The incidence of transient neurologic dysfunction after ascending aortic replacement with circulatory arrest

BACKGROUND: Transient neurologic dysfunction (TND) namely postoperative confusion, delirium, and agitation after aortic operation, particularly after deep hypothermic circulatory arrest (DHCA), remains an underestimated adverse event in the early outcome of these patients. Although no influence on long-term outcome has been reported so far, this entity markedly affects the early outcome and leads to prolonged intensive care unit and hospital stay. METHODS: Between January 1997 and January 2003, 160 consecutive patients (130 type A dissections [81%] and 30 elective atherosclerotic aneurysms [19%]) had surgical repair with DHCA for a thoracic aortic aneurysm limited to the ascending aorta. From those, 40 patients (25%) underwent DHCA alone, whereas in 13 patients (8%) antegrade cerebral perfusion and in 103 patients (64%) retrograde cerebral perfusion was used for further brain protection. RESULTS: The overall incidence of TND was 18% (28 of 160) with a significant association between duration of circulatory arrest and the incidence of TND (13.8% in DHCA < 30 minutes versus 37.9% in DHCA > 40 minutes; p < 0.05). Furthermore the severity of TND was directly associated with the duration of circulatory arrest and age. In contrast, however, the use of retrograde cerebral perfusion had no influence on the incidence of TND, (p < 0.05). Intensive care unit stay as well as hospital stay were prolonged in the patients with TND (intensive care unit 14.3 +/- 14.2 days versus 10.8 +/- 13.7 days, p < 0.05; hospital stay 15.6 +/- 10.1 days versus 11.4 +/- 7.9 days, p < 0.05). CONCLUSIONS: Duration of DHCA, regardless of whether retrograde cerebral perfusion was used, was the most important predictor of the incidence of transient neurologic dysfunction in patients who had replacement of the ascending thoracic aorta. The occurrence of TND leads to impaired functional recovery as well as prolonged intensive care unit and hospital stay.     

Outcomes after ascending aorta and proximal aortic arch repair using deep hypothermic circulatory arrest with retrograde cerebral perfusion: analysis of 207 patients

OBJECTIVES Correction of ascending aorta and proximal aortic arch pathology with numerous surgical techniques having been proposed over the years remains a surgical challenge. This study was undertaken to identify risk factors influencing outcome after aortic arch operations, requiring deep hypothermic circulatory arrest (DHCA). METHODS Between 1993 and 2010, 207 consecutive patients were operated for ascending aorta and proximal arch correction with the use of deep hypothermic circulatory arrest with retrograde cerebral perfusion. All patients were followed up with regular out-patient clinics, transthoracic echocardiography and, when required, chest computed tomography. RESULTS There were 102 (49.3%) emergencies (acute type A dissection) and 105 (50.7%) elective cases. Mean age: 63.5?±?12?years. Mean circulatory arrest time was 25.4?±?13?min. Unadjusted analysis of factors associated with 30-day mortality revealed emergency status, preoperative hemodynamic instability, acute dissection, reoperation, increased circulatory arrest time, postoperative bleeding, postoperative creatinine levels and presence of neurological dysfunction. Multi-adjusted analysis revealed duration of circulatory arrest as the only and main factor related to death. Thirty-day mortality was 2.4% for the elective and 7.2% for emergencies cases. Survival during long-term follow-up was 93, 82 and 53% at 1, 5 and 10?years, respectively. CONCLUSIONS Ascending aorta and proximal aortic arch replacement with brief duration of deep hypothermic circulatory arrest combined with retrograde cerebral perfusion is a safe method with acceptable short- and long-tem results.     

升主动脉和弓部动脉瘤的外科治疗

目的：总结升主动脉和弓部动脉瘤手术治疗经验，以期进一步提高手术疗效。方法：自2000年7月至2002年5月应用深低温停循环（DHCA）和上腔静脉逆行脑灌注（RCP）技术手术治疗升主动脉和弓部动脉瘤20例，其中急症手术5例。施行全弓置换术2例，全弓置换和象鼻手术3例，半弓置换术15例。同期行Bentall手术8例，升主动脉置换术或同时行主动脉瓣置换术12例，冠状动脉旁路移植术1例。结果：术后早期死亡1例，短时间浅昏迷1例，呼吸功能不全2例，肾功能不全2例，无晚期死亡。结论：DHCA和RCP技术是手术治疗升主动脉和弓部瘤的安全、有效方法，急性A型夹层动脉瘤的手术方式取决于内膜破裂口的位置；正确掌握DHCA和RCP技术，手术方式和手术技术、围术期处理是提高手术疗效的关键因素。     

Surgical technique to avoid circulatory arrest and direct arch vessel cannulation during neonatal aortic arch reconstruction.

