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The Journal of Thoracic and Cardiovascular Surgery, Vol 102, 85-93, Copyright © 1991 by The American Association for Thoracic Surgery and The Western Thoracic Surgical Association
J Bachet, D Guilmet, B Goudot, JL Termignon, G Teodori, G Dreyfus, D Brodaty, C Dubois and P Delentdecker
Profound hypothermia associated with circulatory arrest is the commonest
method of cerebral protection during operations on the aortic arch. This
technique allows a limited time to perform the aortic repair, however. It
also necessitates prolonged cardiopulmonary bypass to rewarm the patient.
This may be the cause of coagulation disorders or infection. Selective
perfusion of the carotid arteries can also be used. When the perfusion is
derived from the main arterial line, however, the repair of the aorta
requires that the vessel be crossclamped, and cannot be performed in an
"open, bloodless" manner. To avoid the disadvantages of both techniques, we
have developed a new technique of cerebral protection. After a regular
cardiopulmonary bypass has been established, the carotid arteries are
cannulated and perfused with blood cooled at 6 degrees to 12 degrees C,
through a separate heat exchanger, while the core temperature is maintained
at moderate hypothermia (25 degrees to 28 degrees C, rectal). To perform
the "open" distal repair, the cardiopulmonary bypass is discontinued while
the carotid perfusion is maintained (250 to 350 ml/min). When the distal
repair is completed, cardiopulmonary bypass is resumed and the carotid
perfusion is discontinued. Between 1984 and June 1989, 54 patients (mean
age 55 years) were operated on with this method (45 elective operations, 9
emergency procedures). Mean duration of cardiopulmonary bypass was 121
minutes (65 to 248), and mean duration of circulatory arrest was 22 minutes
(10 to 51). The electroencephalogram, routinely recorded, showed return of
the cerebral activity after a mean time of 12 minutes and normal activity
after a mean time of 66 minutes. There was no intraoperative death.
Hospital mortality rate was 13% (7/54). One death was related to neurologic
disorders. All patients but one awakened normally within 8 hours after
operation. Two patients (4.3%) experienced a transient neurologic episode
(lateral hemianopia) 9 and 11 days postoperatively. There was no
hemorrhagic complication (24-hour average blood loss: 840 +/- 540 ml). In
our experience the technique of "cold cerebroplegia" has been demonstrated
to provide excellent cerebral protection. It requires no prolonged
cardiopulmonary bypass and does not limit the time necessary to perform the
aortic repair. It may be considered as a safe alternative to profound
hypothermia associated with circulatory arrest.
ARTICLES
Cold cerebroplegia. A new technique of cerebral protection during operations on the transverse aortic arch
Service de Chirurgie Cardio-Vasculaire, Hopital Foch. Universite, Suresnes, France.
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