Outcome of Less Invasive Proximal Arch Replacement With Moderate Hypothermic Circulatory Arrest Followed by Aggressive Rapid Re-Warming in Emergency Surgery for Type A Acute Aortic Dissection

Abstract

Circ J 2009; 73: 69 -72 urgical mortality rates during emergency operation for type A acute aortic dissection (AAD) are still estimated to range from 9 to 30%, and is associated with postoperative complications such as cerebral injury, bleeding, renal failure, and pneumonia caused by longer operation time (>6 h), longer cardiopulmonary bypass (CPB) time (>4 h), deep hypothermia, and circulatory arrest (DHA). 1 If surgical stress could be minimized by shortening the duration of brain ischemic stress, CPB and operative procedures, the surgical outcome for patients with AAD could be further improved. In the majority of patients, an ascending or hemiarch replacement is sufficient, as the intimal tear is generally located in the ascending or the proximal aortic arch. 2 Recently, it has been reported that moderate hypothermic arrest at 26-28°C without any adjunctive cerebral protection was safe in patients undergoing hemiarch aortic replacement. 3 We have established a new procedure for proximal arch replacement for patients with moderate hypothermic arrest without cerebral perfusion, which is followed by aggressive rapid re-warming to shorten the duration of brain ischemia, CPB, and overall surgery. We report here on the initial results of this procedure for an octogenarian with AAD 4 and have since performed this procedure for all the patients undergoing an emergency proximal arch replacement for AAD. The aim of this study is to assess the mid-term outcome of our newly modified technique. MethodsBetween March 2002 and February 2008, 114 patients underwent emergency surgery for AAD at our institution. The extent of aortic replacement was decided based on the location of the intimal tear (tear-oriented surgery). Ascending/hemiarch aortic replacement was performed in patients with the intimal tear localized in the ascending aorta or in the lesser curvature of the transverse aortic arch proximal to the left subclavian artery. In this series, 85 (74.6%) consecutive patients underwent ascending/hemiarch aortic replacement. We retrospectively reviewed these patients. Institutional review board approval was provided before publication of this manuscript and reporting of the information. Fifty patients (58.8%) were female, and the average age was 66.9±12.0 years, ranging from 36 to 90 years.

Surgery for Acute Type A Aortic Dissection in Octogenarians

“…We believe that operations should be performed with a minimum of invasive stress to reduce operative mortality. Hata et al proposed a “less invasive quick replacement” to reduce operative times, with no postoperative complications or mortality in a small series of patients aged >80 years 17,18 . This technique uses moderate hypothermic arrest (28 °C) without cerebral perfusion.…”

“…Hata et al proposed a "less invasive quick replacement" to reduce operative times, with no postoperative complications or mortality in a small series of patients aged >80 years. 17,18 This technique uses moderate hypothermic arrest (28 • C) without cerebral perfusion. During open distal anastomosis, circulating blood in the CPB circuit is warmed to 40 • C by a maximum level of heat exchanger.…”

Effect of Limb Ischemic Preconditioning on Myocardial Injury in Patients Undergoing Mitral Valve Replacement Surgery - A Randomized Controlled Trial -

“…19 Many factors influence with postoperative recovery, such as CPB time, cross-clamp time, surgical techniques, CPB mode etc. CI, the cumulative postoperative dosage of dobutamine, intensive care stay and postoperative hospital stay were not statistically different.…”

Direct Axillary Arterial Cannulation Using Seldinger's Technique in Aortic Dissection

“…Several studies have shown that side graft cannulation has several advantages over direct arterial cannulation [10-12]. In these series, the exposed axillary artery was clamped for arteriotomy and the angled or straight arterial cannula was inserted for direct cannulation.…”