Official reprint from UpToDate®
www.uptodate.com ©2016 UpToDate®

Anesthesia for aortic surgery requiring deep hypothermia

Albert T Cheung, MD
Section Editor
Jonathan B Mark, MD
Deputy Editor
Nancy A Nussmeier, MD, FAHA


Open surgical repair of portions of the ascending aorta or aortic arch may require temporary interruption of cerebral and systemic blood flow [1]. Deliberate hypothermia is induced with the aid of cardiopulmonary bypass (CPB) to protect the brain and other vital organs from ischemia during this period of elective circulatory arrest. Deep hypothermic circulatory arrest (DHCA) permits surgical reconstruction of the aortic arch without crossclamping a diseased aorta or instrumenting and possibly injuring aortic arch branch vessels. Selective antegrade cerebral perfusion (SACP) is a technique to perfuse the brain using the CPB circuit by direct cannulation of the axillary artery or aortic arch branch vessels. Retrograde cerebral perfusion (RCP) is a technique to improve the safety of DHCA by providing partial perfusion to the brain using the cardiopulmonary bypass circuit during interruption of antegrade cerebral perfusion.

This topic discusses anesthetic management and strategies for cerebral protection during cardiac surgical procedures requiring CPB with a period of DHCA, RCP, or SACP. Management of routine CPB and weaning from CPB are discussed separately. (See "Weaning from cardiopulmonary bypass (CPB)".)

Surgical indications and techniques to accomplish repairs of the ascending aorta and aortic arch are reviewed in other topics. (See "Overview of open surgical repair of the thoracic aorta", section on 'Ascending aorta' and "Overview of open surgical repair of the thoracic aorta", section on 'Aortic arch'.)


The preanesthetic consultation for patients undergoing cardiac surgical procedures is discussed separately. (See "Preanesthetic consultation for cardiac surgery".)

If emergency surgical repair of acute ascending aortic dissection (Stanford type A) is necessary, surgical and preanesthetic evaluation and preparation are expedited so that induction of general anesthesia can proceed without delay. Risk of mortality due to complications (eg, acute aortic regurgitation, cardiac tamponade, stroke, myocardial infarction) is estimated to be as high as 1 to 2 percent per hour after symptom onset (figure 1). (See "Preanesthetic consultation for cardiac surgery", section on 'Emergency surgery' and "Management of acute aortic dissection", section on 'Ascending (type A) aortic dissection'.)


Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Sep 2016. | This topic last updated: Oct 13, 2016.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2016 UpToDate, Inc.
  1. Hiratzka LF, Bakris GL, Beckman JA, et al. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with Thoracic Aortic Disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine. Circulation 2010; 121:e266.
  2. Ono M, Brady K, Easley RB, et al. Duration and magnitude of blood pressure below cerebral autoregulation threshold during cardiopulmonary bypass is associated with major morbidity and operative mortality. J Thorac Cardiovasc Surg 2014; 147:483.
  3. Murphy GS, Hessel EA 2nd, Groom RC. Optimal perfusion during cardiopulmonary bypass: an evidence-based approach. Anesth Analg 2009; 108:1394.
  4. Hogue CW Jr, Palin CA, Arrowsmith JE. Cardiopulmonary bypass management and neurologic outcomes: an evidence-based appraisal of current practices. Anesth Analg 2006; 103:21.
  5. Nishiwaki K, Komatsu T, Shimada Y, et al. Severe tracheal compression caused by false aneurysm arising from the ascending aorta: successful airway management using induced hypotension and bronchoscopy. Anesthesiology 1990; 73:1047.
  6. MacGillivray RG. Tracheal compression caused by aneurysms of the aortic arch. Implications for the anaesthetist. Anaesthesia 1985; 40:270.
  7. Kutcher WL, Kaufman BS. Occlusion of the right pulmonary artery by an acute dissecting aortic aneurysm. Crit Care Med 1988; 16:564.
  8. Downey RJ, Austin JH, Pepino P, et al. Right ventricular obstruction in aortic dissection: a mechanism of hemodynamic collapse. Ann Thorac Surg 1996; 61:988.
  9. Ullery BW, Hobbs RD, Cheung AT. Reversible spinal cord ischemia as a complication of acute aortic intramural hematoma. Vascular 2015; 23:427.
