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Prolonged postoperative respiratory support after proximal thoracic aortic surgery: Is deep hypothermic circulatory arrest a risk factor?

ABSTRACT: In addition to the pulmonary risks associated with cardiopulmonary bypass, thoracic aortic surgery using deep hypothermic circulatory arrest (DHCA) may subject the lungs to further injury. However, this topic has received little investigation to date.A prospective cohort review was performed on all patients undergoing proximal thoracic aortic surgery with (n = 478) and without (n = 135) DHCA between July 2005 and February 2013 at a single institution. The primary outcome was prolonged postoperative respiratory support (PPRS), defined as any of the following: >1 day of mechanical ventilation at either fraction of inspired oxygen >0.4 and/or positive end-expiratory pressure >5 mm Hg, >2 days of supplemental O2 requirement of at least 2.5 L/min, or discharge with new O2 requirement. Independent risk factors for PPRS were identified using multivariable logistic regression.Postoperative respiratory support was required in 100 patients (20.9%) with and 30 patients (22.2%) without DHCA (P = .74). Independent predictors of PPRS after proximal aortic surgery included the following: age, diabetes, history of stroke, preoperative creatinine, American Society of Anesthesiologists class 4, redo-sternotomy, total arch replacement, and transfusion requirement. Use of DHCA was not an independent risk factor for PPRS in the entire cohort. Subanalysis of only DHCA patients revealed that longer DHCA times were independently associated with PPRS.Prolonged postoperative respiratory support is common after proximal aortic surgery. The use of DHCA was not associated with this complication in the overall cohort, although longer DHCA times were predictive when only the subset of patients undergoing DHCA was analyzed. Knowledge of the risk factors for PPRS after proximal aortic surgery should improve preoperative risk stratification and postoperative management of these patients.

SUBMITTER: Schechter MA

PROVIDER: S-EPMC5142518 | biostudies-literature | 2016 Feb

REPOSITORIES: biostudies-literature

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Prolonged postoperative respiratory support after proximal thoracic aortic surgery: Is deep hypothermic circulatory arrest a risk factor?

Schechter Matthew A MA Shah Asad A AA Englum Brian R BR Williams Judson B JB Ganapathi Asvin M AM Davies John D JD Welsby Ian J IJ Hughes G Chad GC

Journal of critical care 20151106 1

<h4>Purpose</h4>In addition to the pulmonary risks associated with cardiopulmonary bypass, thoracic aortic surgery using deep hypothermic circulatory arrest (DHCA) may subject the lungs to further injury. However, this topic has received little investigation to date.<h4>Materials and methods</h4>A prospective cohort review was performed on all patients undergoing proximal thoracic aortic surgery with (n = 478) and without (n = 135) DHCA between July 2005 and February 2013 at a single institution ...[more]

PMID: 26700606

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Project description:Resolution agonists, including lipid mediators and peptides such as annexin A1 (ANXA1), are providing novel approaches to treat inflammatory conditions. Surgical trauma exerts a significant burden on the immune system that can affect and impair multiple organs. Perioperative cerebral injury after cardiac surgery is associated with significant adverse neurological outcomes such as delirium and postoperative cognitive dysfunction. Using a clinically relevant rat model of cardiopulmonary bypass (CPB) with deep hypothermic circulatory arrest (DHCA), we tested the pro-resolving effects of a novel bioactive ANXA1 tripeptide (ANXA1sp) on neuroinflammation and cognition. Male rats underwent 2 h CPB with 1 h DHCA at 18°C, and received vehicle or ANXA1sp followed by timed reperfusion up to postoperative day 7. Immortalized murine microglial cell line BV2 were treated with vehicle or ANXA1sp and subjected to 2 h oxygen-glucose deprivation followed by timed reoxygenation. Microglial activation, cell death, neuroinflammation, and NF-κB activation were assessed in tissue samples and cell cultures. Rats exposed to CPB and DHCA had evident neuroinflammation in various brain areas. However, in ANXA1sp-treated rats, microglial activation and cell death (apoptosis and necrosis) were reduced at 24 h and 7 days after surgery. This was associated with a reduction in key pro-inflammatory cytokines due to inhibition of NF-κB activation in the brain and systemically. Treated rats also had improved neurologic scores and shorter latency in the Morris water maze. In BV2 cells treated with ANXA1sp, similar protective effects were observed including decreased pro-inflammatory cytokines and cell death. Notably, we also found increased expression of ANXA1, which binds to NF-κB p65 and thereby inhibits its transcriptional activity. Our findings provide evidence that treatment with a novel pro-resolving ANXA1 tripeptide is neuroprotective after cardiac surgery in rats by attenuating neuroinflammation and may prevent postoperative neurologic complications.

Project description:BACKGROUND:Various studies evaluated the relationship between hypothermic circulatory arrest and neurological outcome in patients undergoing replacement of ascending aorta. The current analysis focuses on the effect of moderate hypothermic circulatory arrest (MHCA) on elderly patients. The aim of our study was to evaluate the impact of MHCA on neurological outcomes in elderly patients undergoing replacement of the ascending aorta. RESULTS:We retrospectively analyzed 905 consecutive patients, who underwent elective replacement of ascending aorta in MHCA (24?±?2?°C, nasopharyngeal) between 2001 and 2015. Patients with acute aortic dissection were excluded from this study. Patients were divided into two groups: those aged 75?years and older (elderly group 22.4%, n?=?203) and those younger than 75?years (younger group 77.6%, n?=?702). The average age was 63.2?±?10.2 in the young group vs. 78.7?±?3.0?years in elderly group (p?<?0.001). The elderly group had a significantly higher EuroSCORE II [26.7% (18.1, 36.3) vs. 11.6% (7.4, 19.9); p?<?0.001)]. The incidence of coronary heart disease (49.8% vs. 35.6%, p?<?0.001) and chronic renal failure (17.2% vs. 9.1%, p?=?0.001) was significantly higher in the elderly group. Intraoperatively, the time of MHCA [14?min (12, 17) vs. 15?min (12, 18); p?=?0.42], cardiopulmonary bypass [139?min (110, 183) vs. 144?min (113, 189); p?=?0.225], and cross-clamping [91?min (63, 116) vs. 92?min (65, 127); p?=?0.348] was similar in both groups. Postoperatively, a higher incidence of delirium was significantly reported in the elderly group (24.1% vs. 9.0%, p?<?0.001). However, there was no significant difference regarding neurological complications between both groups. A 30-day mortality was acceptable for the elderly group, but significantly higher compared with the younger group (7.1% vs. 3.5%, p?=?0.031). CONCLUSIONS:Our study suggests that surgical replacement of the ascending aorta in MHCA can also be applied safely in elderly patients without increasing the risk of severe neurological complications.

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Prolonged postoperative respiratory support after proximal thoracic aortic surgery: Is deep hypothermic circulatory arrest a risk factor?

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Prolonged postoperative respiratory support after proximal thoracic aortic surgery: Is deep hypothermic circulatory arrest a risk factor?

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