Deep hypothermic circulatory arrest (DHCA) has been used routinely for surgery involving the aortic arch. Recently, techniques have been developed that avoid circulatory arrest and maintain low-flow cerebral perfusion (LFCP) in an attempt to avoid the potential neurological sequelae associated with DHCA. We describe a technique of LFCP that avoids circulatory arrest and direct cannulation of the arch vessels. Five patients underwent reconstruction of the aortic arch with concomitant biventricular intracardiac repair. The distal ascending aorta was cannulated and patients were systemically cooled. The cannula was advanced into the innominate artery and snared in place prior to opening and reconstructing the aorta with continuous LFCP. In all five patients, we completely avoided circulatory arrest and direct cannulation of the arch vessels. All patients survived and there were no adverse neurological outcomes.     

Effects of deep hypothermic circulatory arrest on outcome after resection of ascending aortic aneurysm

BACKGROUND: Aneurysm of the ascending aorta is a common finding especially in patients with aortic valve diseases. The aim of this study was to analyze early and midterm outcome in patients operated on for aneurysm of the ascending aorta with or without the use of deep hypothermic circulatory arrest (DHCA). METHODS: Between January 1996 and December 2000, 133 of 410 patients with thoracic aortic pathology were operated on for an aortic aneurysm limited mainly to the ascending aorta. Early and midterm outcomes were assessed and quality of life (QOL) evaluated using the Short-Form 36 Health Survey Questionnaire (SF-36). RESULTS: Sixty patients (group 1) were operated on with DHCA and 73 patients (group 2) without DHCA. In-hospital mortality was identical in both groups (9.6% versus 6.7%; p = not significant) whereas postoperative transient neurologic events were significantly more frequent in group 1 (6.7% versus 0%; p < 0.05). Midterm clinical outcome was not different between groups but QOL showed significant impairment in daily functional physical and emotional activity in group 1 patients compared with group 2 and an age-matched standard population. CONCLUSIONS: The risk of transient neurologic complications is significantly increased with the use of DHCA and QOL is impaired without benefits in the long-term outcome especially among older patients.     

Is aortic surgery using hypothermic circulatory arrest in octogenarians justifiable?

OBJECTIVE: This study was undertaken to analyze the risk of mortality and neurological complications after aortic surgery requiring hypothermic circulatory arrest (HCA) in octogenarians. METHODS: All patients of >80 years at the time of aortic surgery requiring HCA since 1988 were examined. Of 51 patients, 23 were male; the median age was 83. Twenty-six (51%) had proximal repair; the arch was replaced in eight (16%), and 17 (33%) had descending aorta repair. Eleven (22%) were emergencies. Multivariate analysis was carried out to determine the risk factors for in-hospital mortality and/or stroke (adverse outcome) using variables with P<0.1 after univariate analysis. RESULTS: The hospital mortality was 16%. Five patients suffered strokes (9.8%): only one survived >6 months, and three died before discharge. The overall adverse outcome was 22%, but elective operation was associated with much better results, with an adverse outcome of only 3.6% after operations via a median sternotomy. Adverse outcome was strikingly higher with more distal resections via a left thoracotomy: 47 vs. 8.8% for ascending aorta/arch resections (P=0.003). Emergency operation via a lateral thoracotomy was associated with a prohibitively high adverse outcome. Twenty-nine patients (73%) had temporary neurological dysfunction (TND). Multivariate analysis revealed emergency operation (P=0.01; odds ratio (OR), 10.6) and operations via a lateral thoracotomy (P=0.008; OR, 11) as independent preoperative predictors of adverse outcome. The overall survival was 66% at 2 years and 39% at 5 years, compared with 85 and 52% among age- and sex-matched controls. CONCLUSIONS: Aortic surgery utilizing HCA in octogenarians can be performed with an acceptable risk of mortality and stroke. From the evidence in this study, it seems that elective aneurysm repair via a median sternotomy can be undertaken for the usual indications, even in octogenarians. However, the enhanced vulnerability of the brain in the elderly is reflected by a high early mortality following stroke, and a high incidence of TND. Emergency operations increase the possibility of adverse outcome dramatically, and patients who require a lateral thoracotomy are at significantly higher risk than those operated via a median sternotomy.     

