Without Deep Hypothermia

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بسم الله الرحمن الرحيم.

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Presentation transcript:

Without Deep Hypothermia Aortic Symposium 2010 AATS Branch First Aortic Arch Repair Without Deep Hypothermia Or Circulatory Arrest George Matalanis, Rhiannon Koirala Austin Medical Centre Melbourne, Australia

Problems with Current Techniques Circulatory arrest (CA) Maximum “safe” period Opportunity for air/debris embolism Deep hypothermia (DH) Prolonged bypass Coagulopathy Retrograde Cerebral perfusion Negligible nutritive flow Unilateral Antegrade Perfusion Contralateral hypoperfusion Ipsilateral hyperperfusion Bilateral Antegrade Perfusion Direct cannulation risks View obstruction

Collateral Anatomy NOT like Carotid Endarterectomy Without shunt complete reliance on CIRCLE OF WILLIS 15% inadequate ICA stump pressure Even then Stroke risk < 3% if clamp time < 10-15 min

Collaterals Available in Individual Proximal Arch Branch Clamping Subclavian Right carotid Left carotid Carotid Upper body External carotid Internal carotid Lower body

Cannulation and bypass Dual upper and lower body inflow  pressure gradients Maintenance of body perfusion after innominate clamping Direct Ascending Aorta - alternative in PVD/thoracoabdominal atheroma

Reconstruction Sequence

Patients 30 cases: Jul 2005- Oct 2009 Male : Female = 19:11 Age: 62 (28-85) Smoking: 57% Hypertension: 63% CVD: 23% CAD: 30% Elective 18 (60%) Urgent/Emergent 12 (40%) Type A dissection 16 (53%) Re-operation 4 (13%)

Concomitant Procedures Aortic Root:19 (63%) Valve sparing: 14 (74%) David: 3 Other valve sparing: 11 Bentall’s: 5 (26%) Mechanical: 3 Tissue: 2 Separate AVR: 2 (7%) Elephant Trunk: 4 (13%) Regular: 2 Frozen: 2 CABG: 6 (20%)

Early outcomes Mortality: 1 (3.3%) Neurological Dysfunction: 4 (13%) 85 y.o, late presenting Ac Type A Neurological Dysfunction: 4 (13%) All focal/embolic: Amourosis Fugax Hemianopia, Hemiparesis, Dysphasia. Complete recovery: 3 Residual deficit: 1 (hemianopia)

Other Morbidity Re-exploration: 3 (10%) Mechanical Cardiac support: 1*(3.3%) Renal support: 1* (3.3%) Tracheostomy: 1 (3.3%) Sternal infection: nil * mortality

Benefits Ventilation < 24 hrs: 12 (40%) ICU stay < 2 days: 14 (47%) Hospital stay ≤ 7 days: 10 (33%) NO TRANSFUSION: 8 (26.7%) 2 of these were re-operative cases

Conclusions Branch First aortic arch repair is a safe procedure : 3.3% Mortality 3.3% permanent Stroke Applicable to urgent and complex cases Haemostatic 27% no blood/product transfusion Better visceral organ protection 1.3% CVVH Allows complete and unhurried repair Avoid late deaths from undertreated aortic segments Avoid difficult redo for persistent/recurrent aortic pathology