Technical advances in total aortic arch replacement (original) (raw)
Related papers
Technical advances in total aortic arch replacement. Discussion
The Annals of Thoracic Surgery, 2004
Background. We compared the effects of using hypothermic circulatory arrest (HCA) alone, HCA combined with selective cerebral perfusion (SCP), and use of SCP with a trifurcated graft (T) on outcome after aortic arch repair.
Annals of thoracic and cardiovascular surgery: official journal of the Association of Thoracic and Cardiovascular Surgeons of Asia
Objective: Despite theoretical advantages of antegrade (ACP) and retrograde cerebral perfusion (RCP) in addition to deep hypothermic arrest (DHA) in aortic arch surgery, there is still controversy about the best method of cerebral protection. We reviewed our experience with neurological outcome after aortic arch repair over the last five years. Methods: Sixty-two patients undergoing aortic arch repair were reviewed. Five patients (8.1%) had Marfan's syndrome, 11 (17.7%) had previous cardiac operations, and 13 (21.0%) also received coronary bypass grafting (CABG). The extent of arch replacement was proximal level in 40 (64.5%), distal level in 18 (29.0%), and total in 13 (21.0%). The method of cerebral protection was DHA alone in 14 patients, DHA with RCP in 23, and DHA with ACP in 25. Pre-, intra-, and postoperative variables in the three categories of cerebral protection were compared. Specifically, the independent predictors of mortality, stroke, and temporary neurological dysfunction (TND) were examined. Results: Overall hospital mortality was 5 (8.0%). Stroke occurred in 4 patients (6.4%), and TND in 5 (8.0%). There were no significant differences among the groups in mortality or neurological dysfunction. Total brain exclusion time (TBET) was significantly longer in ACP (DHA, 25.2±12.0 min; ACP, 61.8±44.1 min; RCP, 36.4±20.5 min; p=0.023). Multivariate analysis showed a trend for TBET of longer than 90 minutes as a predictor of stroke (p=0.06; odds ratio, 7.9). The actuarial survival rate was 88.7% at five years (DHA, 85.7%; ACP, 80.0%; RCP, 100%; no significant difference). Conclusions: Despite more complicated arch repairs requiring a significantly longer cerebral exclusion time which were performed in the group receiving ACP, there was no significant increase in stroke or death rates. Increasing confidence in the ability of ACP has led us to perform the most appropriate arch repair without compromising the extent of replacement for fear of exceeding the "safe" period of circulatory arrest. (Ann Thorac Cardiovasc Surg 2003; 9: 174-9)
European Journal of Cardio-Thoracic Surgery, 2010
Objectives: Antegrade cerebral perfusion (ACP) during hypothermic circulatory arrest (HCA) for ascending/transverse arch repair is used for cerebral protection. This study evaluates ACP in combination with retrograde cerebral perfusion (RCP) during extended HCA and compares it to RCP-only. Methods: Between January 2005 and April 2007, we performed 64 consecutive arch repairs requiring extended HCA (>40 min). RCPonly was used with 34 patients and ACP with brief RCP ('integrated') was used with 30 patients. Mean HCA time was 51 AE 13 min. Mean RCP-only time was 47 AE 9.6 min; in the integrated group, mean ACP time was 42 AE 14.4 min with an added RCP time of 10.8 AE 7.6 min. For the entire cohort, 95% (61/64) underwent total arch repair, and 67% (43/64) had elephant trunk reconstruction. Variables predictive of mortality and neurological outcomes were analysed prospectively, but technique selection was non-randomised. Results: Preoperative and operative variables did not differ between the RCP-only and the integrated groups except for aortic valve replacement, which was more frequently performed in the integrated group (33% (10/30) vs 12% (4/34), P = 0.05), and preoperative renal dysfunction, which was more frequent in the RCP group (26% (9/34) vs 7% (2/30), P = 0.04). No significant difference was observed in outcomes between the groups; however, the integrated group had higher mortality, stroke and temporary neurological deficit than RCP-only. Conclusions: The observed trends in actual outcomes were a cause for concern. ACP combined with a short period of RCP did not provide better outcomes than RCP-only. The use of RCP remains warranted in our experience.