Predictors of adverse outcome and transient neurological dysfunction after ascending aorta/hemiarch replacement

Background. This study was undertaken to determine predictors of adverse outcome and transient neurological dysfunction after replacement of the ascending aorta with an open distal anastomosis.

Methods. All 443 patients (300 male, median age 63) undergoing replacement of the ascending aorta with an open distal anastomosis between 1986 and 1998 were included in the analysis. The ascending aorta alone was replaced in 190 (42.9%); 253 (57.1%) also had proximal arch replacement. Median hypothermic circulatory arrest (HCA) time was 25 minutes (range 12 to 68). Either death or permanent neurological dysfunction were considered adverse outcome (AO).

Results. Adverse outcome occurred in 11.5% (51 of 443) of patients overall: in 7.4% of elective (20 of 269) or urgent (4 of 54) operations, but in 17% (19 of 113) of emergencies. Multivariate analysis of the group as a whole revealed that significant (p < 0.05) independent preoperative predictors of AO were age greater than 60 [odds ratio (OR) 2.2], hemodynamic instability (OR 2.7), and dissection (OR 1.9). For the 435 operative survivors, procedural variables predictive of AO were contained rupture (OR 2.8) and HCA time (OR 1.03/min). When only the 271 elective patients were analyzed separately, the need for a concomitant procedure (p = 0.009, OR 3.6) and HCA time (p = 0.002, OR 1.06/min) were the only predictors of AO in multivariate analysis. Transient neurological dysfunction (TND) occurred in 86 of 392 patients (22%). Significant predictors of TND for all patients without AO were age (OR 1.06/y), HCA time (OR 1.04/min), coronary artery disease (OR 2.2), hemodynamic instability (OR 3.4), and acute operation (OR 2.2). Survival of discharged patients was 93% at 1 year and 83% at 5 years.

Conclusions. Early elective operation and shorter HCA time during ascending aorta/hemiarch surgery will reduce both AO and TND.     

Similar Cerebral Protective Effectiveness of Antegrade and Retrograde Cerebral Perfusion During Deep Hypothermic Circulatory Arrest in Aortic Surgery: A Meta‐Analysis of 7023 Patients

In aortic arch surgery, deep hypothermic circulatory arrest (DHCA) combined with cerebral perfusion is employed worldwide as a routine practice. Even though antegrade cerebral perfusion (ACP) is more widely used than retrograde cerebral perfusion (RCP), the difference in benefit and risk between ACP and RCP during DHCA is uncertain. The purpose of this meta‐analysis is to compare neurologic outcomes and early mortality between ACP and RCP in patients who underwent aortic surgery during DHCA. PubMed, EMBASE, and the Cochrane Library were searched using the key words “antegrade,” “retrograde,” “cerebral perfusion,” “cardiopulmonary bypass,” “extracorporeal circulation,” and “cardiac surgery” for studies reporting on clinical endpoints including early mortality, stroke, temporary neurologic dysfunction (TND), and permanent neurologic dysfunction (PND) in aortic surgery requiring DHCA with ACP or RCP. Heterogeneity was analyzed with the Cochrane Q statistic and I² statistic. Publication bias was tested with Begg's funnel plot and Egger's test. Thirty‐four studies were included in this meta‐analysis, with 4262 patients undergoing DHCA + ACP and 2761 undergoing DHCA + RCP. The overall pooled relative risk for TND was 0.722 (95% CI = [0.579, 0.900]), and the z‐score for overall effect was 2.9 (P = 0.004). There was low heterogeneity (I² = 18.7%). The analysis showed that patients undergoing DHCA + ACP had better outcomes than those undergoing DHCA + RCP in terms of TND, while there were no significant differences between groups in terms of PND, stroke, and early mortality. This meta‐analysis indicates that DHCA + ACP has an advantage over DHCA + RCP in terms of TND, while the two methods show similar results in terms of PND, early mortality, and stroke.     

