Analysis of the neuronal damage severity and cognitive status in patients after operations on the aortic arch

Aim. To assess the neuronal damage severity and cognitive status in conditions of unilateral antegrade cerebral perfusion through the brachiocephalic trunk during surgical reconstruction of the thoracic aorta.

Material and methods. The study included 144 patients with aneurysm and dissection of the thoracic aorta. Patients underwent reconstructive surgery under cardiopulmonary bypass, unilateral antegrade cerebral perfusion and circulatory arrest. Before and after the intervention, a cognitive status analysis was performed using the Montreal Cognitive Assessment (MoCA), Amatinu test and Schulte tables. The dynamics of neuron-specific enolase (NSE), a marker of neuronal damage, was determined perioperatively.

Results. The duration of cardiopulmonary bypass was 155 [115; 201] min, cardioplegic arrest — 100 [72; 150] min, unilateral perfusion — 20 [15; 51] min,circulatory arrest — 20 [15; 30]min.Hospital mortality was 7% (10 cases). Neurological complications were noted in 12 (8%) cases. All patients in the postoperative period (within 24 hours) showed an increase in NSE compared with baseline values (3,3 μg/L and 2,07 μg/L, respectively, p=0,0003), but not exceeding the upper limit of normal (9,9 μg/l). According to the results of psychometric tests, which were carried out upon admission to the hospital and 2 weeks after the operation, there were no negative changes (MoCA test: 24 [21; 26] points — 26 [24; 27] points, p=0,00001; Schulte tables: 288 [240; 368] s — 278 [241; 328] s, p=0,01; Amatuni sample 264 [216; 297] s — 254 [221; 280] s, p=0,57).

Conclusion. Based on the analysis of the perioperative dynamics of neuronspecific enolase and cognitive tests, unilateral cerebral perfusion through the brachiocephalic trunk is effective and relatively safe. This method of perfusion protection of the brain helps to minimize postoperative neurological complications during operations on the thoracic aorta.

1. Griepp RB, Luozzo G. Hypothermia for aortic surgery. J Thorac Cardiovasc Surg. 2013;145(3):56-8. doi:10.1016/j.jtcvs.2012.11.072.

2. Misfeld M, Mohr F, Etz C. Best strategy for cerebral protection in arch surgery — antegrade selective cerebral perfusion and adequate hypothermia. J. Ann Cardiothorac Surg 2013;2(3):331-8. doi:10.3978/j.issn.2225-319X.2013.02.05.

3. Kozlov BN, Panfilov DS, Ponomarenko IV, et al. The new technique of unilateral antegrade cerebral perfusion during aortic arch surgery. Russian Journal of Cardiology and Cardiovascular Surgery. 2015;8(1):30-4. (In Russ.) doi:10.17116/kardio20158130-34.

4. Kornilov IA, Sinelnikov YuS, Soynov IA, et al. Risk assessment of renal and neurological complications in newborn after aortic reconstruction. Patologiya krovoobrashcheniya i kardiokhirurgiya. 2015;19(1):84-9. (In Russ.) doi:10.21688/1681-3472-2015-1-84-89.

5. Tian DH, Wan B, Bannon PG et al. A meta-analysis of deep hypothermic circulatory arrest versus moderate hypothermic circulatory arrest with selective antegrade cerebral perfusion. J. Ann Cardiothorac Surg. 2013;2(2):148-58. doi:10.3978/j.issn.2225-319X.2013.03.13.

6. Numata S, Tsutsumi Y, Monta O, et al. Acute type A aortic dissection repair with mildtomoderate hypothermic circulatory arrest and selective cerebral perfusion. The Journal of cardiovascular surgery. 2015;56(4):525-30.

7. Okita Y, Miyata H, Motomura N, Takamoto S. A study of brain protection during total arch replacement comparing antegrade cerebral perfusion versus hypothermic circulatory arrest, with or without retrograde cerebral perfusion: Analysis based on the Japan Adult Cardiovascular Surgery Database. J. Thorac. Cardiovasc. Surg. 2015;149(2):65-73. doi:10.1016/j.jtcvs.2014.08.070.

8. Malvindi PG, Scrascia G, Vitale N. Is unilateral antegrade cerebral perfusion equivalent to bilateral cerebral perfusion for patients undergoing aortic arch surgery? Interact Cardiovasc Thorac Surg. 2008;7(5):891-7. doi:10.1510/icvts.2008.184184.