Outcomes of Aortic Arch Replacement Performed Without Circulatory Arrest or Deep Hypothermia
AORTA, 2013
Background: Aortic arch replacement using standard techniques, including deep hypothermic circulatory arrest and selective antegrade cerebral perfusion, is still associated with significant mortality and cerebral morbidity. We have previously described the "branch-first" technique that avoids circulatory arrest or profound hypothermia with excellent outcomes. We now describe our clinical experience with a larger cohort of patients as well as follow-up of our earlier results. We also describe a further technical simplification to this technique. Methods: From 2005 to 2010, 43 patients underwent a "branch-first continuous perfusion" technique for aortic arch replacement. In this technique, arterial perfusion is peripheral, usually by femoral inflow. Disconnection of each arch branch and anastomosis to a perfused trifurcation graft proceeds sequentially from the innominate to the left subclavian artery, with uninterrupted perfusion of the heart and viscera by the peripheral cannula. In the first cohort perfusion to the trifurcation graft was by right axillary cannulation. Since 2009, a modification was introduced such that perfusion is supplied directly by a sidearm on the trifurcation graft. This was used in the last 18 patients of this series. After reconstruction of the debranched arch and ascending aorta, the common stem of the trifurcation graft is anastomosed to the arch graft. In this series, there were 27 males, and mean age was 63 ؎ 13 years. Fifteen cases (35%) were performed with urgent/emergent priority. Nineteen patients (44%) were operated for aortic dis-section, and the remainder for aneurysms. Seven patients (16%) had previously undergone a cardiac surgical procedure. Results: There were two (4.7%) early mortalities while one patient (2.3%) experienced a permanent stroke. One patient (2%) required mechanical support while three (7%) required hemofiltration for renal support. Extubation was achieved within 24 hours in 21 patients (49%) while 19 (42%) were discharged from the Intensive Care Unit (ICU) within two days. Eight patients (19%) did not require any transfusion of red cells or platelets. Mean follow-up duration was 21 ؎ 19 months and was 100% complete. At three years, survival was 95 ؎ 3.2%. No patients required subsequent aortic reoperation during this early follow-up period. Conclusions: This modified branch-first continuous perfusion technique brings us closer to the goal of arch surgery without cerebral or visceral circulatory arrest and the morbidity of deep hypothermia. Our early experience is encouraging although greater numbers and longer follow-up will reveal the full potential of this approach.
Brain and Lower Body Protection During Aortic Arch Surgery
Background. Deep hypothermic circulatory arrest (DHCA) at ≤20°C for aortic arch surgery has been widely used for decades, with or without cerebral perfusion (CP), antegrade (ACP) or retrograde. In recent years nadir temperature progressively increased to 26-28 °C (moderately hypothermic circulatory arrest, MHCA), adding ACP. Aim of this multicentric study is to evaluate early results of aortic arch surgery and if DHCA with 10-minute of cold reperfusion at the same nadir temperature of the CA before rewarming (delayed rewarming, DR) can provide a neuroprotection and a lower body protection similar to that provided by MHCA+ACP. Methods. Two-hundred-ten patients were included in the study. DHCA+DR was used in 59 patients and MHCA+ACP in 151. Primary endpoints were death, neurologic event (NE), temporary (TNE) or permanent (permanent neurologic deficit, PND), and need of renal replacement therapy (RRT). Results. Operative mortality occurred in 14 patients (6.7%), NEs in 17 (8.1%) and PN...
The Journal of Thoracic and Cardiovascular Surgery, 2014
Objective: To evaluate our extensive clinical experience using deep hypothermic circulatory arrest (DHCA) as a sole method of cerebral protection during aortic arch surgery, with an emphasis on determining the safe duration of DHCA. Methods: A total of 490 consecutive patients (303 males [61.8%], mean age, 62.7 AE 13.5 years) underwent surgical interventions on the aortic arch with straight DHCA for cerebral protection. Of the procedures, 65 (13.3%) were either urgent or emergency. Aortic aneurysms (n ¼ 417, 85.1%) and dissections (n ¼ 71, 14.5%) were the main indications for surgery. Results: The mean DHCA duration was 29.2 AE 7.9 minutes at a mean bladder temperature of 18.7 C. The overall mortality was 2.4% (12 of 490), and elective mortality was 1.4% (6 of 425). The seizure rate was 1.4% (7 of 490). Six patients (1.2%) developed renal failure that required dialysis. The postoperative stroke rate was 1.6% (8 of 490) and was 1.2% (5 of 425) for the elective cases. The overall stroke rate for patients requiring <50 minutes of DHCA was 1.3% (6 of 478), significantly different from the 16.7% (2 of 12) stroke rate for patients requiring >50 minutes of DHCA (P ¼ .014). Multivariate analysis revealed a DHCA time >50 minutes (odds ratio, 5.11 AE 4.01, P ¼ .038) and aortic dissection (odds ratio, 3.59 AE 1.72, P ¼ .008) to be strong predictors of composite adverse outcomes. Conclusions: Straight DHCA is a safe and effective technique of cerebral protection for the absolute majority of interventions involving the aortic arch. At experienced centers, up to 50 minutes of DHCA can be considered safe, without significant postoperative mortality or neurologic sequelae.