Comparison of operative techniques in acute type A aortic dissection performing the distal anastomosis

OBJECTIVE: The aim of our retrospective study was to evaluate early and midterm clinical outcomes of two surgical techniques: open anastomosis in deep hypothermic circulatory arrest (DHCA) compared to anastomosis with clamped aorta while continuing on extracorporeal circulation (CECC). METHODS: Between November 1997 and February 2002, 67 patients were operated for acute type A aortic dissection. Records of 35 patients with isolated replacement of the ascending aorta without intervention on the aortic arch were retrospectively reviewed. The influence of two techniques (DHCA n = 15, CECC n = 20) on clinical outcome and midterm follow up was investigated. RESULTS: There were no statistically significant differences in preoperative data. Female gender in the DHCA group was coincidentally more frequent. Intraoperative management did not result in different early clinical outcome. 30-day mortality was not statistically different. Mean follow up time was 20.7 +/- 11.1 months in the DHCA group and 28.7 +/- 14.3 months in the CECC group. One-year and 3-year survival estimates in DHCA group were 85%+/- 7% and 79%+/- 9%, respectively. In the CECC group similar survivals were 80%+/- 10% and 73%+/- 11%, respectively. No statistically significant differences between the two groups were obtained in early or midterm outcome. CONCLUSION: While there is no difference in clinical outcome in surgical treatment of acute type A aortic dissection with or without circulatory arrest, there are some practical technical advantages if the distal anastomosis is performed in an open manner. Probably the long-term outcome too is better with this anastomosis technique.     

主动脉弓部手术75例

目的 总结主动脉弓部手术的方法和临床经验。方法75例弓部手术中74例采用深低温停循环（DHcA）技术，其中54例脑保护采用上腔静脉逆灌（RCP），20例采用右腋动脉顺灌（SCP）；仅1例在中度低温体外循环下行局部切除吻合。升主动脉和半弓置换53例，其中同期行降主动脉腔内支架植入术11例，弓部内膜破口修补6例，降主动脉近端内膜破口修补3例；升主动脉和全弓置换20例，其中同期行传统象鼻手术12例，降主动脉腔内支架植入4例；单纯弓部瘤切除缝合及弓部置换各1例。同期手术包括17例Bentall手术，12例AVR，3例Cabrol手术，5例二尖瓣成形术，9例主动脉瓣悬吊成形术等。DHCA9～120min，平均42．3min。结果手术死亡5例，死亡率6．7％。主要并发症为呼吸功能不全11例，肾功能不全7例，一过性精神异常9例。结论DHCA＋RCP及DHCA＋SCP技术均是主动脉弓部手术的有效方法，但后者更适用于复杂的弓部手术；手术范围和方式取决于病变性质和范围，术前状况和手术技术是影响手术效果的决定因素。     

Hypothermic circulatory arrest does not increase the risk of ascending thoracic aortic aneurysm resection.

OBJECTIVE: The purpose of this study was to investigate the safety and efficacy of a period of deep hypothermic circulatory arrest (DHCA) during elective replacement of the ascending thoracic aorta. SUMMARY BACKGROUND DATA: DHCA has been implemented in ascending thoracic aortic aneurysm resection whenever the anatomy or pathology of the aorta or arch vessels prevents safe or adequate cross-clamping. Profound hypothermia and retrograde cerebral perfusion have been shown to be neurologically protective during ascending aortic replacement under circulatory arrest. METHODS: The authors conducted a retrospective analysis of 91 consecutive patients who underwent repair of chronic ascending thoracic aortic aneurysms from 1986 to present. The authors hypothesized that patients undergoing DHCA with or without retrograde cerebral perfusion during aneurysm repair were at no greater operative risk than patients who received aneurysm resection while on standard cardiopulmonary bypass. RESULTS: There were no significant differences in hospital mortality, stroke rate, or operative morbidity between patients repaired on DHCA when compared to those repaired on cardiopulmonary bypass. CONCLUSIONS: DHCA with or without retrograde cerebral perfusion does not result in increased morbidity or mortality during the resection of ascending thoracic aortic aneurysms. In fact, this technique may prevent damage to the arch vessels in select cases and avoid the possible complications associated with cross-clamping a friable or atherosclerotic aorta.     

