Cardiosurgery - Skopje

Surgery for acute aortic dissection using moderate Surgery for acute aortic dissection using moderate hypothermia and antegrade cerebral perfusion hypothermia and antegrade cerebral perfusion

via the right subclavian arteryvia the right subclavian artery

Special Hospital for Surgery Special Hospital for Surgery “ “ Filip Vtori”, Skopje, MacedoniaFilip Vtori”, Skopje, Macedonia

A. Temelkovska, I. Kajevski, N. Hristov,Z. Mitrev

May, 2010

Cardiosurgery - Skopje

Acute aortic dissection (AAD) has one of the highest mortality rate in modern medicine, with a 68% mortality at 48 hours

The aim of surgery is to prevent aortic rupture, pericardial tamponade and to relieve aortic regurgitation, neurologic injury.

Various techniques have been proposed as means to protect the central nervous system. They all have both advantages and disadvantages

Cardiosurgery - Skopje

Demographic data

• 103 patients• 79 males. • Mean age 54.3 10.3 • Emergency surgery 29%• 10 patients previous cardiovascular surgery.

Cardiosurgery - Skopje

45 patients(44%) hemodynamic instable, shock, pericardial tamponade, myocardial ischemia or superior vena cava compression.

5 were (2,3%) comatose, 8 (4%) had newly developed transient ischemic attack, 1 patient had stroke

10 had(4,5%) visceral ischemia , limb ischemia in 15 (6,8%) and 6 (2,7%) presented with acute renal failure.

Cardiosurgery - Skopje

Diagnosis was made using:1 patient MRI, 78 patients (80%) with CT,103 (100%) patients TEE

50 (49%) DeBakey type II,53 patients (51%) DeBakey type I

Mild/moderate aortic regurgitation was present 78 patients(80%),severe aortic regurgitation in 25 patients (20%).

Preoperative ejection fraction was 50.7 6.8.

Cardiosurgery - Skopje

•Right subclavian artery antegrade body/ antegrade cerebral perfusion

•Snarred innominate artery

•Occlusion left carotid and subclavian artery

•Upper pressure limit 60-70 mmHg

•Flow rates 10ml/kg body weight

•Temperature 30C

•Retrograde blood cardioplegia

CEREBRAL PERFUSION VIA DIRECT CANNULATION OF THE RIGHT SUBCLAVIAN ARTERY IN AORTIC DISSECTION

Cardiosurgery - Skopje

Cardiosurgery - Skopje

Early on, we performed 13 revisions due to bleeding.

We developed suction assisted bio glue application on the anastomosis lines, forcing the bio glue to impregnate the anastomotic site and needle holes. As result, there was no re-exploration or early deaths as result of bleeding in the last 40 cases.

Mitrev Z, Interact Cardiovasc Thorac Surg. 2007

Cardiosurgery - Skopje

Table. 1 Operative techniques

Tube graft replacement AA 1

Tube graft replacement AA + hemiarch

83

Total 84

Tube graft replacement AA + total arch

8

Bentall AA + total arch 3

Bentall AA + hemiarch 3

Tirone David AA + hemiarch

10

Aortic root reconstr.+AV suspension+ AA + hemiarch

3

Total 27

Complex procedures

AV suspension 18

AV replacement 1

ACBP 3

Simple procedures

Additional procedures

Cardiosurgery - Skopje

Table.2 Extracorporal circulation data

ECC – extracorporal circulation, ACP- antegrade cerebral perfusion,SD – standard deviation

  Tube graft replacement + AV resuspension

Complex procedures

ECC time, minutes, mean SD 105.6 16 223.6 53.2

ACP time, minutes, mean SD 24.7 6.5 35.6 22.3

ACP flow, ml, mean SD 862 113

ACP pressure, mmHg, mean SD 71 6

Nasopharyngeal temperature, C, mean SD

30.8 2.4

Cardiosurgery - Skopje

All patients but 10(10%) showed normal awakening within 8 hours postoperatively.

8 patients of the complex group had a fatal neurologic complication, the cause of coma and death was multiorgan failure and low cardiac output in 4pts, and bleeding in 2 patients.

5 patients had non-fatal neurologic complications. Transient neurologic dysfunction, defined as postoperative confusion, agitation and delirium.

Cardiosurgery - Skopje

Average extubation time was 11.8 5.8 hours, except in 18 patients (19%) that required prolonged ventilation.

Average in hospital stay was 9.0 3.5,

except in 17 patients (complex group) who required prolonged in-hospital stay.

Cardiosurgery - Skopje

Mortality rate of the complex group with

cardiogenic shock was 27%

Mortality rate of the simple group was 4%

Cardiosurgery - Skopje

ACP via right subclavian artery enables safe period for circulatory arrest with effective cerebral perfusion, at the same time avoiding complications of the selective arch vessels cannulation.

Moderate hypothermia 30 C shortens the cooling and rewarming time, thus reducing the complications related to long pump times.

Dissection of the right subclavian artery was present in one patient, with succesfull cannulation and selective brain perfusion, and reconstruction of the artery following decannulation.

There were no malperfusion cases.

Cardiosurgery - Skopje

Conclusion

Direct subclavian artery cannulation for extracorporal circulation and antegradeperfusion using moderate hypothermia (30), along with suction assisted bio glue application,is simple, fast and safe method for treatment of acute aortic dissection with excellent operative and early postoperative results