9. Misfeld M, Mohr F, Etz C. Best strategy for cerebral protection in arch surgery — antegrade selective cerebral perfusion and adequate hypothermia. Ann Cardiothorac Surg. 2013;2(3):331-8. doi:10.3978/j.issn.2225-319X.2013.02.05.

10. Angeloni E, Benedetto U, Takkenberg JJ, et al. Unilateral versus bilateral antegrade cerebral protection during circulatory arrest in aortic surgery: a meta-analysis of 5100 patients. J Thorac Cardiovasc Surg. 2014;147(1):60-7. doi:10.1016/j.jtcvs.2012.10.029.

11. Ozatik MA, Kocabeyoglu S, Kücüker SA, et al. Neurochemical markers during selective cerebral perfusion via the right brachial artery. Interact. Cardiovasc. Thorac. Surg. 2010;10(6):948-52. doi:10.1510/icvts.2009.228858.

12. Bakhtiary F, Dogan S, Zierer A, et al. Antegrade cerebral perfusion for acute type A aortic dissection in 120 consecutive patients. Ann. Thorac. Surg. 2008;85(2):465-9. doi:10.1016/j.athoracsur.2007.10.017.

13. Belov YuV, Charchyan ER, Akselrod BA, et al. Cerebral and visceral organ protection during aortic arch surgery. Intraoperative tactics and monitoring details. Patologiya krovoobrashcheniya i kardiokhirurgiya. 2016;20(4):34-44. (In Russ.) doi:10.21688-1681-3472-20164-34-44.

14. Di Eusanio M, Schepens MA, Morshuis WJ, et al. Antegrade selective cerebral perfusion during operations on the thoracic aorta: factors influencing survival and neurologic outcome in 413 patients. J. Thorac. Cardiovasc. Surg. 2002;124:1080-6.

15. Bockeria LA, Garmanov SV. Surgical treatment of aneurysms of the ascending aorta and aortic arch with the use of selective antegrade cerebral perfusion. Annaly Khirurgii.2013;3:23-30. (In Russ.) Бокерия Л. А., Гарманов С. В. Хирургическое лечение аневризм восходящего отдела и дуги аорты в условиях селективной антеградной перфузии головного мозга. Анналы хирургии. 2013;3:23-30.

16. Shi-Min Yuan. Biomarkers of cerebral injury in cardiac surgery. Anatol J Cardiol. 2014;14(7):638-45. doi:10.5152/akd.2014.5321.

17. Schaefer ST, Koenigsperger S, Olotu C, Saller T. Biomarkers and postoperative cognitive function: could it be that easy? Curr Opin Anaesthesiol. 2019;32(1):92-100. doi:10.1097/ACO.0000000000000676.

18. Sosnovsky EA, Puras JV, Talypov AE. Biochemical markers of head injury. Russian journal of neurosurgery. 2014;(2):83-91. (In Russ.) doi:10.17650/1683-3295-2014-0-2-83-91.

19. Newman MF, Grocott HP, Mathew JP, et al. Report of the substudy assessing the impact of neurocognitive function on quality of life 5 years after cardiac surgery. Stroke. 2001;32(12):2874-81. doi:10.1161/hs1201.099803.

20. Bokeriia LA, Golukhova EZ, Polunina AG, et al. Cognitive functions after on-pump operations at early and delayed postoperative follow-ups. Kreativnaya kardiologiya. 2011;(2):71-88. (In Russ.)

21. Shnayder NA, Shprakh VV, Salmina AB. Post-operative cognitive dysfunction. Krasnoyarsk: KrasGMA, 2005 p. 96. (In Russ.)

22. Rasmussen LS, Larsen K, Houx P, et al. The assessment of postoperative cognitive function. Acta Anaesth. Scand. 2001;45(3):275-89. doi:10.1034/j.1399-6576.2001.045003275.x.

23. Novitskaya-Usenko LV. Post-operative cognitive dysfunction in an anesthesiologist’s practice. Meditsina neotlozhnykh sostoyaniy. 2017;4(83):9-15. (In Russ.) doi:10.22141/2224-0586.4.83.2017.107418.