Risk factor analysis for ascending aorta and aortic arch repair using selective cerebral perfusion with open technique: role of open-stent graft placement

AIM: The present study was designed to identify risk factors that may induce adverse outcome defined as permanent neurological dysfunction and mortality after aortic arch surgery using selective cerebral perfusion by logistic regression analysis and to reveal the role of open stent-graft placement. METHODS: One hundred and nineteen consecutive patients underwent ascending aorta and/or aortic arch operation with open technique between 1995 and 2005 were examined. Ascending aorta and/or hemiarch was replaced in 28 patients, total arch in 75 patients, and proximal or distal aortic arch replacement in 16 patients. Open stent-graft placement was used in 25 patients. RESULTS: The in-hospital mortality rate was 9.2%. Permanent neurological dysfunction occurred in 10 patients (8.4%). Thoracotomy (P=0.0331) and cardiopulmonary bypass time (P=0.0238) were significant risk factors for permanent neurological dysfunction. Preoperative shock (P=0.0266) was significant independent risk factor for mortality. Emergent operation (P=0.0454), thoracotomy (P=0.0232), and cardiopulmonary bypass time (P=0.0379) were significant independent risk factors for adverse outcome. The duration of selective cerebral perfusion was not associated with adverse outcome. Open stent-graft placement has no need of thoracotomy for aneurysm extending descending thoracic aorta and time variables concerning the operation were significantly shorter in the patients with open stent-graft placement than in patients with standard operation for total arch replacement. CONCLUSIONS: Thoracotomy was significant risk factor for adverse outcome after aortic arch repair using selective cerebral perfusion. Total arch replacement with open stent-graft placement can avoid the need of thoracotomy and reduce time variables concerning the operation to improve the surgical RESULTS:     

经上腔静脉逆行灌注脑保护在主动脉瘤手术中的应用

目的　探讨在主动脉瘤手术中应用经上腔静脉逆行灌注的脑保护效果。　方法　 65例主动脉瘤患者分 2组 ,15例采用深低温停循环 (DHCA) ,5 0例经上腔静脉逆行灌注 (RCP)进行脑保护。术中比较 2组患者不同时间颈内静脉的血乳酸含量 ,对部分RCP患者测定了灌注血和回流血的流量分布 ,以及灌注血和回流血的氧含量。　结果　DHCA组停循环时间为 10 0～ 63 0min ,平均(3 5 9± 18 8)min ;RCP组为 16 0～ 81 0min ,平均 (45 5± 17 2 )min。术后至清醒时间DHCA组为4 4～ 9 4h ,平均 (7 1± 1 6)h ;RCP组 2 0～ 9 0h ,平均 (5 4± 2 2 )h。DHCA组手术死亡 3例 ,RCP组死亡 1例 ;术后神经系统并发症DHCA组 3例 (死亡 2例 ,成活 1例 ) ,RCP组 1例 (存活 )。手术总成功率和神经系统并发症发生率RCP组分别为 96%和 2 % ,DHCA组为 67%和 2 0 % (P <0 0 5 )。RCP组再灌注期间颈内静脉血乳酸含量增高幅度低于DHCA组 [(4 4± 0 6)mmol/Lvs (6 2± 0 9)mmol/L ,P <0 0 1],经头臂和下腔静脉血流量测定显示约 2 0 %血液经头臂动脉回流 ,灌注血和回流血氧差9 0 0～ 13 67ml/L ,证实RCP期间脑组织有氧利用。　结论　在主动脉瘤手术中 ,应用RCP可以延长停循环的安全时限 ,是可行的脑保护方法     

Replacement of the ascending and transverse aortic arch: determinants of long-term survival

