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      Cerebral oxygen desaturation in patients with totally thoracoscopic ablation for atrial fibrillation : A prospective observational study

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          Abstract

          Background:

          Epicardial radiofrequency ablation for stand-alone atrial fibrillation under total video-assisted thoracoscopy has gained popularity in recent years. However, severe cardiopulmonary disturbances during the surgery may affect cerebral perfusion and oxygenation. We therefore hypothesized that regional cerebral oxygen saturation (rSO 2) would decrease significantly during the surgery. In addition, the influencing factors of rSO 2 would be investigated.

          Methods:

          A total of 60 patients scheduled for selective totally thoracoscopic ablation for stand-alone atrial fibrillation were enrolled in this prospective observational study. The rSO 2 was monitored at baseline (T0), 15 min after anesthesia induction (T1), 15 minute after 1-lung ventilation (T2), after right pulmonary vein ablation (T3), after left pulmonary vein ablation (T4) and 15 minute after 2-lung ventilation (T5) using a near-infrared reflectance spectroscopy -based cerebral oximeter. Arterial blood gas was analyzed using an ABL 825 hemoximeter. Associations between rSO 2 and hemodynamic or blood gas parameters were determined with univariate and multivariate linear regression analyses.

          Results:

          The rSO 2 decreased greatly from baseline 65.4% to 56.5% at T3 ( P < .001). Univariate analyses showed that rSO 2 correlated significantly with heart rate (r = -0.173, P = .186), mean arterial pressure (MAP, r = 0.306, P = .018), central venous pressure (r = 0.261, P = .044), arterial carbon dioxide tension (r = -0.336, P = .009), arterial oxygen pressure (PaO 2, r = 0.522, P < .001), and base excess (BE, r = 0.316, P = .014). Multivariate linear regression analyses further showed that it correlated positively with PaO 2 (β = 0.456, P < .001), MAP (β = 0.251, P = .020), and BE (β = 0.332, P = .003).

          Conclusion:

          Totally thoracoscopic ablation for atrial fibrillation caused a significant decrease in rSO 2. There were positive correlations between rSO 2 and PaO 2, MAP, and BE.

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          Most cited references33

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          The surgical treatment of atrial fibrillation. III. Development of a definitive surgical procedure.

          Anne B. Chang, J P Boineau, R Schuessler … (1991)
          On the basis of the known electrophysiologic mechanisms of atrial fibrillation, multiple surgical procedures were designed and tested in dogs to determine the feasibility of developing a surgical cure for human atrial fibrillation. These experimental studies culminated in a surgical approach that effectively creates an electrical maze in the atrium. The atrial incisions prevent atrial reentry and allow sinus impulses to activate the entire atrial myocardium, thereby preserving atrial transport function postoperatively. Since September 1987, this surgical procedure has been applied in seven patients, five with paroxysmal atrial fibrillation of 2 to 9 years' duration and two with chronic atrial fibrillation of 3 and 10 years' duration. All seven patients have been cured of atrial fibrillation and none is receiving any postoperative antiarrhythmic medications.
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            Arterial and venous contributions to near-infrared cerebral oximetry.

            M Kurth, Kirsty S. Nicolson, Jonathan J. Rome … (2000)
            Cerebral oximetry is a noninvasive bedside technology using near-infrared light to monitor cerebral oxygen saturation (Sco2) in an uncertain mixture of arteries, capillaries, and veins. The present study used frequency domain near-infrared spectroscopy to determine the ratio of arterial and venous blood monitored by cerebral oximetry during normoxia, hypoxia, and hypocapnia. Twenty anesthetized children aged < 8 yr with congenital heart disease of varying arterial oxygen saturation (Sao2) were studied during cardiac catheterization. Sco2, Sao2, and jugular bulb oxygen saturation (Sjo2) were measured by frequency domain near-infrared spectroscopy and blood oximetry at normocapnia room air, normocapnia 100% inspired O2, and hypocapnia room air. Among subject conditions, Sao2 ranged from 68% to 100%, Sjo2 from 27% to 96%, and Sco2 from 29% to 92%. Sco2 was significantly related to Sao2 (y = 0. 85 x -17, r = 0.47), Sjo2 (y = 0.77 x +13, r = 0.70), and the combination (Sco2 = 0.46 Sao2 + 0.56 Sjo2 - 17, R = 0.71). The arterial and venous contribution to cerebral oximetry was 16 +/- 21% and 84 +/- 21%, respectively (where Sco2 = alpha Sao2 + beta Sjo2 with alpha and beta being arterial and venous contributions). The contribution was similar among conditions but differed significantly among subjects (range, approximately 40:60 to approximately 0:100, arterial:venous). Cerebral oximetry monitors an arterial/venous ratio of 16:84, similar in normoxia, hypoxia, and hypocapnia. Because of biologic variation in cerebral arterial/venous ratios, use of a fixed ratio is not a good method to validate the technology.
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              Influence of changes in blood pressure on cerebral perfusion and oxygenation.

