Case presentation Cerebral infarction after surgery for acute type I aortic dissection R1 王佳茹.
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Transcript of Case presentation Cerebral infarction after surgery for acute type I aortic dissection R1 王佳茹.
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Case presentation
Cerebral infarction after surgery for acute type I aortic dissection
R1 王佳茹
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Patient data
Chart number: 4304428Age/Sex: 49 y/o, MaleDate of admission: Sep. 3, 2003Date of operation: Sep. 3, 2003
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Brief history
Chronic hypertension for more than 10 years without regular medical control
Sudden-onset chest pain with radiation to back on the morning of Sep. 3, 2003
He went to ER of En-Chu-Kong H. where CXR was arranged and revealed cardiomegaly and widened mediastinum.
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Echocardiography
linear echoes in the ascending aorta are suggestive of dissection of the ascending aorta.
Intimal flap visualized in the ascending and descending aorta.
There is no pericardial effusionLVEF = 78%
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Computed tomography
Ascending aorta, aoric arch and descending aorta are involved.
There is no pericardial effusionAortic valves and orifices of coronary
arteries are intact.Abdominal aorta above the level of renal
arteries is involved.
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Brief history
Under the impression of acute type 1 aortic dissection, he was transferred to our hospital for surgical intervention.
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Physical examination
Vital sign: HR 70/min, RR 20/min, BP 197/103 mmHg, BT 37C,
Conscious clear, E4V5M6Acute ill-looking, Regular heart beat without murmurSymmetric and intact peripheral pulseDifference of BP measured on both arms is
prominent.
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At OR
BW: 100kg, Hb : 14ASA classification : IIIeSet up monitorsArterial cannulation on both wrists Induction with fentanyl 250ug, Rapifen
1000ug and pentothal 500mg Muscle relaxant with Esmeron 100mg
initially, and changed to Pavulon thereafterOn Endo and CVP
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Maintenance
Gas: isoflurane, initially
desflurane, during CPBO2 combined with air, without N2O BP control with Perdipine and Millisrol
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TEE
DAA, type I, intima tear at aortic arch near brachiocephalic trunk
Mod-severe AR due to paradoxical movement of intimal flap
Brachiocephalic trunk involvement is equivocal. The possibility is very high according to hemodynamic profile. ( R’t arm 86/65 mmHg while L’t arm 130/70 mmHg)
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Median sternotomy is performed, the patient is placed on CPB.
Cannulation of Right axillary artery, SVC and IVC
Prime with albumin, lactate Ringer’s, solumedrol, 20% Mannitol and Sod. Bicarbonate
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After systemic hypothermia to 15°C, Pentothal was given and circulatory arrest was started.
The head is covered with ice bags
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OP finding
Good LV contractilityNo pericardial effusionAsAo dissection: intimal tear at lesser
curvature side of aortic archAsAo about 5cm in diameter with eccymosisPre-op AR: moderate,
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During circulatory arrest
Retrograde cerebral perfusion via SVC was failed
Intermittent antegrade cerebral perfusion via right axillary cannula, with a balloon occluder placed in brachiocephalic artery, was performed during distal aortic anastomosis with an open technique.
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During circulatory arrest
Ascending aortic grafting with 30 mm hemashield vascular graft was performed.
After distal anastomosis was completed, the vascular graft was clamped; systemic perfusion was restarted, and rewarming was done.
Aortic valve suspension and proximal anastomosis were done during rewarming.
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At OR
The patient was weaned from CPB successfully, and he was send to SICU for post-op care.
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Duration
Partial bypass time: 5 hrs and 39 minsTotal bypass time: 5 hrs and 18 minsAorta X-clamp time: 2 hrs and 46 minsCirculatory arrest time: 1 hr and 10 mins
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Post-op condition
Focal seizure and generalized seizure
Glasgow Coma Scale: E1VtM4
CT of head revealed decreased density with loss of gray-white matter differentiation at Right fronto-temporal lobe, and Right side MCA infarction with brain edema was impressed.
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Post-op condition
Fever Acute renal failure, r/o nephrotoxicity of
aminoglycoside related.
-> CVVHDICExpire on 9/30
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Discussion
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Classification of aortic dissection
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Surgery on the ascending aorta
median sternotomy and CPBconcomitant aortic valve replacement and
coronary reimplantation ( Bentall precedure)
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Surgery involving the aortic arch
median sternotomy and CPB with deep hypothermic circulatory arrest (DHCA)
Achieve optimal cerebral protection with systemic and topical hypothermia.
Hypothermia to 15°C, thiopental infusion to maintain a flat EEG, methylprednisolone or dexamethasone, mannitol, and phenytoin are also commonly used.
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Surgery involving the descending thoracic aorta
Left thoracotomy without CPBOne-lung anesthesia greatly facilitates
surgical exposure and reduces pulmonary trauma from retractors.
