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Routine Hypothermia with Circulatory Arrest and Retrograde Cerebral Perfusion

for Ascending Aortic Reconstruction

Aortic Symposium 2010

Andrew W. ElBardissi, MD, MPH

Sary F. Aranki, MD

Lawrence H. Cohn, MD

Stanton K. Shernan, MD

Daniel J. FitzGerald, CCP, LP

R. Morton Bolman III, MD

Division of Cardiac SurgeryBrigham and Women’s Hospital

Natural History of Aneurysmal Disease

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Background•Aneurysmal ascending aortic degeneration includes aortic tissue proximal to the innominate artery

•Aortic cross-clamping leaves a segment of aneurysmal distal ascending aorta

Surgical Result following Reconstruction

Closed Distal Anastomosis Open Distal Anastomosis

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Objective

•Evaluate outcomes of elective ascending aortic reconstruction with open distal anastomosis (with RCP) versus closed distal anastomosis with aortic cross-clamping.

Methods687 patients with Ascending Aortic

Reconstruction (2005-Present)

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305 patients

Aortic Dissections

Complex aortic arch reconstructions

195 closed distal (CD)anastomosis

110 open distal (OD)

anastomosis with RCP

1:1 Propensity Matching

99 CD 99 OD

• Primary endpoint–CVA–Temporary Neurologic Deficit–Ventilator Hours– ICU Hours–Length of Stay

• Secondary endpoint–30-day mortality– Intermediate-term Survival

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Methods

Preoperative Characteristics

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OD (n=99) CD (n=99) p-valueAge 60±12 61±12 0.6

Male Gender n(%) 76 (77%) 72 (73%) 0.52Caucasion n(%) 93 (94%) 97 (98%) 0.39Diabetes n(%) 5 (5%) 6 (6%) 0.76

COPD n(%) 88 (89%) 87 (88%) 0.83Hyperlipidemia n(%) 49 (50%) 55 (56%) 0.39Hypertension n (%) 57 (57%) 61 (62%) 0.56

Serum Creatnine 0.98±.23 1.1±0.4 0.17History of CVA n(%) 4 (4%) 6 (6%) 0.52

Previous MI n(%) 4 (4%) 9 (9%) 0.15CHF n(%) 23 (23%) 24 (24%) 0.86

Angina n(%) 16 (16%) 20 (20%) 0.46NYHA Classification 0.43

I 42 (42%) 37 (37%)II 40 (40%) 41 (41%)III 20 (20%) 20 (20%)IV 0 (0%) 1 (1%)

Hemodynamic DataNormal sinus rhythm n(%) 87 (86%) 89 (89%) 0.66

Ejection Fraction 59 ±8 57±13 0.23Mean PAP 23±7 22±8 0.24

Aortic Stenosis n(%) 29 (29%) 37 (37%) 0.27Aortic Stenosis Gradient (mmHg) 35±17 38±20 0.25

Operative Characteristics

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OD (n=99) CD (n=99) p-valueReoperation n (%) 23 (23%) 18 (18%) 0.38CPB time (minutes) 206±95 160±79 0.0005

Cross-clamp time (minutes) 156±73 120±73 0.0006DHCA Temperature (Celsius) 21 . .

DHCA Time 21±8 (11, 50) . .RCP Time 17±8 (3, 50) . .

Concomitant ProceduresAortic valve replacement 22 (22%) 30 (30%) 0.55

CABG 24 (24%) 19 (19%) 0.39

Results

CVA (%) TND (%)0%

1%

2%

RCP CPB

n=1 n=2 n=2 n=1

P=0.42 P=0.57

Ventilator Hours ICU Stay (hours) Length of Stay (days)

0

10

20

30

40

50

60

70

80

P=0.20

P=0.44

P=0.52

0.50

0.55

0.60

0.65

0.70

0.75

0.80

0.85

0.90

0.95

1.00

0.00 300 900

Follow-up (days)

1200

No difference in 30 day (OD, 0% vs. CD, 1%, p=0.59) or Intermediate-term Mortality

P=0.30

• Open distal reconstruction of ascending aorta in AAA repair– No difference in operative mortality,

stroke, temporary neurologic deficit, ventilator hours, ICU hours, or LOS compared to closed distal with aortic x-clamping

– Should be considered as a routine treatment strategy, as it allows removal of AA in its entirety

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Conclusions