  10. Wolberg AS, Meng ZH, Monroe DM 3rd, Hoffman M. A systematic evaluation of the effect of temperature on coagulation enzyme activity and platelet function. J Trauma 2004; 56:1221.
  11. Warren OJ, Smith AJ, Alexiou C, et al. The inflammatory response to cardiopulmonary bypass: part 1--mechanisms of pathogenesis. J Cardiothorac Vasc Anesth 2009; 23:223.
  12. Warren OJ, Watret AL, de Wit KL, et al. The inflammatory response to cardiopulmonary bypass: part 2--anti-inflammatory therapeutic strategies. J Cardiothorac Vasc Anesth 2009; 23:384.
  13. American Society of Anesthesiologists. Standards for Basic Anesthetic Monitoring. www.asahq.org/Search.aspx?q=standards+basic+anesthetic+monitoring (Accessed on March 29, 2016).
  14. Hahn RT, Abraham T, Adams MS, et al. Guidelines for performing a comprehensive transesophageal echocardiographic examination: recommendations from the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists. Anesth Analg 2014; 118:21.
  15. American Society of Anesthesiologists and Society of Cardiovascular Anesthesiologists Task Force on Transesophageal Echocardiography. Practice guidelines for perioperative transesophageal echocardiography. An updated report by the American Society of Anesthesiologists and the Society of Cardiovascular Anesthesiologists Task Force on Transesophageal Echocardiography. Anesthesiology 2010; 112:1084.
  16. Stecker MM, Cheung AT, Pochettino A, et al. Deep hypothermic circulatory arrest: I. Effects of cooling on electroencephalogram and evoked potentials. Ann Thorac Surg 2001; 71:14.
  17. James ML, Andersen ND, Swaminathan M, et al. Predictors of electrocerebral inactivity with deep hypothermia. J Thorac Cardiovasc Surg 2014; 147:1002.
  18. Englum BR, Andersen ND, Husain AM, et al. Degree of hypothermia in aortic arch surgery - optimal temperature for cerebral and spinal protection: deep hypothermia remains the gold standard in the absence of randomized data. Ann Cardiothorac Surg 2013; 2:184.
  19. Coselli JS, Crawford ES, Beall AC Jr, et al. Determination of brain temperatures for safe circulatory arrest during cardiovascular operation. Ann Thorac Surg 1988; 45:638.
  20. Hemmerling TM, Olivier JF, Basile F, et al. Bispectral index as an indicator of cerebral hypoperfusion during off-pump coronary artery bypass grafting. Anesth Analg 2005; 100:354.
  21. Kertai MD, Whitlock EL, Avidan MS. Brain monitoring with electroencephalography and the electroencephalogram-derived bispectral index during cardiac surgery. Anesth Analg 2012; 114:533.
  22. Chandran Mahaldar DA, Gadhinglajkar S, Sreedhar R. Sevoflurane requirement to maintain bispectral index-guided steady-state level of anesthesia during the rewarming phase of cardiopulmonary bypass with moderate hypothermia. J Cardiothorac Vasc Anesth 2013; 27:59.
  23. Murkin JM, Adams SJ, Novick RJ, et al. Monitoring brain oxygen saturation during coronary bypass surgery: a randomized, prospective study. Anesth Analg 2007; 104:51.
  24. Zheng F, Sheinberg R, Yee MS, et al. Cerebral near-infrared spectroscopy monitoring and neurologic outcomes in adult cardiac surgery patients: a systematic review. Anesth Analg 2013; 116:663.
  25. Subramanian B, Nyman C, Fritock M, et al. A Multicenter Pilot Study Assessing Regional Cerebral Oxygen Desaturation Frequency During Cardiopulmonary Bypass and Responsiveness to an Intervention Algorithm. Anesth Analg 2016; 122:1786.
  26. Steppan J, Hogue CW Jr. Cerebral and tissue oximetry. Best Pract Res Clin Anaesthesiol 2014; 28:429.
  27. Fischer GW, Lin HM, Krol M, et al. Noninvasive cerebral oxygenation may predict outcome in patients undergoing aortic arch surgery. J Thorac Cardiovasc Surg 2011; 141:815.
  28. Rubio A, Hakami L, Münch F, et al. Noninvasive control of adequate cerebral oxygenation during low-flow antegrade selective cerebral perfusion on adults and infants in the aortic arch surgery. J Card Surg 2008; 23:474.