BACKGROUND: Although little has been published on the natural history of aneurysms of the ascending aorta and aortic arch, long-term prognosis of untreated aneurysms is generally poor. We reviewed our 10-year experience in the repair of the ascending aorta and aortic arch to evaluate long-term outcome. METHODS: Between January 1991 and May 2001, we repaired 423 aneurysms of the ascending aorta or aortic arch using profound hypothermic circulatory arrest. Median age was 65 years. Retrograde cerebral perfusion (RCP) was used in 357 cases. Mean pump and RCP times were 139 and 33.9 minutes, respectively. Survival was ascertained by direct patient contact or by searching the social security death index. Survival was analyzed by Kaplan-Meier stratified analysis and by multivariate Cox regression. RESULTS: Overall actuarial survival was 72% at 5 years and 71% at 10 years after surgery. Univariate analysis identified increasing age (p < 0.0001), chronic obstructive pulmonary disease (p < 0.014), concurrent unoperated aneurysm (p < 0.005), arch involvement (p < 0.042), pump time (p < 0.0004), concurrent aortic valve replacement (p < 0.009), and postoperative renal failure (p < 0.0002) as factors that negatively influenced survival. Multivariate analysis identified increasing age (p < 0.0001) and pump time (p < 0.0001). RCP did not have a significant independent effect on the long-term survival. CONCLUSIONS: Our experience indicates that repair of the ascending aorta and aortic arch can be accomplished with good long-term survival.     

Long-term effectiveness of operative procedures for stanford type a aortic dissections

BACKGROUND: The object was to evaluate the long-term effectiveness of strategies for managing the aortic root and distal aorta in type A dissections. METHODS: From 1990 to 1999, 50 patients (32 men (64.07%); 18 women, (36.0%); mean age 57.4 +/- 11.1 years) underwent operation for ascending aortic dissection. Surgical strategies included aortic root replacement with a composite graft (21/50; 42.0%), valve replacement with supracoronary ascending aortic graft (3/50, 6%), and valve preservation or repair (26/50; 52.0%). RESULTS: Overall hospital mortality rate was 18.0%. Follow-up was completed for 47 patients (94.0%) and ranged from 1 month to 10.5 years (mean 28.8 months). Actuarial survival for patients discharged from the hospital was 84% at 1 year, 75% at 5 years, and 66% at 10 years. There was no significant difference between the various procedures regarding mortality, neurological complications, long-term survival, and proximal reoperations. The ascending aorta alone was replaced in 8 of 50 patients (16%), ascending and hemiarch in 30 of 50 patients (60%), and arch and proximal descending aorta in 12 of 50 patients (24%). Hospital mortality (11.5%, 20.0%, and 16.7%, respectively; p > 0.05) and 5- and 10-year survival (p > 0.05) were not statistically dependent on the extension of the resection distally. Residual distal dissection was not associated with a decrease in late survival. With regard to emergency surgery (36/50) there was no significant difference in hospital mortality (p > 0.05) and 5-year survival (p > 0.05) between those who had undergone coronary angiography (19/36; 52.8%) on the day of surgery with those who had not (17/36; 47.2%). CONCLUSIONS: Preservation or repair of the aortic valve can be recommended in the majority of patients with type A dissection. Distal extension of the resection does not increase surgical risk. Residual distal dissection does not decrease late survival. Preoperative coronary angiography may not affect survival in patients undergoing emergency surgery.     

Minimized mortality and neurological complications in surgery for chronic arch aneurysm: axillary artery cannulation, selective cerebral perfusion, and replacement of the ascending and total arch aorta

OBJECTIVE: Cerebral complication is still a major concern in surgery for arteriosclerotic aortic arch disease. For preventing this complication, axillary artery cannulation, selective cerebral perfusion, and replacement of the ascending and arch aorta were applied to thoracic aortic aneurysm involving aortic arch. METHOD: From May 1999 to July 2002, consecutive 39 patients with true aneurysm (29 patients) or chronic aortic dissection (10 patients) involving aortic arch underwent replacement of the ascending and arch aorta with an elephant trunk under hypothermic cardiopulmonary bypass through the axillary artery cannulation and selective cerebral perfusion. The brain was continuously perfused without any intermission through the axillary artery. Concomitant operation included coronary artery bypass grafting (CABG) in two patients, aortic valve replacement (AVR) in one, Bentall operation in two, mitral valve replacement (MVR) in one, and aortic valve sparing operation in one. Patient age at operation was 40-84 (72 + 9) years and 24 of them were older than 70 years of age. RESULTS: There was one operative death (2.5%) due to bleeding from the left lung, and one hospital death due to respiratory failure. Postoperative permanent neurological dysfunction was found in one patient (2.5%). Two patients presented temporary neurological dysfunction (5%). Thirty-six of the 39 patients were discharged from hospital on foot. CONCLUSION: Continuous perfusion through the axillary artery with selective cerebral perfusion and replacement of the ascending and arch aorta may minimize cerebral complication leading to satisfactory results in patients with chronic aortic aneurysm involving aortic arch.     

