J Thorac Cardiovasc Surg 2006;132:735
© 2006 The American Association for Thoracic Surgery
Reply to the Editor
John A. Elefteriades, MD,
Nikola Dobrilovic, MD,
Arjet Gega, MD
Department of Cardiothoracic Surgery, Yale University School of Medicine, New Haven, Conn
We appreciate the thoughtful commentary from Dr Wheatley. We are aware of the imaginative work being done in catheter-based treatment of aortic diseases at the Arizona Heart Institute.
There are certainly many clever ways to "manipulate" the anatomy of the aortic arch to make stent therapy feasible, and we applaud the exploration of these techniques. We disagree, however, with the undercurrent of fear of deep hypothermic circulatory arrest (DHCA) manifest in Dr Wheatley's letter.
DHCA is a proven modality in aortic surgery, with a vast clinical experience demonstrating its clinical utility and safety.1–4
At our own institution, Dr Arjet Gega has just completed (for upcoming submission) a review of 400 patients operated on under "straight" DHCA, without any adjunctive retrograde or antegrade cerebral perfusion. This experience included all comers: ascending, arch, descending, and thoracoabdominal; elective and emergency; and ruptured and nonruptured. Overall mortality was 6.5%, stroke rate was 4.9%, and reexploration for bleeding was 3.9%. Cerebral protection was excellent, with most strokes embolic in origin. The supposed bleeding diathesis of DHCA is simply not a problem. It is not uncommon for us to find the morning's DHCA patient extubated, vibrantly conversant, and having a light supper by the time of evening rounds. DHCA need not be feared. At our institution we marvel at the protective abilities of this technique, and we are pleased to call upon them at every opportunity.
Current results for surgery under DHCA at many expert centers worldwide sets a standard that will be hard to exceed with clever extra-anatomic and catheter based modalities. In fact, it remains to be shown in careful analysis of large clinical series that the alternative modalities can even come close to meeting the excellent results of traditional, direct arch surgery under DHCA.
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References
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- Minatoya K, Ogino H, Matsuda H, Sasaki H, Yagihara T, Kitamara S. Surgical management of distal arch aneurysm. another approach with improved results. Ann Thorac Surg 2006;81:1353-1357.[Abstract/Free Full Text]
- Appoo JJ, Augoustides JG, Pochettino A, Savino JS, McGarvey ML, Cowie DC, et al. Perioperative outcome in adults undergoing elective deep hypothermic circulatory arrest with retrograde cerebral perfusion in proximal aortic arch repair. evaluation of protocol-based care. J Cardiothorac Vasc Anesth 2006;20:3-7.[Medline]
- Svensson LG, Nadolny EM, Penney DL, Jacobson J, Kimmel WA, Entrup MH, et al. Prospective randomized neurocognitive and S-100 study of hypothermic circulatory arrest, retrograde brain perfusion, and antegrade brain perfusion for aortic arch operations. Ann Thorac Surg 2001;71:1905-1912.[Abstract/Free Full Text]
- Goldstein LJ, Davies RR, Rizzo JA, Davila JJ, Cooperberg MR, Shaw RK, et al. Stroke in surgery of the thoracic aorta. incidence, impact, etiology, and prevention. J Thorac Cardiovasc Surg 2001;122:935-945.[Abstract/Free Full Text]
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A new surgical paradigm: Hybrid open and endovascular repair of the ascending aorta and aortic arch for acute type A dissection
- Grayson H. Wheatley, III
J. Thorac. Cardiovasc. Surg. 2006 132: 734-735.
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