Total arch replacement in octogenarians

OBJECTIVES We investigated the effect of a preoperative age ≥80 years on postoperative outcomes in patients who underwent isolated elective total arch replacement using mild hypothermic lower body circulatory arrest with bilateral antegrade selective cerebral perfusion. METHODS A total of 140 patients who had undergone isolated elective total arch replacement between January 2007 and December 2020 were enrolled in the present study. We compared postoperative outcomes between 30 octogenarian patients (≥80 years old; Octogenarian group) and 110 non-octogenarian patients (≤79 years old; Non-Octogenarian group). RESULTS Overall 30-day mortality and hospital mortality were 0% in both groups, and there was no significant difference in overall survival between the 2 groups (log-rank test, P = 0.108). Univariable Cox proportional hazard analysis showed that age as continuous variable was only the predictor of mid-term all-cause death (hazard ratio 1.08, 95% confidence interval 1.01–1.16; P = 0.037), but not in the Octogenarians subgroup (P = 0.119). CONCLUSIONS Preoperative age ≥80 years is not associated with worse outcomes postoperatively after isolated elective total arch replacement with mild hypothermic lower body circulatory arrest and bilateral antegrade selective cerebral perfusion.

Innominate artery dissection during cerebral perfusion. The exception that proves the rule.

Bilateral antegrade selective cerebral perfusion has the undisputed advantage of being more physiological and theoretically ensuring complete perfusion of the whole brain. However, it requires longer execution times and manipulation of the epiaortic vessels. On the other hand, unilateral selective cerebral perfusion (u-ASCP) avoids the vessels manipulation, placement of catheters into the ostia of the great vessels which clutters the operative field and incurs both atherosclerotic and air embolism risk. Neverthless, an ongoing debate about which technique yields the best clinical outcomes is still open.

Performing Antegrade Selective Cerebral Perfusion Using the AV Cannula: A Novel Approach

Antegrade selective cerebral perfusion has become the preferred choice for brain protection during aortic arch surgery. To perform antegrade selective cerebral perfusion, cannulas have been introduced directly into the ostia of the supra-aortic vessels (SAV) after institution of hypothermic circulatory arrest and opening the aortic arch. We describe a different surgical technique with a new type of cannula for antegrade selective cerebral perfusion. This cannula, called AV (Andrea Venturini) cannula, has been designed to be introduced in the SAV directly using a standard guidewire technique (Seldinger's technique). The AV cannula can also be introduced from the ostia of the SAV if preferred. The AV cannula can be introduced before the institution of hypothermic circulatory arrest and before opening the aortic arch. One great advantage of this technique is that the ostia of the SAV remain free from a cannula, allowing the operator easier access and a faster anastomosis or reimplantation.

Early outcome of aortic balloon occlusion during total aortic arch replacement with the frozen elephant trunk technique for aortic dissection

OBJECTIVES The aim of this study was to propose and evaluate the new operative technique of aortic balloon occlusion in total aortic arch replacement (TAR) with the frozen elephant trunk that can significantly decrease the time of circulatory arrest and increase the hypothermic cardiopulmonary bypass (CPB) temperature. METHODS Between 2010 and 2018, 1335 patients with aortic dissection who underwent TAR with the frozen elephant trunk were included in the study. The newest 80 cases were treated with aortic balloon occlusion. To illustrate the difference with the new procedure, 1255 conventional TAR cases served as the historical control. Femoral and right axillary artery cannulations were used for CPB and antegrade selective cerebral perfusion. Circulatory arrest was implemented at the nasopharyngeal temperature of 28°C with continuous antegrade selective cerebral perfusion. After the stent graft was inserted into the true lumen of the descending aorta, the aortic balloon in a sheath was deployed into the stent graft and positioned at the metal part of the stent graft. When the balloon was inflated with enough saline to compress the stent graft, the sheath was simultaneously pressed by hand to properly fix the balloon and avoid displacement. Then femoral perfusion could be resumed. RESULTS The aortic balloon occlusion technique was successful in all patients, with the median duration of circulatory arrest being 5 (interquartile range 3–7) min. The 30-day mortality rate was 6.25% (5/80), whereas with the conventional method it was 9.40% (118/1255). The postoperative conscious revival (8.67 vs 11.40 h, P < 0.001) and mechanical ventilation times (19.70 vs 24.45 h, P = 0.02) were significantly shorter. Decreases in postoperative acute kidney injuries (13.75% vs 32.11%, P = 0.001) and liver injuries (8.75% vs 37.61%, P < 0.001) were also observed. The patients were transfused with lesser quantities of red blood cells, plasma and platelets. CONCLUSIONS The aortic balloon occlusion technique is a feasible way to shorten circulatory arrest significantly, to obviate the need for deep hypothermia in TAR with the frozen elephant trunk and to provide favourable protective effects on the central nervous, haematological and visceral systems. With these satisfactory results, this technique deserves further investigation.

Antegrade selective cerebral perfusion reduced in-hospital mortality and permanent focal neurological deficit in patients with elective aortic arch surgery†

OBJECTIVESWe retrospectively evaluated the outcome after elective aortic arch surgery with circulatory arrest to determine the impact of different brain protection strategies on neurological outcome and early and late survival.METHODSA total of 925 patients were included. The patients were assigned to 2 groups based on the type of cerebral protection strategy used during circulatory arrest [hypothermic circulatory arrest (HCA) n = 224; antegrade selective cerebral perfusion (ASCP) n = 701]. The propensity score matching (1:1; 210 vs 210 patients) approach was used to minimize selection bias and to obtain comparable groups.RESULTSThe overall in-hospital mortality and permanent focal neurological deficit rates were 5.6% (n = 52) and 5.4% (n = 50) and were significantly lower in patients who received ASCP (4.4% and 3.4%, respectively) as compared to those who underwent HCA (9.4% and 11.6%, respectively) (P = 0.005 and P < 0.001). The propensity-matched analysis showed significantly lower rates of in-hospital mortality [3.8% vs 9.5% (HCA)] and permanent focal neurological deficit in ASCP group [2.9% vs 11.9% (HCA)]. Multivariable logistic regression analysis revealed left ventricular ejection fraction <30%, age >70 years, coronary artery disease, circulatory arrest time >40 min and mitral valve disease as independent predictors of in-hospital mortality. The use of ASCP was protective for early survival. Cox regression analysis revealed that long-term mortality was independently predicted by age, left ventricular ejection fraction <30%, total arch replacement, prior cardiac surgery, PVD, chronic obstructive pulmonary disease and previous stroke, whereas ASCP was protective for late survival.CONCLUSIONSElective aortic arch surgery is associated with acceptable early and late outcomes. The ASCP is associated with a significant reduction in-hospital mortality and occurrence of permanent neurological deficits.