  29. Orihashi K, Sueda T, Okada K, Imai K. Near-infrared spectroscopy for monitoring cerebral ischemia during selective cerebral perfusion. Eur J Cardiothorac Surg 2004; 26:907.
  30. Olsson C, Thelin S. Regional cerebral saturation monitoring with near-infrared spectroscopy during selective antegrade cerebral perfusion: diagnostic performance and relationship to postoperative stroke. J Thorac Cardiovasc Surg 2006; 131:371.
  31. Aono M, Sata J, Nishino T. [Regional cerebral oxygen saturation as a monitor of cerebral oxygenation and perfusion during deep hypothermic circulatory arrest and selective cerebral perfusion]. Masui 1998; 47:335.
  32. Orihashi K, Sueda T, Okada K, Imai K. Malposition of selective cerebral perfusion catheter is not a rare event. Eur J Cardiothorac Surg 2005; 27:644.
  33. Harrer M, Waldenberger FR, Weiss G, et al. Aortic arch surgery using bilateral antegrade selective cerebral perfusion in combination with near-infrared spectroscopy. Eur J Cardiothorac Surg 2010; 38:561.
  34. Higami T, Kozawa S, Asada T, et al. Retrograde cerebral perfusion versus selective cerebral perfusion as evaluated by cerebral oxygen saturation during aortic arch reconstruction. Ann Thorac Surg 1999; 67:1091.
  35. Yamashita K, Kazui T, Terada H, et al. Cerebral oxygenation monitoring for total arch replacement using selective cerebral perfusion. Ann Thorac Surg 2001; 72:503.
  36. Blas ML, Lobato EB, Martin T. Noninvasive infrared spectroscopy as a monitor of retrograde cerebral perfusion during deep hypothermia. J Cardiothorac Vasc Anesth 1999; 13:244.
  37. Ogino H, Ueda Y, Sugita T, et al. Monitoring of regional cerebral oxygenation by near-infrared spectroscopy during continuous retrograde cerebral perfusion for aortic arch surgery. Eur J Cardiothorac Surg 1998; 14:415.
  38. Janelle GM, Mnookin S, Gravenstein N, et al. Unilateral cerebral oxygen desaturation during emergent repair of a DeBakey type 1 aortic dissection: potential aversion of a major catastrophe. Anesthesiology 2002; 96:1263.
  39. Santo KC, Barrios A, Dandekar U, et al. Near-infrared spectroscopy: an important monitoring tool during hybrid aortic arch replacement. Anesth Analg 2008; 107:793.
  40. Orihashi K, Sueda T, Okada K, Imai K. Detection and monitoring of complications associated with femoral or axillary arterial cannulation for surgical repair of aortic dissection. J Cardiothorac Vasc Anesth 2006; 20:20.
  41. Rhee AJ, Kahn RA. Laboratory point-of-care monitoring in the operating room. Curr Opin Anaesthesiol 2010; 23:741.
  42. Uhlig C, Bluth T, Schwarz K, et al. Effects of Volatile Anesthetics on Mortality and Postoperative Pulmonary and Other Complications in Patients Undergoing Surgery: A Systematic Review and Meta-analysis. Anesthesiology 2016; 124:1230.
  43. Fleisher LA, Fleischmann KE, Auerbach AD, et al. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2014; 130:2215.
  44. Ansley DM, Raedschelders K, Choi PT, et al. Propofol cardioprotection for on-pump aortocoronary bypass surgery in patients with type 2 diabetes mellitus (PRO-TECT II): a phase 2 randomized-controlled trial. Can J Anaesth 2016; 63:442.
  45. Hare GM. Studying propofol-induced cardioprotection: from mechanism to clinical phenomenon and back again. Can J Anaesth 2016; 63:392.
  46. Jakobsen CJ, Berg H, Hindsholm KB, et al. The influence of propofol versus sevoflurane anesthesia on outcome in 10,535 cardiac surgical procedures. J Cardiothorac Vasc Anesth 2007; 21:664.
  47. Yan TD, Bannon PG, Bavaria J, et al. Consensus on hypothermia in aortic arch surgery. Ann Cardiothorac Surg 2013; 2:163.
