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J Thorac Cardiovasc Surg 2007;133:1637-1639
© 2007 The American Association for Thoracic Surgery
Brief Communication |
a Department of Thoracic and Cardiovascular Surgery, Johann-Wolfgang-Goethe University, Frankfurt/Main, Germany
b Department of Biomedical Statistics, Johann-Wolfgang-Goethe University, Frankfurt/Main, Germany.
Received for publication December 17, 2006; accepted for publication January 8, 2007. * Address for reprints: Farhad Bakhtiary, MD, Department of Thoracic and Cardiovascular Surgery, Johann Wolfgang Goethe University, Theodor Stern Kai 7, 60590 Frankfurt am Main, Germany. (Email: farhad{at}bakhtiary.de).
Complex aortic arch procedures pose significant challenges to the cardiac surgeon, as well as significant morbidity to the patient. Different techniques for preservation of cerebral and distal organ function have been demonstrated.1-3
Numerous publications have suggested using total circulatory arrest with systemic temperatures of less than 18°C, but this method can be associated with long operation times and severe coagulation disorders. More recently, antegrade cerebral perfusion has generated increasing interest because it allows aortic arch operations at mild hypothermia.4 For complex procedures, preservation of spinal cord and abdominal organ function remains a problem with this technique, possibly leading to postoperative acute renal failure, neurological deficits, or malfunction of intestinal organs.
This work describes our initial experience with a new perfusion cannula, allowing perfusion of cerebral vessels and the descending aorta with one cannula (Figure 1). This perfusion setup enables "warm" arch surgery with optimal brain and distal organ perfusion, avoiding circulatory arrest with attention to comfortable conditions at the distal anastomosis of the aortic arch.
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Patients are positioned supine on the operating table with the right upper extremity in close proximity to the body. After induction of anesthesia and tracheal intubation, the left radial artery and left femoral artery are cannulated for blood pressure monitoring. A transesophageal echocardiographic probe is placed. Temperature is monitored through esophageal and rectal sensor probes.
After systemic heparinization (300 IU/kg), the right subclavian artery is exposed and cannulated with an 18F to 22F flexible arterial cannula designed by Dr Aybek. After median sternotomy, the right atrium is cannulated with a double-stage venous cannula (Edwards Lifescience, Irvine, Calif). Our standard cardiopulmonary bypass (CPB) circuit includes a membrane oxygenator (Avant Physio, Dideco Stöckert, München, Germany) and heat exchanger (Jostra AG, Hirrlingen, Germany).
CPB is started, and the heart is arrested with intermittent retrograde and selective antegrade cold blood cardioplegia. Cooling is limited to 30°C rectal temperature. The innominate and left common carotid arteries are snared with elastic loops and occluded at the time of initiation of the antegrade cerebral perfusion (ACP) to prevent backflow and thus cerebral steal phenomena. If necessary, the left subclavian artery is blocked with a Fogarty catheter. ACP is conducted with a 30°C arterial perfusate flow in a pressure-controlled manner at a maximum of 75 mm Hg. After transaction of the aorta distal to the subclavian artery, the new cannula (Joline) will be inserted into the descending aorta for protection of the spinal cord and the abdominal organs. Then the balloon is inflated, and distal 30°C perfusion is achieved with a flow of 500 until 100 mL. Blood pressure levels for the distal perfusion are maintained at 50 mm Hg. Balloon occlusion of the descending aorta provides a bloodless surgical field and optimal conditions for suturing the aortic anastomosis. Aortic arch resection and replacement are performed with standard techniques depending on the underlying disease, with almost no time limitation. After distal and arch anastomosis, the cannula will be removed from the descending aorta, and proximal repair of the aorta follows during rewarming. The patient is placed in a head-down position, deairing is performed, and finally the prosthetic graft is clamped just proximally to the innominate artery. At this point, the elastic loops around the innominate and left common carotid arteries are released, and the arterial flow is returned to full-body perfusion. The decision making regarding proximal repair strategy is mostly based on the surgical inspection of the involvement of the aortic root, aortic valve, and coronary ostia.
Ten patients (7 male and 3 female patients) underwent operative treatment of the diseased aortic arch because of chronic aneurysm involvement (n = 6, 60%) or acute dissection (n = 4, 40%). Table 1 contains patient characteristics, and Table 2 shows the operative and postoperative data and complications. Only one patient died on the 14th postoperative day because of intestinal bleeding with a history of ulcus ventriculi after an initial uncomplicated postoperative course. No patient experienced permanent neurological deficits, acute renal failure, or significant intestinal organ malfunction.
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Adequate perfusion of the abdominal organs, spinal cord, and lower extremities remains a great challenge in the treatment of the diseased aortic arch, especially if deep hypothermic circulatory arrest is avoided. The described new perfusion technique with a novel cannula for distal perfusion allows aortic arch procedures at mild hypothermia with preservation of distal organ function.
Initial experience with this technique demonstrated simple handling of the cannula, safety of the perfusion technique, and promising clinical results, with no significant impairment of spinal chord, renal, or intestinal organ function in the first 10 patients. Based on these experiences, we started to use this perfusion technique with 30°C mild systemic hypothermia together with ACP as our standard for aortic arch operations. In avoiding ischemia and deep hypothermia, this technique might help to reduce CPB time and deep hypothermia–related side effects.
References
This article has been cited by other articles:
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  R. Di Bartolomeo, E. Pilato, D. Pacini, C. Savini, and M. Di Eusanio Cerebral protection during surgery of the aortic arch MMCTS, January 1, 2011; 2011(0221): mmcts.2010.004457 - mmcts.2010.004457. [Abstract] [Full Text] [PDF]
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 F. Bakhtiary, S. Dogan, A. Zierer, O. Dzemali, F. Oezaslan, P. Therapidis, F. Detho, T. Wittlinger, S. Martens, P. Kleine, et al. Antegrade Cerebral Perfusion for Acute Type A Aortic Dissection in 120 Consecutive Patients Ann. Thorac. Surg., February 1, 2008; 85(2): 465 - 469. [Abstract] [Full Text] [PDF]
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 P. Totaro and V. Argano Innovative technique to treat acute cerebral and peripheral malperfusion during type A aortic dissection repair Interact CardioVasc Thorac Surg, February 1, 2008; 7(1): 133 - 135. [Abstract] [Full Text] [PDF]
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