Prolonged circulatory arrest in moderate hypothermia with retrograde cerebral perfusion: Is brain ischemic?

Background: Circulatory arrest (CA), which provides a bloodless field and good visualization without the need of aortic cross-clamp, is commonly used to facilitate repair of aortic lesions. However, extended periods of CA may impair cerebral metabolism and cause ischemic injury. Studies were performed to evaluate the efficacy of retrograde cerebral perfusion (RCP) in protecting the brain from ischemic injury during a prolonged period of CA in moderate hypothermia. Methods and Results: Twenty three patients (18 men and 5 women) were operated on for aortic lesions (17 acute type A aortic dissection and 6 chronic type A aortic dissection with Marfan's syndrome). The aortic operations were performed with CA (58 to 104 minutes; mean±SD, 75±12 minutes) at a rectal temperature of 23.3±0.5°C (21°C to 25°C). For RCP, cold (14°C to 18°C) oxygenated blood (300 mL/min) was pumped to the superior vena cava with internal jugular venous pressure of 15±5 mm Hg. The cardiopulmonary bypass time was 157±18 minutes. Cortical blood flow during RCP detected by subdural laser Doppler probe was 10±5% of baseline. Percent oxygen extraction and pyruvate and lactate levels (26±2% and 0.43±0.17 and 45±16 mg/dL) were insignificantly different from those before CA (28±3% and 0.71±0.08 and 62±20 mg/dL, P>.05). Creatine kinase-BB isoenzyme was undetectable. All but 1 patient survived the operation (95.5%) and woke up without neurological deficit. Follow-up (mean, 13 months) was complete in all survivors. There were no late deaths. Cerebral functional studies performed 3 months after discharge showed results insignificantly different from those of the normal control subjects. Conclusions: There is no evidence of ischemia of the brain during prolonged moderate hypothermic CA with the aid of RCP. Retrograde cerebral perfusion effectively extends the safe time of CA. Deep hypothermia during CA seems unnecessary.