1. 1 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 Surgery Brigham and Women’s Hospital

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3. 3 Aneurysmal ascending aortic degeneration includes aortic tissue proximal to the innominate artery Aneurysmal ascending aortic degeneration includes aortic tissue proximal to the innominate artery Aortic cross-clamping leaves a segment of aneurysmal distal ascending aorta Aortic cross-clamping leaves a segment of aneurysmal distal ascending aorta

4. Surgical Result following Reconstruction Closed Distal Anastomosis Open Distal Anastomosis

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6. 6 Evaluate outcomes of elective ascending aortic reconstruction with open distal anastomosis (with RCP) versus closed distal anastomosis with aortic cross- clamping. Evaluate outcomes of elective ascending aortic reconstruction with open distal anastomosis (with RCP) versus closed distal anastomosis with aortic cross- clamping.

7. 687 patients with Ascending Aortic Reconstruction (2005-Present) 7 195 closed distal (CD) anastomosis 110 open distal (OD) anastomosis with RCP 99 CD 99 OD

8. Primary endpointPrimary endpoint –CVA –Temporary Neurologic Deficit –Ventilator Hours –ICU Hours –Length of Stay Secondary endpointSecondary endpoint –30-day mortality –Intermediate-term Survival 8

9. 9 OD (n=99)CD (n=99)p-value Age60±1261±120.6 Male Gender n(%)76 (77%)72 (73%)0.52 Caucasion n(%)93 (94%)97 (98%)0.39 Diabetes n(%)5 (5%)6 (6%)0.76 COPD n(%)88 (89%)87 (88%)0.83 Hyperlipidemia n(%)49 (50%)55 (56%)0.39 Hypertension n (%)57 (57%)61 (62%)0.56 Serum Creatnine0.98±.231.1±0.40.17 History of CVA n(%)4 (4%)6 (6%)0.52 Previous MI n(%)4 (4%)9 (9%)0.15 CHF n(%)23 (23%)24 (24%)0.86 Angina n(%)16 (16%)20 (20%)0.46 NYHA Classification0.43 I42 (42%)37 (37%) II40 (40%)41 (41%) III20 (20%) IV0 (0%)1 (1%) Hemodynamic Data Normal sinus rhythm n(%)87 (86%)89 (89%)0.66 Ejection Fraction59 ±857±130.23 Mean PAP23±722±80.24 Aortic Stenosis n(%)29 (29%)37 (37%)0.27 Aortic Stenosis Gradient (mmHg)35±1738±200.25

10. 10 OD (n=99)CD (n=99)p-value Reoperation n (%)23 (23%)18 (18%)0.38 CPB time (minutes)206±95160±790.0005 Cross-clamp time (minutes)156±73120±730.0006 DHCA Temperature (Celsius)21.. DHCA Time21±8 (11, 50).. RCP Time17±8 (3, 50).. Concomitant Procedures Aortic valve replacement22 (22%)30 (30%)0.55 CABG24 (24%)19 (19%)0.39

11. n=2 n=1 P=0.42P=0.57 P=0.20 P=0.44 P=0.52 No difference in 30 day (OD, 0% vs. CD, 1%, p=0.59) or Intermediate-term Mortality P=0.30

12. 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 12