Thorakale Aortenchirurgie unter moderater Hypothermie und kalter Gehirnperfusion

Background

This study was undertaken to identify pre- and perioperative risk factors to mortality and permanent neurological dysfunction (PND) and temporary neurological dysfunction (TND) in a large patient cohort, all operated under moderate hypothermic circulatory arrest (HCA) and selective antegrade cerebral perfusion (SACP) in a single centre.

Patient and Methods

Between November 1999 and March 2006, 319 patients at a median age of 65 years (range 21–86, 201 male) underwent elective aortic arch surgery with moderate HCA at 25°C and additional SACP at 14°C. Sixty-nine had additional coronary artery bypass grafts or valve procedures. Ninety-four (29%) had total arch repair. Statistical analysis was carried out to determine the risk factors for 30-day mortality as well as for TND and PND.

Results

Overall mortality was 7.8% (15% in cases with repeat surgery vs 4.8% in nonrepeats, P=0.002). Twenty-seven (8.5%) suffered from PND, and six (22%) died during hospital stay (P=0.004). There was TND detected in 32 patients (10%). Stepwise logistic regression revealed age (P=0.001, OR 1.09/year), repeat surgery (P=0.008, OR 5.04), preoperative neurological events (P=0.004, OR 3.44), CAD (P=0.051, OR 3.58), and cardiopulmonary bypass duration (P<0.001, OR 1.01/min) as risk factors for mortality. The PND was associated with preoperative renal insufficiency (P=0.026, OR 3.34) and operation duration (P<0.001, OR 1.01/min), whereas TND occurred in patients with coronary artery disease (P=0.04, OR 2.41), and prolonged cardiopulmonary bypass duration (P=0.05, OR 1.01/min).

Conclusion

Thoracic aortic surgery including aortic arch using HCA and SACP can be performed with excellent results in elective patients, especially those without previous surgery. Nevertheless PND is associated with high hospital mortality. Neurological complications seem to be strongly associated with general atherosclerotic changes as well as the extent of surgery.     

Cardiopulmonary bypass for thoracic aortic aneurysm: a report on 488 cases

Our objective was to investigate different cardiopulmonary bypass (CPB) techniques for thoracic aortic aneurysm retrospectively. Four hundred and eighty-eight patients with thoracic aortic aneurysm received surgical treatment. Total CPB was used routinely in 331 cases with ascending aortic aneurysm. When the aneurysm expanded to the aortic arch, brain protection was executed by adopting deep hypothermia circulatory arrest (DHCA) or DHCA combined with retrograde cerebral perfusion (RCP). Selected cerebral perfusion via carotid artery was used in three cases and separated upper and lower body perfusion in five cases. Left heart bypass was adopted for the surgeries of 157 cases with descending aortic aneurysm. In two of the cases, ventricular defibrillation could not be achieved, and then bypass was altered to separated upper and lower body perfusion to acquire satisfactory outcome. In the ascending aortic aneurysm group, DHCA time in the 17 patients was 10-63 minutes (mean 35.58 +/- 18.81 min), and DHCA +/- RCP time in 61 patients was 16-81 minutes (mean 43.43 +/- 17.91 min). Total mortality of aortic aneurysm surgery requiring full CPB was 5.4% (18/331), in which eight patients died in emergency operations. The total mortality of emergency operation was 11.9% (8/67). In the descending aortic aneurysm group, time of left heart bypass was 125.56 +/- 57.28 min, and the total mortality was 7% (11 of 157 patients). Three patients developed postoperative paraplegia. Techniques for extracorporeal circulation for surgery of the aorta are dependent on the nature of the disease and require a flexible approach to meet the specific anatomical challenge. The ability to alter the perfusion circuit to meet unexpected situations should be anticipated and planned for. In this series, we have varied our approach to perfusion techniques as required with acceptable outcome data as compared to the international literature.     

