1. SAFETY OF UNILATERAL Vs BILATERAL CEREBRAL PERFUSION DURING AORTIC SURGERY ASSESSED USING REGIONAL CEREBRAL OXYGEN SATURATION MONITORING IRCCS “Foundation Hospital S Matteo” Totaro P Paris M Amoroso F Milanesi E Maurelli M Vigano’ M Pavia

2. Selective Antegrade Cerebral Perfusion (SACP) has probably become the gold standard for cerebral protection during aortic surgery. Background However Some technical aspects related to the management of SACP remain controversial. Open Issues Site of Arterial Cannulation Unilateral Bilateral Degree of Hypothermia Extension of SACP

3. P.Totaro… Safety of unilateral cerebral perfusion… ATS 2009 Background ATS 2010

4. P.Totaro… Safety of unilateral cerebral perfusion… Objective Objective of the present study is to evaluate the efficacy of Unilateral Selective Antegrade Cerebral Perfusion (uSACP) compared to Bilateral Antegrade Cerebral Perfusion (bSACP) during Aortic Surgery Patients Population (2006 – June 2010) Patients60 Sex Male Female 23 (38) 37 (62) Age at operation65±14 BSA1.8±0.2 Aortic Dissection30 (50) Surgical Details Patients60 Arterial Cannulation Axillary Femoral 54 (90) 6 (10) Deep Hypothermia6 (10) SACP bSCAP (Group A) uSCAP (Group B) 23 (38) 37 (62)

5. NIRS Monitoring Background P.Totaro… Safety of unilateral cerebral perfusion…

6. PRO CONS - Easy to manage - Easy Interpretation - Cost-effective - Reproducible - No dedicated technician - Allows for prompt action - Still under-utilized - Sensitive to the location - No significant difference shown in terms of action - No correlation to neurological impairment following CABG Key Point For NIRS Monitoring We have to consider the trend of rCSo for any single patient and not the absolute value compared between different patients

7. P.Totaro… Safety of unilateral cerebral perfusion… NIRS Advanced Analysis CROCS Cumulative Reduction of Regional Oxygen Cerebral Saturation >25 % MOCS Overall Mean Oxygen Cerebral Saturation MDDCA Maximum Drop of Regional Oxygen Cerebral Saturation During Circulatory Arrest LOCS Lowest Oxygen Cerebral Saturation

8. P.Totaro… Safety of unilateral cerebral perfusion… ParameterGroup A bSACP Group B uSACP p Patients2337 Sex Male Female 14 (60) 9 (40) 26 (70) 11 (30) 0,3 Age at operation66±1766±130,6 Acute Dissection13 (56)17 (45)0,12 BSA1.77±0.231.85±0.220,16 Results Groups were homogeneous for preoperative characteristics ECC Time249±91193±700,02 Aortic Cross Clamp119±5286±380,02 Hypothermia Deep Moderate 12 (55) 11 (45) 6 (16) 31 (84)0,037 Lower NF Temperature (°)22±425±20,001 Circulatory Arrest Time53±3240±310,18 Surgical Parameters

9. P.Totaro… Safety of unilateral cerebral perfusion…MOCS Overall Mean Oxygen Cerebral Saturation % Near Infra-Red Spectroscopy Results Baseline %

10. P.Totaro… Safety of unilateral cerebral perfusion… % LOCS Lowest Oxygen Cerebral Saturation MDDCA Maximum Drop of Regional Oxygen Cerebral Saturation During Circulatory Arrest %

11. P.Totaro… Safety of unilateral cerebral perfusion… % CROCS Cumulative Reduction of Regional Oxygen Cerebral Saturation >25 baseline min PercentageMinute

12. P.Totaro… Intermittent circulatory arrest... Conclusions Continuous NIRS monitoring during uSACP did not show any significant differences when compared to bSACP These data seems to confirm that in the majority of patients uSACP should warranty adeguate cerebral perfusion and protection during aortic surgery