HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Richard A. Jonas Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Jonas, R. A. Search for Related Content PubMed PubMed Citation Articles by Jonas, R. A.

J Thorac Cardiovasc Surg 1999;117:196
© 1999 Mosby, Inc.

LETTERS TO THE EDITOR

Deep hypothermic circulatory arrest and retrograde cerebral perfusion

I was disturbed when I read the article by Okita and associates concerning deep hypothermic circulatory arrest (DHCA) and retrograde cerebral perfusion (RCP) in patients undergoing operations on the aortic arch in the January 1998 issue of the Journal (1998;115:129-38). I have several major concerns about the paper. The most important concern relates to the fact that the authors are describing a relatively new technique of cerebral protection, namely RCP, and yet they have failed to include among their investigators or authors any neurologists or psychologists. There is no statement in the methods section of the paper regarding complete neurologic examination of their patients and whether this was performed before and after the operations. My own experience would suggest that a simple retrospective chart review relying on observations by surgical residents is inadequate to detect subtle focal neurologic deficits. For example, how many of these patients had careful assessment of their visual fields? How many patients had their postoperative fine motor skills compared with their preoperative fine motor skills? In fact, even a neurologic examination will not detect many of the cognitive deficits that can only be identified by careful psychometric testing. In the absence of such testing, it is unjustified for the authors to make the statement: "We empirically consider that a DHCA + RCP period of up to 80 minutes under a nasopharyngeal temperature of 18°C is safe." This statement is all the more questionable after viewing Figs. 1, which demonstrates that patients who underwent a combined DHCA + RCP time of 70 to 80 minutes had an incidence of death or delirium that was greater that 50%. The authors state: "Postoperative transient delirium has been defined as a transient minor neurologic deficit such as disorientation and character change with no neurologic sequelae." This statement bears resemblance to the previously often heard statement within pediatric cardiac surgery that seizures in the early postoperative period in infants are of no long-term significance. Our prospective randomized trial of DHCA ¹ has demonstrated that perioperative seizures do indeed have an association with subsequent impairment, as assessed by our developmental psychologists using comprehensive testing at age 1 year and 4 years with ongoing studies of this same cohort at age 8 years.

Until clinical studies have been undertaken with careful preoperative and postoperative neurologic examination by neurologists, as well as psychometric testing, I believe that surgeons should be cautious in using RCP as a means of extending DHCA. If it is possible to extrapolate from the pediatric experience with DHCA, periods of DHCA greater that 30 to 45 minutes in length at a tympanic membrane temperature of 15°C should be used with great caution.

Richard A. Jonas, MD
Cardiovascular Surgeon-in-Chief
Children's Hospital
William E Ladd Professor of Surgery
Harvard Medical School
Boston, MA 02115

12/8/93653

References

1. Bellinger DC, Jonas RA, Rappaport LA, Wypij D, Wernovsky G, Kuban KCK, et al. Developmental and neurologic status of children after heart surgery with hypothermic circulatory arrest or low-flow cardiopulmonary bypass. N Engl J Med 1995;332:549-55.[Abstract/Free Full Text]
   

This article has been cited by other articles:

				B. Ji, L. Sun, J. Liu, M. Liu, G. Sun, G. Wang, Z. Liu, Z. Feng, and C. Long The application of a modified technique of SCP under DHCA during total aortic arch replacement combined with stented elephant trunk implantation Perfusion, September 1, 2006; 21(5): 255 - 258. [Abstract] [PDF]

This Article Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Richard A. Jonas Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Jonas, R. A. Search for Related Content PubMed PubMed Citation Articles by Jonas, R. A.