiple peaks and valleys; the curves were analyzed for early rate of thrombus formation (upswing), thrombus retention time (full width at half maxima of the RPDC-peak), and rate of embolization (downswing) on both catheters. The four parameters (mean +/- SD) of thrombosis on catheters and integral of the radioactivity time curve for the 3 hr duration of imaging were calculated from normalized counts/sec. The rate of thrombus formation and rate of embolization are higher for the control than HBPC, suggesting that heparin-bonding decreases the early rate of thrombosis and embolization. The thrombus adhesivity and retention time appear shorter for the control catheter, indicating that the control thrombogenic catheter forms multiple thrombi and emboli than HBPC. The integral appears larger for the control catheter than HBPC. In vivo (dynamic) studies, in vitro studies, and critical analyses of the radioactivity time curve were essential for complete evaluation of thrombogenicity of catheters and other cardiovascular prostheses