  48. Hu Z, Wang Z, Ren Z, et al. Similar cerebral protective effectiveness of antegrade and retrograde cerebral perfusion combined with deep hypothermia circulatory arrest in aortic arch surgery: a meta-analysis and systematic review of 5060 patients. J Thorac Cardiovasc Surg 2014; 148:544.
  49. Cook RC, Gao M, Macnab AJ, et al. Aortic arch reconstruction: safety of moderate hypothermia and antegrade cerebral perfusion during systemic circulatory arrest. J Card Surg 2006; 21:158.
  50. Gega A, Rizzo JA, Johnson MH, et al. Straight deep hypothermic arrest: experience in 394 patients supports its effectiveness as a sole means of brain preservation. Ann Thorac Surg 2007; 84:759.
  51. Chau KH, Ziganshin BA, Elefteriades JA. Deep hypothermic circulatory arrest: real-life suspended animation. Prog Cardiovasc Dis 2013; 56:81.
  52. Engelman R, Baker RA, Likosky DS, et al. The Society of Thoracic Surgeons, The Society of Cardiovascular Anesthesiologists, and The American Society of ExtraCorporeal Technology: Clinical Practice Guidelines for Cardiopulmonary Bypass--Temperature Management During Cardiopulmonary Bypass. Ann Thorac Surg 2015; 100:748.
  53. Nussmeier NA, Cheng W, Marino M, et al. Temperature during cardiopulmonary bypass: the discrepancies between monitored sites. Anesth Analg 2006; 103:1373.
  54. GORDON AS, MEYER BW, JONES JC. Open-heart surgery using deep hypothermia without an oxygenator. J Thorac Cardiovasc Surg 1960; 40:787.
  55. McCullough JN, Zhang N, Reich DL, et al. Cerebral metabolic suppression during hypothermic circulatory arrest in humans. Ann Thorac Surg 1999; 67:1895.
  56. Gaynor JW, Nicolson SC, Jarvik GP, et al. Increasing duration of deep hypothermic circulatory arrest is associated with an increased incidence of postoperative electroencephalographic seizures. J Thorac Cardiovasc Surg 2005; 130:1278.
  57. Okita Y, Minatoya K, Tagusari O, et al. Prospective comparative study of brain protection in total aortic arch replacement: deep hypothermic circulatory arrest with retrograde cerebral perfusion or selective antegrade cerebral perfusion. Ann Thorac Surg 2001; 72:72.
  58. Fleck TM, Czerny M, Hutschala D, et al. The incidence of transient neurologic dysfunction after ascending aortic replacement with circulatory arrest. Ann Thorac Surg 2003; 76:1198.
  59. Cheung AT, Bavaria JE, Pochettino A, et al. Oxygen delivery during retrograde cerebral perfusion in humans. Anesth Analg 1999; 88:8.
  60. Jungwirth B, Mackensen GB, Blobner M, et al. Neurologic outcome after cardiopulmonary bypass with deep hypothermic circulatory arrest in rats: description of a new model. J Thorac Cardiovasc Surg 2006; 131:805.
  61. Bachet J. What is the best method for brain protection in surgery of the aortic arch? Selective antegrade cerebral perfusion. Cardiol Clin 2010; 28:389.
  62. Lee AP, Acker M, Kubo SH, et al. Mechanisms of recurrent functional mitral regurgitation after mitral valve repair in nonischemic dilated cardiomyopathy: importance of distal anterior leaflet tethering. Circulation 2009; 119:2606.
  63. Immer FF, Moser B, Krähenbühl ES, et al. Arterial access through the right subclavian artery in surgery of the aortic arch improves neurologic outcome and mid-term quality of life. Ann Thorac Surg 2008; 85:1614.
  64. Kazui T, Inoue N, Yamada O, Komatsu S. Selective cerebral perfusion during operation for aneurysms of the aortic arch: a reassessment. Ann Thorac Surg 1992; 53:109.
  65. Akata T, Setoguchi H, Shirozu K, Yoshino J. Reliability of temperatures measured at standard monitoring sites as an index of brain temperature during deep hypothermic cardiopulmonary bypass conducted for thoracic aortic reconstruction. J Thorac Cardiovasc Surg 2007; 133:1559.
  66. Grigore AM, Grocott HP, Mathew JP, et al. The rewarming rate and increased peak temperature alter neurocognitive outcome after cardiac surgery. Anesth Analg 2002; 94:4.
