State of the Art in Aortic Arch Surgery

State of the Art in Aortic Arch Surgery

State of the Art in Aortic Arch Surgery
Hazim J. Safi, MD
Professor and Chair
Department of Cardiothoracic and Vascular Surgery
The University of Texas Medical School at Houston
Memorial Hermann Heart & Vascular Institute
8th European Symposium of Vascular
Biomaterials
May 2013
Surg Gynecol Obstet 1955; 101:667
Ascending Arch Repair
Surg Clin North Amer 1962; 42:1543-1554
January 1984
Mortality Rate: 25%
The Iceman, ca 4000 BC (Copper Age)
National Geographic
CIRCULATORY ARREST
> 40” =
Stroke
> 65” =
Mortality
Antegrade Perfusion
Methods to Extend Brain Ischemia
Tolerance
Ueda - RCP 1986
LeMole - 1981
Oschner - Air Embolus
Retrograde Cerebral Perfusion
RCP / CA
HbO2
SVC
Brain
Cooling Phase
Neuromonitoring
Arrest Phase
1/1991 – 2/2010
1193 Ascending Arch
64%
36%
Mean Age: 63 years
Procedures (n=1439)
Arch 62%
Elephant Trunk 20%
Ascending 94%
Aortic Root 27%
CABG 13%
Methods
AXC Time
CPB
RCP Time
83 min.
(6-306)
144 (11-535)
26
(3-112)
Results (n=1225)
Operative Mortality
eGFR
9.4%
3%
Stroke
Acute Renal Failure
Prolonged Ventilation
2.2%
5.4%
19%
Univariate Analysis: Mortality
Variable
%
p-value
> 72
14.0
0.002
CAD
13.5
0.02
Acute Dissection
13.9
0.004
Emergency operation
6.9
0.0001
4 quartiles GFR
18
0.001
1st quartile GFR
3
Pump time >179
18
0.001
Multivarible Analysis: Mortality
Variable
OR
p-value
GFR<90
3.34
0.0001
Pump>120 min
1.81
0.02
Acute Dissection
2.07
0.002
RCP
0.41
0.0004
Univarible Analysis: Stroke
Variable
Age (<50)
%
1.0
p
3.8
0.04
Acute Dissection
3.7
0.7
Chronic Dissection
1.9
0.5
Emergency
4.9
0.04
(>72)
GFR:
>100
1.3
<60
4.3
0.05
RCP (>40)
1.7
0.002
No RCP
30
Circulatory Arrest
Multivarible Analysis: Stroke
Variable
Odd Ratio
p
Emergency
2.17
0.03
Age
1.04
0.008
Conclusions
§  Randomized trials are needed but
difficult to perform
§  RCP reduced stroke and death
Ascending & Arch - GFR
Correctly Classified
N Cr / Ab GFR
80% of patients with
normal sCr but abnormal
GFR
Estrera et al. Ann Surg 2008
30-Day Mortality
19.6% 10.0% 8.6%
4.7%
1983
BRAIN
§  Profound Hypothermia
§  Circulatory Arrest
§  Retrograde Cerebral Perfusion
HEART
§  Antegrade
§  Retrograde Cardioplegia
SPINAL CORD
§  DAP
§  CSF drainage
§  Moderate hypothermia
Extensive Aortic Aneurysm
Median Age 66 (16 - 87 yr)
123 (52%)
117 (48%)
Extensive Aortic Aneurysm
240 First Stage
149 Second Stage
389 Total Operations
Extensive Aortic Aneurysm
Stage 1
Stroke*
224 RCP 3/224 (1.3%)
16 no RCP
2/16 (12.5%)
P<0.003*
Extensive Aortic Aneurysm
Stage 2
Neuro Deficit
125 Adjunct 1/125 (1.6%)
24 no Adjunct
0/24 (0.0%)
Extensive Aortic Aneurysm
Mortality
Stage 1 23/240
Stage 2 19/149
(9.5%)
(10.4%)
Survival
Extensive Aortic Aneurysm
Conclusion
§  Long term survival is excellent
with repair stage 1 & 2
§  Timely treatment of second stage is
essential to prevent rupture/death
Dissection
The Passing of King George
On October 23, 1760 George II rose at 6
am, asked for his chocolate and
repaired to his closet-stool. The valet
heard a “noise louder than the royal
wind and a groan.” The King was lying
on the floor. The surgeon Mr. Andrews
bled his Majesty but in vain. The King
was dead.
…pericardium
extended
At necropsy Dr. Nicholis
found thewith
pericardium
extended
coagulated
blood
andwith
a coagulated
transverse
blood and a transverse fissure on the
fissure
on
the
inner
side
the
inner
side
of the
ascending
aortaof
3.75
cm long through which blood had
ascending
aorta 3.75 cm…
passed to form an ecchymosis, which
was interpreted as an incipient
aneurysm of the aorta.
Aortic Dissection
Type A (I + II)
SURGERY
Type A
§  Initial Stabilization
§  CPB
§  Profound Hypothermia
§  Circulatory Arrest
§  RCP
§  Open Technique
366 Type A Dissection
Acute
Chronic
217 (59%)
149 (41%)
Aortic Type A Dissection
Mortality
Overall
(10.1%)
Acute
(14.0%)
Chronic
(8.5%)
30-Day Mortality
Acute Type A
26.6% 17.1% 13.3% 6.9%
30-Day Mortality
Acute Type A
13.3% 3.5%
0.0%
4.2%
Mortality*
Acute Dissection (p<0.02)
GFR (p<0.004)
* Multivariable analysis
Stroke
Type A Dissection
Overall
(4.1%)
Acute
(1.8%)
Chronic
(2.3%)
Memorial Hermann
Heart & Vascular Institute
Thank You