Asian Cardiovasc Thorac Ann 2003;11:85-86
© 2003 Asia Publishing EXchange Ltd
Modified Circuit for Retrograde Cerebral Perfusion
Anil Bhan, MCh,
Shiv Kumar Chaudhary, MCh,
Rajesh Sharma, MCh,
Milind Hote, MS,
Rajeev Gupta, BSc,
Panangipalli Venugopal, MCh
Cardiothoracic Centre, All India Institute of Medical Sciences, New Delhi, India
For reprint information contact: Anil Bhan, MCh Tel.: 91 11 656 1123 Fax: 91 11 686 2663 email: anil_bhan{at}hotmail.com Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India.
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ABSTRACT
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A modified circuit for delivery of retrograde cerebral perfusion during ascending aortic or aortic arch surgery is described. The technique was applied in 15 patients who showed good postoperative recovery.
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INTRODUCTION
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A successful outcome of surgical repair of ascending aortic and transverse arch aneurysms and type A aortic dissection is largely dependent on the adequacy of cerebral protection. Retrograde cerebral perfusion (RCP) was first used as an adjuvant to profound hypothermia and circulatory arrest by Ueda and colleagues.1 Several subsequent reports confirmed its effectiveness.2,3 We have modified the circuit to make it easier to set up.
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TECHNIQUE
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The patient is operated upon via a median sternotomy. Cardiopulmonary bypass is established with bicaval and femoral arterial cannulation. Ascending aortic or arch surgery is performed using deep-hypothermic circulatory arrest and RCP. The conventional circuit for delivery of RCP uses a sidearm on the arterial inflow line, which is attached to the superior vena cava (SVC) cannula via an inverted Y-connector (Figure 1
). The other limb of the Y-connector is attached to the venous drainage line. In our simplified circuit, instead of directly connecting the 2 caval cannulae through a Y-connector to the 0.5-inch venous line, an additional small segment of 3/8th inch tubing, (approximately 10 cm long) obtained from the arterial end of the circuit, and a 3/8th–3/8th inch plastic connector with a Luer-Lok side-port is used between the SVC cannula and the venous line. The patient is cooled down to 18°C and the circulation is stopped. The soft tubing in the SVC line is clamped and the SVC cannula is snared. The cardioplegia line is disconnected from the cardioplegia cannula, and the remaining fluid in the line is discarded. This line is connected to the Luer-Lok side-port in the SVC line (Figure 2). RCP is now started through the cardioplegia delivery system at a flow rate of 400 to 500 mL•min-1, keeping the SVC pressure below 25 mm Hg. The perfusate temperature is maintained at 10°C. On termination of circulatory arrest, flow is initiated from the arterial inflow line, while RCP is continued for a further 2 to 4 min. After ensuring complete deairing of the cranial vessels and the arch, RCP is stopped and the side-port on the SVC connector is closed.
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Figure 1. Conventional circuit for delivery of retrograde cerebral perfusion. A Y-connector on the arterial line delivers priming solution to the superior vena cava via an inverted Y-connector. IVC = inferior vena cava, SVC = superior vena cava.
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Figure 2. Modified circuit. Cerebral perfusion is delivered using a separate roller pump in the cardioplegia line, which is attached to the superior vena cava cannula through a straight connector with a side-port. IVC = inferior vena cava, SVC = superior vena cava.
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DISCUSSION
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Between March 2000 and January 2001, the modified circuit was used in 15 patients who underwent ascending aortic or aortic arch operations at our institute. Ages ranged from 9 to 65 years. Preoperative diagnoses were type A aortic dissection (5) and ascending aortic and/or aortic arch aneurysm (10). Bentall’s procedure was applied in 11 patients, arch replacement in 3, and the elephant-trunk technique in 1. Mean cardiopulmonary bypass and aortic crossclamp times were 135 ± 22.5 min and 110 ± 27 min, respectively. Circulatory arrest ranged from 22 to 61 min, and RCP time from 26 to 67 min. Postoperative survival was 100% with no neurological deficit. Patients were awake 4 to 9 hours after the operation and required ventilation for 16 to 72 hours. They were discharged from the hospital after 8 to 21 days.
Some problems with the conventional circuit described in Figure 1
include its complex arrangement and the need for extra tubing. Our circuit offers several distinct advantages. Firstly, it is easy and simple to install, without the need for extra tubing or a complicated circuit. In rare circumstances where RCP has not been planned from the outset, the circuit can be assembled with minimal delay. Secondly, the perfusate temperature can be more effectively controlled. In our experience, the perfusate could be rapidly cooled down to 10°C or even lower. In the conventional circuit, this is not possible as a larger volume of blood requires cooling. Thirdly and most importantly, the cerebral circulation and the aortic arch can be deaired completely with the modified circuit. At the termination of total circulatory arrest, we continue RCP along with arterial inflow. This prevents entrapment of any air in the cerebral circulation or the arch. In the conventional circuit, once the arterial inflow is started, it is not possible to continue RCP. Therefore, we believe that the modified circuit is a simple, safe, effective, and probably superior method of delivering RCP.
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Acknowledgments
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The authors are thankful to Prof. Ivatury M Rao who suggested this modified circuit.
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REFERENCES
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- Ueda Y, Miki S, Kusuhara K, Okita Y, Tahata T, Yamanaka K. Surgical treatment of aneurysm or dissection involving the ascending aorta and aortic arch, utilizing circulatory arrest and retrograde cerebral perfusion. J Cardiovasc Surg (Torino)
1990;31:553–8.[Medline]
- Coselli JS, Buket S, Djutanoric B. Aortic arch operation: current treatment and results. Ann Thorac Surg
1995;59:19–27.[Abstract/Free Full Text]
- Deeb GM, Jenkins E, Bolling SF, Brunsting LA, Williams DM, Quint LE, et al. Retrograde cerebral perfusion during hypothermic circulatory arrest reduces neurologic morbidity. J Thorac Cardiovasc Surg
1995;109:259–68.[Abstract/Free Full Text]
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ABSTRACT
INTRODUCTION
