1. Neurocognitive dysfunction after Arch replacement Kumamoto central hospital Department of Cardiovascular surgery Nakatsu Taro, Koshiji Takaaki, Sakakibara Yutaka, Hagio Kouji, Ishigami masanosuke Department of Anesthesia Baba Tomoko Kumamoto central hospital Department of Cardiovascular surgery Nakatsu Taro, Koshiji Takaaki, Sakakibara Yutaka, Hagio Kouji, Ishigami masanosuke Department of Anesthesia Baba Tomoko

2. Purpose There are many reports about cerebral infarction after arch replacement, but few about neurocognitive function. This study is aimed to evaluate neurocognitive outcome after arch replacement. There are many reports about cerebral infarction after arch replacement, but few about neurocognitive function. This study is aimed to evaluate neurocognitive outcome after arch replacement.

3. Patients Patients : 62 cases (elective) TAA 55, Dissection 7 Patients : 62 cases (elective) TAA 55, Dissection 7 Concomitant procedure CABG14 (2 ３ %) AVR5(8.1%) Modified Bentall2(3.2%) Concomitant procedure CABG14 (2 ３ %) AVR5(8.1%) Modified Bentall2(3.2%) Gender : Male 40, Female 22 Age: 71±8.8 y.o. (34-84)

4. Patients Characteristics History of CVD8 (13%) Carotid Artery Disease (75% ≦ ) 6 (9.7%) Neurological Dysfunction3 (4.8%) Cerebral Infarction (MRI)25 (40%)

5. Deep-hypothermic circulatory arrest ＆ Selective cerebral perfusion Pump 1 Pump 2 Perfusion pressure 30 ～ 40mmHg 250ml/min 200ml/min Occlusion Balloon or Clamp Occlusion Balloon or Clamp Perfusion Catheters (14Fr. 12Fr) CPB SCP Core cooling to rectal temperature of 20 ℃

6. Operative Results Operation time (min)478±135 CPB time (min)302±80.7 Aortic cross-clamping time (min)186±44.6 Circulatory arrest time (min) 82.3±29.2 SCP time (min) 133±35.5 Minimum rectal temperature ( ℃ ) 21±1.5 Brachiocepharic artery perfusion pressure (mmHg) 31.8±10 Left carotid artery perfusion pressure (mmHg) 41.3±8.5 Stroke3 (4.8%) Hospital death2 (3.2%)

7. Methods 4 Tests Hasegawa Dementia Scale Kana-Pick Up Test Digit span Digit symbol test 4 Tests Hasegawa Dementia Scale Kana-Pick Up Test Digit span Digit symbol test Timing Before operation ＆ 7days after operation Timing Before operation ＆ 7days after operation Definition of Neurocognitive dysfunction 1)Positive test : 20% ≦ impairment from baseline 2)At least 2 positive tests of the 4

8. Hasegawa Dementia Scale (HDS) General function Frequently performed dementia scale in JapanFrequently performed dementia scale in Japan

9. Kana-Pick Up Test Executive function 2 tasks in 2 minutes ・ Reading a short story ・ Finding specific letters Score Number of the letters 2 tasks in 2 minutes ・ Reading a short story ・ Finding specific letters Score Number of the letters

10. Digit Span Attention & Recent memory Score Forward + Backward Score Forward + Backward

11. Digit Symbol Test Attention & Psychomotor speed Score Number of the rights in 90 seconds Score Number of the rights in 90 seconds

12. Results of 4 Tests Baseline (n=53) 7days (n=53) P HDS 26.7±2.5326.9±2.660.40 Kana-Pick Up Test 19.6±10.118.6±11.60.27 Digit span 12.2±3.3111.7±2.680.18 Digit symbol test 32.4±14.128.4±14.1 ＜ 0.05 53 patients: Completely performed 4 Tests Incomplete 9 patients 6 : prolonged ventilation 2 : cerebral infarction 1 : other Incomplete 9 patients 6 : prolonged ventilation 2 : cerebral infarction 1 : other

13. Neurocognitive Dysfunction HDS Kana-Pick Up Test Digit span Digit symbol test Positive 0 (0%) 21 (40%) 9 (17%) 19 (36%) 1)Positive test : 20% ≦ impairment from baseline Neurocognitive dysfunction 16(30%) 2)At least 2 positive tests of 4 2)At least 2 positive tests of the 4

14. Preoperative Predictors of Neurocognitive Dysfunction No Dysfunction (n=37) Dysfunction(n=16)P Age71±9.772±9.00.68 Gendar (male) 22 (59%) 10 (62.5%) 0.84 History of CVD 6 (16%) 2 (13%) 0.73 Neurological dysfunction 1 (2.7%) 2 (13%) 0.16 Cerebral infarction (MRI) 17 (46%) 6 (38%) 0.57 Carotid Artery Disease 3 (8.1%) 2 (13%) 0.62

15. Operative Predictors of Neurocognitive Dysfunction No Dysfunction (n=37) Dysfunction(n=16)P Ope Time 443±92.4455±1210.057 CPB Time 289±79.6294±85.10.21 Clamp Time 178±38.3179±42.20.23 Arrest Time 76.3±24.577.8±26.60.29 SCP Time 124±28.0127±33.70.10 Minimum Temperature 21.2±1.5820.7±3.030.72

16. Coments On average, 22.5% of the CABG patients had a decline of at least 1 standard deviation in at least two of a total of nine or ten tests 2 months after their operation (P <.0001; 95% confidence interval, 18.7%-26.4%). Van Dijk D et al : J Thorac Cardiovasc Surg 2000;120:632-9 31%(22/71) of the patients after deep hypothermic circulatory arrest had a more than 50% negative change in memory or fine motor function and attention 1 week postoperatively. Ergin MA et al : Ann Thorac Surg 1999;67:1887-90 31%(22/71) of the patients after deep hypothermic circulatory arrest had a more than 50% negative change in memory or fine motor function and attention 1 week postoperatively. Ergin MA et al : Ann Thorac Surg 1999;67:1887-90

17. Coments

18. Conclusions This study shows the high prevalence (30%) of neurocognitive dysfunction after arch replacement at the POD7. Follow up for long-term neurocognitive outcome and its impact on the quality of life are required. This study shows the high prevalence (30%) of neurocognitive dysfunction after arch replacement at the POD7. Follow up for long-term neurocognitive outcome and its impact on the quality of life are required.