  67. Grocott HP, Mackensen GB, Grigore AM, et al. Postoperative hyperthermia is associated with cognitive dysfunction after coronary artery bypass graft surgery. Stroke 2002; 33:537.
  68. Bar-Yosef S, Mathew JP, Newman MF, et al. Prevention of cerebral hyperthermia during cardiac surgery by limiting on-bypass rewarming in combination with post-bypass body surface warming: a feasibility study. Anesth Analg 2004; 99:641.
  69. Stecker MM, Cheung AT, Pochettino A, et al. Deep hypothermic circulatory arrest: II. Changes in electroencephalogram and evoked potentials during rewarming. Ann Thorac Surg 2001; 71:22.
  70. Lazar HL, McDonnell M, Chipkin SR, et al. The Society of Thoracic Surgeons practice guideline series: Blood glucose management during adult cardiac surgery. Ann Thorac Surg 2009; 87:663.
  71. Ream AK, Reitz BA, Silverberg G. Temperature correction of PCO2 and pH in estimating acid-base status: an example of the emperor's new clothes? Anesthesiology 1982; 56:41.
  72. Groom RC, Froebe S, Martin J, et al. Update on pediatric perfusion practice in North America: 2005 survey. J Extra Corpor Technol 2005; 37:343.
  73. Connolly S, Arrowsmith JE, Klein AA. Deep hypothermic circulatory arrest. continuing education in anaesthesia, critical care & pain 2010; 10:138.
  74. Hoover LR, Dinavahi R, Cheng WP, et al. Jugular venous oxygenation during hypothermic cardiopulmonary bypass in patients at risk for abnormal cerebral autoregulation: influence of alpha-Stat versus pH-stat blood gas management. Anesth Analg 2009; 108:1389.
  75. Ghadimi K, Gutsche JT, Setegne SL, et al. Severity and Duration of Metabolic Acidosis After Deep Hypothermic Circulatory Arrest for Thoracic Aortic Surgery. J Cardiothorac Vasc Anesth 2015; 29:1432.
  76. Ghadimi K, Gutsche JT, Ramakrishna H, et al. Sodium bicarbonate use and the risk of hypernatremia in thoracic aortic surgical patients with metabolic acidosis following deep hypothermic circulatory arrest. Ann Card Anaesth 2016; 19:454.
  77. DeFoe GR, Ross CS, Olmstead EM, et al. Lowest hematocrit on bypass and adverse outcomes associated with coronary artery bypass grafting. Northern New England Cardiovascular Disease Study Group. Ann Thorac Surg 2001; 71:769.
  78. Habib RH, Zacharias A, Schwann TA, et al. Adverse effects of low hematocrit during cardiopulmonary bypass in the adult: should current practice be changed? J Thorac Cardiovasc Surg 2003; 125:1438.
  79. Karkouti K, Djaiani G, Borger MA, et al. Low hematocrit during cardiopulmonary bypass is associated with increased risk of perioperative stroke in cardiac surgery. Ann Thorac Surg 2005; 80:1381.
  80. Swaminathan M, Phillips-Bute BG, Conlon PJ, et al. The association of lowest hematocrit during cardiopulmonary bypass with acute renal injury after coronary artery bypass surgery. Ann Thorac Surg 2003; 76:784.
  81. Wang Y, Ji H. Comparison of Two Different Red Blood Cell Transfusion Thresholds on Short-Term Clinical Outcomes of Patients Undergoing Aortic Surgery With Deep Hypothermic Circulatory Arrest. J Cardiothorac Vasc Anesth 2016; 30:1163.
  82. Kim WH, Park MH, Kim HJ, et al. Potentially modifiable risk factors for acute kidney injury after surgery on the thoracic aorta: a propensity score matched case-control study. Medicine (Baltimore) 2015; 94:e273.
  83. Parolari A, Pesce LL, Pacini D, et al. Risk factors for perioperative acute kidney injury after adult cardiac surgery: role of perioperative management. Ann Thorac Surg 2012; 93:584.
  84. Arnaoutakis GJ, Bihorac A, Martin TD, et al. RIFLE criteria for acute kidney injury in aortic arch surgery. J Thorac Cardiovasc Surg 2007; 134:1554.
Topic Outline