              S Galvin, Y. Tzeng, Philip Ainslie … (2010)
              Cerebral autoregulation (CA) is a critical process for the maintenance of cerebral blood flow and oxygenation. Assessment of CA is frequently used for experimental research and in the diagnosis, monitoring, or prognosis of cerebrovascular disease; however, despite the extensive use and reference to static CA, a valid quantification of "normal" CA has not been clearly identified. While controlling for the influence of arterial Pco(2), we provide the first clear examination of static CA in healthy humans over a wide range of blood pressure. In 11 healthy humans, beat-to-beat blood pressure (radial arterial), middle cerebral artery blood velocity (MCAv; transcranial Doppler ultrasound), end-tidal Pco(2), and cerebral oxygenation (near infrared spectroscopy) were recorded continuously during pharmacological-induced changes in mean blood pressure. In a randomized order, steady-state decreases and increases in mean blood pressure (8 to 14 levels; range: approximately 40 to approximately 125 mm Hg) were achieved using intravenous infusions of sodium nitroprusside or phenylephrine, respectively. MCAv(mean) was altered by 0.82+/-0.35% per millimeter of mercury change in mean blood pressure (R(2)=0.82). Changes in cortical oxygenation index were inversely related to changes in mean blood pressure (slope=-0.18%/mm Hg; R(2)=0.60) and MCAv(mean) (slope=-0.26%/cm . s(-1); R(2)=0.54). There was a progressive increase in MCAv pulsatility with hypotension. These findings indicate that cerebral blood flow closely follows pharmacological-induced changes in blood pressure in otherwise healthy humans. Thus, a finite slope of the plateau region does not necessarily imply a defective CA. Moreover, with progressive hypotension and hypertension there are differential changes in cerebral oxygenation and MCAv(mean).
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                Author and article information

                Journal
                Journal ID (nlm-ta): Medicine (Baltimore)
                Journal ID (iso-abbrev): Medicine (Baltimore)
                Journal ID (publisher-id): MEDI
                Title: Medicine
                Publisher: Wolters Kluwer Health
                ISSN (Print): 0025-7974
                ISSN (Electronic): 1536-5964
                Publication date Collection: April 2020
                Publication date (Electronic): 24 April 2020
                Volume: 99
                Issue: 17
                Electronic Location Identifier: e19599
                Affiliations
                Department of Anesthesiology and Surgical Intensive Care Unit, Xinhua Hospital affiliated to Shanghai Jiaotong University School of Medicine, China.
                Author notes
                [∗ ]Correspondence: Sai’e Shen, Department of Anesthesiology and Surgical Intensive Care Unit, Xinhua Hospital affiliated to Shanghai Jiaotong University School of Medicine, 1665 Kongjiang Road, Shanghai 200092, China (e-mail: wjzbc97@ 123456126.com ).
                Article
                Publisher ID: MD-D-19-04598 Accession ID: 19599
                DOI: 10.1097/MD.0000000000019599
                PMC ID: 7220728
                PubMed ID: 32332606
                SO-VID: 2ee7d8a8-dc46-4e4a-8e23-817f913f8b61
                Copyright © Copyright © 2020 the Author(s). Published by Wolters Kluwer Health, Inc.
                License:

                This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial License 4.0 (CCBY-NC), where it is permissible to download, share, remix, transform, and buildup the work provided it is properly cited. The work cannot be used commercially without permission from the journal. http://creativecommons.org/licenses/by-nc/4.0

                History
                Date received : 11 June 2019
                Date revision received : 16 February 2020
                Date accepted : 18 February 2020
                Categories
                Subject: 3300
                Subject: Research Article
                Subject: Observational Study
                Custom metadata
                OPEN-ACCESS TRUE

                Keywords: arterial oxygen pressure,atrial fibrillation,mean arterial pressure,regional cerebral oxygen saturation,surgical ablation
                Data availability:
                Keywords: arterial oxygen pressure, atrial fibrillation, mean arterial pressure, regional cerebral oxygen saturation, surgical ablation

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