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Brain protection
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Brain protection
The major complications associated with ascending/arch repair are stroke and encephalopathy.
The incidence of postoperative stroke ranged from 7-15% after thoracic aortic surgery with DHCA, and most of them are embolic in origin.
The major risk factors are circulatory arrest time and whether the transverse arch is involved.
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Brain protection
Goals are to optimize CPP, decrease metabolic requirements, and possibly block mediators of cellular injury.
The most effective strategy is prevention.
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Surgical consideration
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Deep Hypothermic Circulatory Arrest (DHCA)
Permitting a field free of blood and cannulas, allowing thorough inspection of the aneurysm and a careful open distal anastomosis
Reducing the metabolic rate for oxygen, promoting preferential organ perfusion, and increasing tissue oxygen extraction
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Deep Hypothermic Circulatory Arrest (DHCA)
Cooling to 10-13°C in esophagousO2 sat. in the jugular venous bulb > 95%,
indicating maximal metabolic suppression.Cooling > 30mins to prevent a gradual
upright temp. and the intracranial temp. should be protected by packing the head in ice.
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Deep Hypothermic Circulatory Arrest (DHCA)
Gradual rewarming and avoidance of high perfusion temp. are essential.
A duration of DHCA exceeding 25 mins has been shown to produce temporary neurologic dysfunction.
from J. Toracic cardiovascular surgery March,2003
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Deep Hypothermic Circulatory Arrest (DHCA)
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Deep Hypothermic Circulatory Arrest (DHCA)
DHCA was demonstrated to have longer electroencephalographic recovery times and a higher incidence of clinical seizures in the early postoperative period.
from Miller
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During deep Hypothermic Circulatory Arrest (DHCA)
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Retrograde cerebral perfusion
Oxygenated blood is perfused in a retrograde direction through the superior vena cava and the internal jugular veins and to the brain.
providing continued cerebral cooling, delivering nutrition to the brain and flushing out cerebral emboli
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Retrograde cerebral perfusion
Too little capillary flow occurs during RCP (even with occlusion IVC) to confer any meaningful metabolic benefit even during deep hypothermia.
Long durations of RCP are associated with high rates of temporary neurologic dysfunction and an increased risk of stroke and death after aortic surgery.
from J. Toracic cardiovascular surgery March,2003
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Antegrade cerebral perfusion
Total arch replacement using antegrade selective cerebral perfusion with right axillary artery perfusion is a safe and useful alternative for brain protection in total arch
replacement.
Eur J Cardiothorac Surg 2003;23:771-775
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Antegrade cerebral perfusion
It allows a much longer interval of safe circulatory arrest, since the supply of nutrients and oxygen allows maintenance of appropriate level of oxygen metabolism at hypothermic temporature.
Ann Thorac Surg 2002;73:1837-1842
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Antegrade cerebral perfusion
If the total time necessary for aortic arch repair requiring arrest is moderately long, between 40 and 80 mins, the incidence of temporary neurologic dysfunction is clearly lower with ACP than any other alternative.
from J. Toracic cardiovascular surgery March,2003
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Anesthetic considerations
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Monitor
arterial cannula thermodilution PAC TEE EEG transcranial Doppler
transcranial oximetry
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Anesthetic considerations
Prophylactic thiopental infusion ( completely suppressing electroencephalographic activity)
Prior to DHCA, corticosteroid (methylprednisolone 30mg/kg), mannitol (0.5 g/kg), and phenytoin (10-15mg/kg) are also usually administered.
The head is covered with ice bags.
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Anesthetic considerations
Nitrous oxide is to be avoided because of its expansion of air emboli
hyperglycemia should be avoidedmaintain serum glucose in the 100 to 250
mg/dL range.
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Barbiturate
reduce CMR inhibit free radical
formation reduce Ca2+ influx,, potentiate GABAergic
activity, enhance cyclic AMP
production, delay the loss of inotropic
glutamate receptor-mediated transmembrane electrical gradients
reduce glucose transport into cells,
block Na+ channels, reduce glutamate,
aspartate, lactate, and
catecholamines
ANESTHESIOLOGY
1998;89:289-291
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Steroid
Timing of steroid treatment is important for cerebral protection during CPB and circulatory arrest, different timing of steroid administration results in different
inflammatory mediator response. Steroid in CPB prime is not significantly
better than no steroid treatment, while systemic steroid pre-treatment significantly decreases systemic manifestation of inflammatory response and brain damage.
Eur J Cardiothorac Surg 2003;24:125-132
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Steroid
Systemic steroid pretreatment significantly reduced total body edema and cerebral vascular leak and was associated with better immunohistochemical indices of neuroprotection after DHCA.
Ann Thorac Surg 2001;72:1465-1472
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The end