Deep Hypothermia, Circulatory

Arrest, and Brain Protection

Kelly Christy
 History
• 1940 -1950s: Bigelow
– Animal experimental : at 30OC 3 to 10 min safe period to cerebral ischemia,
– below 20°C may extend to 15-24min
• 1951: Dennis et al.
– 2 ASD patient: 1st patient partial AVSD, 2nd patient massive air embolism
• 1952: F. John Lewis and Mansur Taufic
– atrial septal defect repair: 5 minutes of total circulatory arrest at 28°C
• 1953 : John Gibbon
– Pump oxygenator: ASD secundum (succesful case)
•  both cool and warm patients while maintaining organ perfusion.
• 1958: Sealy, et al
– Hypothermia + CPB for intracardiac repair
• 1963: Christiaan Barnard and Velva Schrire
– the first to use DHCA to repair an aortic aneurysm, cooling the patient to 10°C
• 1975 : Griepp
– demonstrated the technique offered a practical and safe approach for aortic
arch surgery.

Rimmer L, Matthew Fok, Et al. The History of Deep Hypothermic Circulatory Arrest in Thoracic Aortic Surgery. Aorta. 2014; 2: 129 –134
 Degree of Hypothermia

Yan TD, Bannon PG, Bavaria J, et al. Consensus on hypothermia in aortic arch surgery. Ann Cardiothorac Surg 2013;2(2):163-168
 Indication for DHCA
• Severe aortic atherosclerosis or calcification (porcelain aorta for
aortic valve replacement)
• Avoidance of aortic wall damage and improved distal
anastomosis (type A dissection)
• Clamp placement too close to a planned suture line – ascending
aortic of hemiarch repairs, arch repair, proximal descending
thoracic aneurysms
• Complex descending thoracic aortic surgery to improve
anastomotic exposure while providing neuroprotection for the
brain and/or spinal cord
• Resection of IVC tumors
• Pulmonary thromboendartectomy
• Complex congenital surgery
• Non cardiac (cerebral aneurysms, AV malformations, Renal cell
carcinoma with caval invasion, other tumour with caval invasion
Bojar, Robert M. Manual of Perioperative care in Adult Cardiac Surgery. John Wiley & Sons, 2011
Conolly S, Arrowsmith JE, Klein AA. Deep hypothermic circulatory arrest. Continuing Education in Anaesthesia, Critical Care & Pain j. 2010; 10: 5
 Safe period for DHCA
• Normothermia: brain injury 4 min of circulatory arrest.
• Cerebral metabolism decreases by 6–7% for every 1OC decrease in
temperature from 37OC
• Circulatory arrest is typically undertaken at 18–20OC and a range of
safe periods for DHCA
• Most patients tolerate 30 min of DHCA without significant
neurological dysfunction
• longer than 40 min  increase in the incidence of brain injury
• Above 60 min  irreversible brain injury
• Longer periods of DHCA are tolerated in neonates and infants
compared with adults. It should be borne in mind that neurological
injury may occur as a result of prolonged CPB and rewarming

Conolly S, Arrowsmith JE, Klein AA. Deep hypothermic circulatory arrest. Continuing Education in Anaesthesia, Critical Care & Pain j. 2010; 10: 5
 Possible Sites of Action

Ibarra FP, Varon J, Meza EGL. Therapeutic Hypothermia: Critical Review of the Molecular Mechanisms of Action. Front
Neurol. 2011; 2: 4.
Conolly S, Arrowsmith JE, Klein AA. Deep hypothermic circulatory arrest. Continuing Education in Anaesthesia, Critical Care & Pain j. 2010; 10: 5
Kamiya H, Hagl C, Kropivnitskaya I, et al. The safety of moderate hypothermic lower body circulatory arrest with selective cerebral perfusion: a
propensity score analysis. J Thorac Cardiovasc Surg 2007;133:501-9.
 Induction and monitoring
• AL (femoral or bilateral radial arterial), CVP,
PA line, TEE
• Temperature monitoring : nasopharynx and
bladder
• Neurological monitoring:
– monitors of cerebral substrate delivery [jugular
bulb oximetry, transcranial Doppler sonography,
and near infrared spectroscopy (NIRS)]
– monitors of cerebral function [quantitative
electroencephalography (qEEG)]
 NIRS
• Human skull is translucent to infrared light
• Regional hemoglobin oxygen saturation (rSo2) may be measured
noninvasively with transcranial near-infrared spectroscopy (NIRS)

