Aortic arch repair using hypothermic circulatory arrest technique associated with pharmacological brain protection

Objective: Hypothermic circulatory arrest is a standard procedure for the t reatment of aortic arch. However, there is a time limit for this procedure. There is now an urgent need to develop prophylactic measures to extend the time Limit. We have used a pharmacological mixture of thiopental, nicardip ine and mannitol for all patients undergoing circulatory arrest since 1991 to extend the safe limit. The purpose of this study was to analyze the neur ological complications demonstrated by these patients and to evaluate the b rain-protective effects of our measure. Methods: The clinical records of 75 consecutive patients undergoing an aortic arch repair using a hypothermic circulatory arrest technique during thr past 8 years were retrospectively r eviewed. Systemic cooling was continued until a total disappearance of EEG activity. Prior to circulatory arrest, 15 or 30 mg/kg of thiopental, 20 mg of nicardipine and 300 mi of mannitol were infused into the venous reservoi r of a cardiopulmonary bypass circuit. Graft replacement was performed in a ll patients and the extent of replacement was a total aortic arch in 43 pat ients, a distal aortic arch in 17, a hemiarch in 13 and a distal aortic arc h and a total descending aorta in two. Results: The duration of circulatory arrest ranged from 16 to 80 min (mean 41.5 min), and it exceeded 45 min in 37 patients. Operative mortality was 10.7% and two patients died of stroke . Three patients had permanent and three other patients had transient neura l deficits. The incidence of stroke was 8.0% as a whole, and no correlation between the incidence of neurological complications and the duration of ci rculatory arrest was found. A multivariate analysis showed that the duratio n of circulatory arrest was determined as a predictor of neither operative mortality nor postoperative stroke. Conclusions: The findings of the presen t study suggest that our pharmacological brain protection appears to be eff ective for safely extending hypothermic circulatory arrest. (C) 2000 Elsevi er Science B.V. All rights reserved.