1. Tenri Hospital Dept. Cardiovascular Surgery Tenri Hospital, Dept. of Cardiovascular Surgery Daisuke Nakatsuka, M.D. Kazuo Yamanaka, M.D., Ph.D. Acute Type A Aortic Dissection Complicated with Cerebral Malperfusion: Acute Type A Aortic Dissection Complicated with Cerebral Malperfusion: Impact of immediate surgical repair on neurological outcome

2. Tenri Hospital Dept. Cardiovascular Surgery ・ Optimal treatment of acute type A aortic dissection(AAAD) complicated with cerebral malperfusion remains controversial. Because… ・ Preoperative neurological deficits --- sign of poor prognosis ・ Cerebral reperfusion by repair --- may worsen neurological outcome Background

3. Tenri Hospital Dept. Cardiovascular Surgery ・ To retrospectively analyze our experience with AAAD complicated by cerebral malperfusion. Objective

4. Tenri Hospital Dept. Cardiovascular Surgery 2007 to 2009 AAAD 56 With Cerebral malperfusion 8 （ 14% ） mean age 72.2 year （ range 54 to 80 ） female 5 ( 62,5% ) Cerebral malperfusion : impaired consciousness newly developed focal neurological deficit Patients

5. Tenri Hospital Dept. Cardiovascular Surgery Indication for Surgical repair ： All AAAD cases except for intramural hematoma Operative Procedure ・ Central cannulation via Asc. Ao ・ Brain protection moderate hypothermia antegrade selective cerebral perfusion (SCP) ・ Resection of intimal tear Treatment

6. Tenri Hospital Dept. Cardiovascular Surgery 1. Monitoring cerebral function with NRS-INVOS 2. Rapid central cannulation for CPB via Asc. Ao 3. Early establishment of antegrade SCP 4. Postoperative moderate hypothermia for 72hours Strategy for Cerebral malperfusion CPB : cardiopulmonary bypass, SCP : selective cerebral perfusion

7. Tenri Hospital Dept. Cardiovascular Surgery Preoperative Status GCS : Glasgow Coma Scale, BCA : brachiocephalic artery, RCCA : right common carotid artery CPR : Cardiopulmonary Resuscitation

8. Tenri Hospital Dept. Cardiovascular Surgery Surgical Interventions PAR: partial arch replacement, TAR: total arch replacement, HAR: hemiarch replacement DHCA: deep hypothermic circulatory arrest, SCP: selective cerebral perfusion

9. Tenri Hospital Dept. Cardiovascular Surgery Surgical Results Case No.2, 3 and 5 were induced postoperative moderate hypothermia for 72 hours. Overall mortality 12.5% (1/8)

10. Tenri Hospital Dept. Cardiovascular Surgery Case No.3 77 year female Presented with loss of consciousness by AAAD Preoperative status: Shock(-), Tamponade （ - ） GCS score: 4, left hemiplegia Procedure: hemiarch replacement Interval from onset to Operation: 150 min Postoperative Hypothermia (34.5 ℃ ) for 72 hours Recovery of Consciousness Duration of respirator 94hours POD 21 Discharge with left hemiparesis Preoperative brain CT Postoperative brain CT LDA

11. Tenri Hospital Dept. Cardiovascular Surgery Summery of GCS score survivor death duration GCS onset pre-opepost-ope 5 10 15 discharge Coma

12. Summery Results of immediate surgical repair for AAAD complicated by cerebral malperfusion were satisfactory. For comatose patients, intervals from onset to operation <3 hours c/w good neurological outcome. Postoperative hypothermia may contribute to brain protection.