Con: DHCA is not required for aortic arch surgery ACTA Lecture Series: October 5, 2012 Alexander J Gregory MD, FRCPC CT Anesthesia Fellow Department of Anesthesiology and Critical Care University of Pennsylvania Hospital System

Definitions Circulatory arrest Antegrade cerebral perfusion (ACP) Hypothermia Neurologic deficit (PND vs TND)

ACP Techniques CPB cannula = UACP cannula CPB cannula + UACP or BACP Direct cannulation vs. graft vs. balloon Spinal cord perfusion Lower body and viscera perfusion

ACP Disadvantages Embolization Dissection Variable cerebral circulation (Circle of Willis) Increased complexity Surgical field clutter Increased cost

Urbanski Zierer Total Non Type A < 30 mins 30-60 mins > 60 mins Mortality 0.9 % 5 % 4 % 3 % 8 % 11 % PND 2 % TND 2.3 % Paraplegia 0 % 0.3 % ---- ARF 1.5 % 6 % ALF

Includes Acute Type-A Dissections Urbanski Zierer Total Non Type A < 30 mins 30-60 mins > 60 mins Mortality 0.9 % 5 % 4 % 3 % 8 % 11 % PND 2 % TND 2.3 % Paraplegia 0 % 0.3 % ---- ARF 1.5 % 6 % ALF Includes Acute Type-A Dissections

Excluding Acute Type-A Dissections Urbanski Zierer Total Non Type A < 30 mins 30-60 mins > 60 mins Mortality 0.9 % 5 % 4 % 3 % 4% 0 % PND 2 % TND 2.3 % Paraplegia 0.3 % ---- ARF 1.5 % 8 % ALF Excluding Acute Type-A Dissections

ACP Disadvantages ? Local axillary neuro = 5/655 (0.8%) Vascular complications = 0/1002 (0%) Ax. post-op compartment synd. = 0/655 (0%) Ax. post-op malperfusion = 0/655 (0%) Carotid hyperperfusion = 0/347 (0%)

Disadvantages of Hypothermia Increased CPB time Coagulopathy Increased vascular resistance Left shift of Oxy-Hgb curve Impaired cerebral autoregulation Impaired immune system Multi-organ dysfunction Rewarming injury

Moderate ACP vs DHCA +/- RCP (Misfeld 2012) ACP + mod DHCA +/- RCP p-value Mortality 9 % 11 % 0.1 PND 14 % < 0.05 TND 16% 0.5 Respiratoty failure 17 % 25 % ARF 15 % 0.2 Low CO syndrome 7 % 4 % 0.3 Sepsis 5 % GI complication 8 %

Mild ACP vs Deep ACP (Watanabe 2011) ACP + mild ACP + deep p-value Mortality 0 % NS CVA 19 % < 0.05 CPB (min) 128 197 < 0.001 OR (min) 303 431 <0.001 ABT (mL) 682 1490 < 0.01 Extubation (hrs) 24 88 Hospital LOS (d) 28 42

Mild ACP vs Moderate ACP (Kaneda 2005) ACP + mild ACP + mod p-value Mortality 10 % NS PND 5 % CPB (min) 146 217 < 0.01 OR (min) 345 510 <0.01 ABT (mL) 1724 3051 < 0.05 Intubation (d) 1.9 4.9 ICU LOS (d) 4.6 8.5

Mild ACP vs Moderate ACP (Numata 2012***) ACP + mild ACP + mod p-value Mortality 6 % > 0.99 PND 10 % 0.39 TND CPB (min) 164 188 <0.05 ARF 4 % 15 % < 0.05 A Fib 16 % 35 % < 0.01 MV > 3 days 7 % 18 % Re-exploration 5 % 11 % 0.15 GI bleed 1 % 0.1

Future Direction CA < 30 minutes: DHCA vs ACP+mild CA 30-45 minutes: RCP vs ACP CA > 45 minutes: ACP + mild vs ACP + deep ACP techniques (ex: UACP vs BACP) Lower body perfusion techniques