Determinants of early and late outcome for reoperations of the proximal aorta

Background

The purpose of this study was to investigate the cause of ascending aorta and aortic arch reoperations and to identify determinants of early and late outcome.

Methods

Between January 1991 and March 2003 we repaired aneurysms of the proximal aorta in 597 patients. Of these patients, 104 had reoperations for replacement of the ascending aorta, aortic root, or transverse aortic arch. Previous surgery was defined as any previous cardiac or proximal aortic repair. Median age was 60 years, and 29 of the patients (28%) were female. Indications for reoperation and replacement of the proximal aorta included acute type A dissection in 6 patients (5.8%), aneurysm with chronic dissection in 60 (57.7%), progression of aneurysm in 23 (22.1%), infection in 12 (1.5%), inflammatory disease in 2 (1.9%), and atheromatous disease in 1 (1.0%). Reoperations included aortic root replacement in 20 patients (19.2%), total arch replacement with elephant trunk in 28 (26.7%), ascending and proximal arch in 39 (37.5%), and ascending aorta in 27 (26.0%). The median interval between operations was 69 months. Retrograde cerebral perfusion was used in 80 (77%) cases.

Results

Chronic dissection was the most common indicator for reoperation in our population, followed by progression of aneurysm and infection. Thirty-day and in-hospital mortality was 13.5% (14 of 104) and 15.4% (16 of 104), respectively. Chronic obstructive pulmonary disease, renal dysfunction, and increased pump time were risk factors for mortality. Median follow-up was 5.02 years. Eight patients died during that period. Estimated survival at 1, 5, and 10 years was 83%, 80%, and 62%, respectively. Freedom from second proximal reoperations was 97.1% (10 of 104). Freedom from subsequent distal thoracic aortic repair was 84.6% (8 of 104).

Conclusions

Reoperations of the ascending aorta and aortic arch can be performed safely with good long-term results. Patients with previous proximal aortic dissection repair need long-term surveillance. Renal dysfunction and chronic obstructive pulmonary disease must be carefully considered before reoperations of the proximal aorta.     

Long-term effectiveness of operative procedures for Stanford type A aortic dissections

BACKGROUND: To evaluate long-term effectiveness of strategies for managing the aortic root and distal aorta in type A dissections. METHODS: From 1990 to 1999, 50 patients (32 men, 64.07%; 18 women, 36.0%; mean age 57.4 y +/- 11.1) underwent operation for ascending aortic dissection. Surgical strategies included aortic root replacement with a composite graft (21/50; 42.0%), valve replacement with supracoronary ascending aortic graft (3/50, 6%), and valve preservation or repair (26/50; 52.0%). RESULTS: Overall hospital mortality rate was 18.0%. Follow-up was completed for 47 patients (94.0%) and ranged from 1 month to 10.5 years (mean 28.8 months). Actuarial survival for patients discharged from the hospital was 84% at 1 year, 75% at 5 years, and 66% at 10 years. There was no significant difference between the various procedures regarding mortality, neurological complications, long term survival and proximal re-operations. The ascending aorta alone was replaced in 8/50 patients (16%), ascending and hemiarch in 30/50 patients (60%) and arch and proximal descending aorta in 12/50 patients (24%) Hospital mortality (11.5, 20.0 and 16.7% respectively; p > 0.05) and 5- and 10-year survival (p > 0.05) were not statistically dependent on the extension of the resection distally. Residual distal dissection was not associated with a decrease in late survival. With regard to emergency surgery (36/50) there was no significant difference in hospital mortality (p > 0.05) and 5 year survival (p > 0.05) between those who had undergone coronary angiography (19/36; 52.8%) on the day of surgery with those who had not (17/36; 47.2%). CONCLUSIONS: Preservation or repair of the aortic valve can be recommended in the majority of patients with type A dissection. Distal extension of the resection does not increase surgical risk. Residual distal dissection does not decrease late survival. Preoperative coronary angiography may not affect survival in patients undergoing emergency surgery.