L: Left Cerebral
R: Right Cerebral
S: Somatic
 Cerebral protection
Cooling
• Systemic cooling is achieved during CPB
• The temperature gradient between water and blood maintained at 100C
• Cerebral cooling  head-cooling blanket through which iced water is
circulated and ice packed around the head
• Uneven colling of the brain is probably a risk factor for brain damage
Rewarming
• When CPB is resumed after a period of DHCA, hypothermic perfusion
should be maintained for 10–20 min before rewarming commences 
reduce the risk of raised intracranial pressure
• When rewarming
– the gradient should be < 50C
– Excessively rapid rewarming with perfusion temperatures > 370C may induce
cerebral ischaemia
 VO2 vs temperature

Hypothermia, Circulatory Arrest, and Cardiopulmonary in BypassKirklin/Barratt-Boyes Cardiac

 Cerebral protection
Acid – base management
‘alpha-stat’ VS ‘pH-stat’

Oxygen Dissociation Curve

 Haemodilution
• haematocrit of 20%, is thought to improve flow in
the microcirculation
• Excessive haemodilution (e.g. Haematocrit 10%)
significantly reduces oxygen carrying capacity and
causes tissue ischaemia
• Recent data suggests maintaining hct in range of
25-30 provides better outcomes
– Higher hematocrits improve tissue flow and
metabolism and decrease leukocyte and endothelial
cell activation
Pharmacological neuroprotection
Cardiopulmonary bypass
 Surgical Technique
• In many centres, the duration of safe DHCA is
extended by the use of retrograde cerebral
perfusion (RCP) or selective antegrade
cerebral perfusion (SACP).
• Although both techniques increase the
complexity of surgery, they do permit a lesser
degree of systemic hypothermia to be used
(22–25C) without compromising safety.
 Retrograde cerebral perfusion
• RCP is performed by infusing cold oxygenated blood
into the superior vena cava cannula at a temperature
of 8° C to 14° C via CPB
• The internal jugular venous pressure is maintained at
less than 25 mm Hg to prevent cerebral edema
• Site proximal to the superior vena cava perfusion
cannula and zeroed at the level of the ear
• Patient is positioned in 10 degrees of Trendelenburg
– To Decrease the risk for cerebral air embolism and prevent
trapping of air
• Flow rates of 200 to 600 mL/min usually can be
achieved
Circuit in RCP
 Anterograde cerebral perfusion
• Perfusion of brain with oxygenated blood
independently of the rest of the body
• At physiological flow and pressure of 10-20
mL/kg/min and >50 mmHg
• Potential to prolong the safe time of circulatory
arrest
• Improved cerebral cooling due to heterogeneous
flow, and its potential application with moderate
instead of deep hypothermia
 Non selective cerebral perfusion
• Non-selective ACP (NSACP), or hemispheric perfusion, refers to
selective cannulation of the right axillary artery with
lefthemispheric perfusion dependent on a patent Circle of Willis
• Advantages of axillary artery cannulation include its use as an
access for conduct of CPB and the relative freedom of the axillary
artery from dissection and atherosclerotic disease, thus, decreasing
the incidence of atheroemboli.
• Potential complications of axillary artery cannulation include
insufficient flow, inadequate right upper limb perfusion,
lymphocele, and brachial plexus injury
• Perfusion of both hemispheres is compromised in cases of absent
communication at the Circle of Willis, which can be present in up to
20% of patients
Circle of Willis
Non selective anterograde perfusion
 Selective anterograde cerebral
perfusion
• Canulation of carotid artery and the
innominate artery, either directly or through a
tube graft.
• The drawbacks of this approach include the
needed dissection of these key vessels
• May lead to vessel injury or embolization and
the inconvenience of added cannulae in the
operative field
Circuit for selective cerebral perfusion
Terima Kasih