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Metabolic relevance during isolation technique in total arch repair for patients at high risk with embolic stroke

Department of Cardiovascular Surgery, Hokkaido University Hospital, Sapporo, Japan

*Corresponding author. Department of Thoracic and Cardiovascular Surgery, University Hospital of Saarland, 66421 Homburg, Germany. Tel.: +49-6841-1632000; fax: +49-6841-1632005.

E-mail address: chtkun{at}uniklinikum-saarland.de (T. Kunihara).

In patients undergoing total arch replacement with protruding or mobile atheroma in the proximal aorta, we isolate cerebral circulation from systemic one by starting selective cerebral perfusion (SCP) before systemic arterial perfusion to prevent aortogenic embolic stroke. We disclose the safety of this isolation technique by measuring cerebral oxygenation and metabolism. Sixty-six patients underwent total arch replacement using SCP since 1998. The isolation technique was applied in sixteen patients. Jugular venous oxygen saturation (SjO₂) was monitored in nine patients undergoing isolation technique (isolation-group) and in thirteen patients of the rest (conventional-group). Oxygen, glucose, and lactate extraction ratio (OER, GER, and LER) were measured at seven time points peri-operatively. The isolation-group had significantly longer SCP time (isolation: 185±52 min vs. conventional: 140±43 min, P<0.01). During cooling, SjO₂ was kept comparable between groups. OER was minimum at the end of cooling and comparable between groups (isolation: 3.8±7.7% vs. conventional: 11.7±13.8%, P=0.37). There were no significant differences in GER and LER between groups. There were neither in-hospital death nor stroke. Temporary neurological dysfunction was observed only in conventional-group (n=3, 23%, P=0.12). Isolation technique for total arch replacement could be performed safely and may provide acceptable results in patients at high risk for embolic stroke.

Key Words: Total arch replacement; Isolation technique; Jugular venous oxygen saturation; Oxygen extraction ratio; Mobile atheroma; Embolic stroke