Systematic review of robotic mitral valve surgery

technique, which avoids all manipulation of the aorta, has been shown to significantly reduce neurological injury compared to an on-pump technique (level 2a) and also an offpump technique with side-clamp (level 2a). During aortic arch surgery, the addition of antegrade cerebral perfusion (level 2a) or retrograde cerebral perfusion (level 3b) to deep hypothermic circulatory arrest (14.1 20 8C) is beneficial. Current evidence suggests that moderate hypothermic circulatory (20.1 28 8C) arrest may also be used with antegrade cerebral perfusion (level 2a). Other beneficial techniques include slow rewarming to avoid hyperthermia (level 2b) and alpha-stat pH management in adults to optimise cerebral blood flow (level 2b). During open repair of extensive thoracoabdominal aneurysms, in addition to reconstruction of the Artery of Adamkiewicz, spinal cord protection may be provided by reimplantation of segmental arteries (level 2b), neurophysiological monitoring with motor or sensory evoked potentials (level 2b), possibly staging repair to allow adaption of the collateral blood supply (level 2b), distal aortic perfusion (level 2b), cerebral spinal fluid drainage (level 2a) alone or with an intrathecal vasodilator (level 2c) or regional spinal cord hypothermia (level 2c) Increased understanding of molecular pathways involved in neurological injury and recovery will lead to novel pharmacological agents and techniques that may have future applications, such as the free radical scavenger edaravone or remote ischaemic preconditioning.