**4. Conclusions**

160 Front Lines of Thoracic Surgery

reperfusion is achieved before re-warming, and maintaining a temperature gradient of less than 10°C in the heat exchanger and avoiding complete re-warming are usually performed. Currently, there is no class of drug representing the standard of practice, but some drugs can be used as adjunctive strategies for cerebral protection. A number of drugs cause EEG burst suppression, resulting in a reduction in the cerebral metabolic rate by approximately 50%, but the most used of these drugs is thiopental at a dose of 5-8 mg/kg. The administration of thiopental results in EEG burst suppression for few minutes at normothermia. Thiopental and/or steroids are administered before circulatory arrest in

There is an inverse relationship between gas solubility and blood temperature. When blood temperature decreases, an apparent respiratory alkalosis occurs due to a decrease in PaCO2 and an increase in pH. To compensate for this PaCO2 reduction, CO2 can be added to the oxygenator (pH-stat management) or the CPB gas sweep rate can be reduced. The technique of pH-stat management was commonly used until the mid-1980s, but there is more recent evidence that pH-stat management can increase the incidence of postoperative cognitive dysfunction when CPB lasts longer than 90 minutes (Murkin et al., 1995). It has been suspected that the increase in CO2 should increase the cerebral blood flow during perfusion phases, uncoupling flow and metabolism. The most used α-stat (not temperature-correcting) requires that neutrality be maintained at only 37°C, and it permits hypothermic alkaline drift. Thus, additional CO2 is not needed. Cellular trans-membrane pH gradients, protein functioning, and enzyme activity are more normal when the pH is allowed to drift into the alkaline range, in parallel with the temperature-dependent pKa of protein and the neutral pH of water. Moreover, a relatively alkaline pH is beneficial before the ischemic insult of circulatory arrest. Despite considerable laboratory and animal research into these mechanisms, substantial controversy remains over which strategy produces the best clinical

Coagulation system management during and after CPB is based on the administration of heparin, followed by neutralization with protamine, and this approach has been unchanged for almost 50 years. Heparin binds to antithrombin-III (AT-III), potentiating the action of AT-III (more than 1000-fold) to inhibit thrombin and factor Xa most importantly (but also factors IXa, XIa, and XIIa). After central venous administration, heparin's effect peaks within 1 minute. The onset of CPB increases the circulating blood volume by approximately 1500 ml, reducing the heparin blood concentration; therefore, 5000 U of heparin are added to the CPB prime. Before CPB, heparin is administered at a dose of 300-400 U/kg to obtain ACT for 420-480 seconds, and successive supplemental doses are guided by monitoring the ACT. Some centres monitor blood heparin concentrations. ACT is prolonged by hypothermia and hemodilution. After CPB weaning is successfully achieved and a satisfactory spontaneous circulation is restored, heparin anticoagulation must be reversed with protamine administration. The most used protamine-heparin ratio is 0.6-1 mg/100 U. Protamine must always be administered slowly to prevent adverse hemodynamic effects. After protamine administration, ACT should return to a value no more than 10% above the basic value. If more prolonged, heparin residual activity is likely, and additional doses of protamine

some centres, without a clear demonstration of beneficial effects.

**3.2.3 pH management during hypothermia** 

outcomes (Duebener et al., 2002).

**3.2.4 Coagulation management** 

In conclusion we think that CPB with HCCA should be considered for atrial thrombi removal in patient affected by several abdominal malignancies such as renal, adrenal carcinomas, primary liver tumours also in presence of a well compensated liver cirrhosis, uterine endometrial stromal tumours and intravascular leiomyomatosis, vena cava leiomysarcoma and others, because it is simpler and safer compared to CPB alone. It permits the careful cleaning of the vena cava, right atrium, ventricle and even of the pulmonary artery in a bloodless field which entails in a lower recurrence rate. Mortality and morbidity seem to be the same when compared to CPB alone but further studies are necessary due to the small number of patients.

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**Part 2** 

**Pediatric Cardiac Surgery** 


**Part 2** 

**Pediatric Cardiac Surgery** 

166 Front Lines of Thoracic Surgery

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**9** 

*Taiwan* 

Ing-Sh Chiu and Chi-Ren Hung

**Restoration of Transposed Great Arteries With** 

*Department of Surgery, National Taiwan University Hospital and* 

 *National Taiwan University, College of Medicine, Taipei,* 

**or Without Subpulmonary Obstruction to Nature** 

*Surgical correction on transposition of the great arteries was proposed by many in the past half-century, and was claimed as the anatomical correction; but the treatment of choice was ever changing. The current technique usually included Lecompte maneuver to bring the pulmonary bifurcation in front of the aorta. Although the ventriculoarterial connection was corrected, it is not "normal" yet---------.* 

Looking back into the evolution of surgical treatments on transposed great arteries (TGA), is full of fascinating and challenging stories. Many pondered the best option to correct this tricky, yet not the most complex congenital heart disease. Some operations that had been replaced by another were later revived. Senning once had been replaced by Mustard as the treatment of choice (Senning, 1959; Mustard, 1964), but was revived because autologous tissue was utilized, although it was more difficult (Quaegebeur, 1977). As people learned the functional implications of the ventricles, both atrial redirection procedures were replaced by the arterial switch operation (ASO) (Jatene et al., 1975; Lecompte et al., 1981; Castaneda et al., 1984). ASO was attempted initially, without transferring the larger right coronary artery, by Mustard (Mustard et al., 1954). Nikaidoh described aortic translocation, which in essence is an ASO including the arterial valve (Nikaidoh, 1984). In the past, few practiced this procedure because of its demanding techniques and potentially worse outcome. However, aortic translocation has recently gained popularity as an alternative to the Rastelli operation and Reparation l'etage ventriculaire (REV) as the treatment for TGA with a left ventricular outflow obstruction (Rastelli, 1969; Yeh et al., 2007; Emani et al., 2009). ASO has become the procedure of choice for TGA (Prêtre et al., 2001; Losay et al., 2002). However, TGA is considered to be a mere reversal of the great arteries anteroposteriorly (Shaher, 1964; Van Mierop, 1971); nonexistence of the normal spiral relationship of the great arteries in TGA has not been widely appreciated. Thus posterior pulmonary bifurcation is mobilised anteriorly to the aorta (the so-called Lecompte maneuver) in an effort simply to reverse transposed great arteries (Lecompte et al., 1981). We proposed an arterial Senning operation 13 years ago, to restore the spiral flow of nature in TGA (Chiu et al., 2000b; Chiu et al., 2002b, Chiu et al., 2010). The role of this operation is still uncertain and it requires continued refinement and development. The thinking process and evolving technique behind how we conceived our currrent technique was published (Chiu et al., 2001). Briefly, mobilization of the pulmonary arteries high above its original site to avoid compression the high take off coronary artey will result in supravalvular pulmonary stenosis (PS), similarly, Lecompte

**1. Introduction** 
