Article
A Decade of Antegrade Cerebral Perfusion with Mild Hypothermia for Aortic Arch Replacement: Single Centre Experience in 345 Consecutive Patients
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Authors
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Faisal Detho
- Johann-Wolfgang Goethe University Hospital, Frankfurt a. Main, Division of thoracic and cardiovascular surgery, Frankfurt am Main
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Andreas Zierer
- Johann-Wolfgang Goethe University Hospital, Frankfurt a. Main, Division of thoracic and cardiovascular surgery, Frankfurt am Main
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Sven Martens
- Johann-Wolfgang Goethe University Hospital, Frankfurt a. Main, Division of thoracic and cardiovascular surgery, Frankfurt am Main
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Anton Moritz
- Johann-Wolfgang Goethe University Hospital, Frankfurt a. Main, Division of thoracic and cardiovascular surgery, Frankfurt am Main
| Published: | May 20, 2011 |
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Outline
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Introduction: Aortic arch replacement remains a surgical challenge because of prolonged operative times, bleeding complications, and a considerable risk of neurologic morbidity and mortality. This study investigates our clinical results after modification of perfusion technique for cardiopulmonary bypass as well as temperature management for these high risk patients.
Materials and methods: Between January 2000 and January 2010, 345 consecutive patients underwent aortic arch repair during selective antegrade cerebral perfusion (ACP) with mild systemic hypothermia (29.3±1.4ºC). Mean age was 66±11 years, 237 patients (69%) were men, 196 patients (57%) had acute type A dissection. Hemiarch replacement was performed in 204 patients (59%) while the remaining 141 patients (41%) underwent total arch replacement.
Results: Cardiopulmonary bypass time accounted for 166±62 minutes, and myocardial ischemic time was 107±43 minutes. Isolated ACP was performed for 36±49 (range 12-135) minutes. Chest tube drainage during the first 24 hours was 643±268 mL. Mean ventilation time was 42±23 hours. We observed new postoperative permanent neurologic deficits in 19 patients (6%) and transient neurologic deficits in 17 patients (5%). The operative mortality rate was 8% (n=28). Among patients with ACP times ≥ 60 min (91±26min; n=56) operative mortality (4/56;7%) and permanent neurologic deficit (3/56;5%) rates were comparable to the entire cohort. Besides other metabolic data, maximum serum lactate (43±19 vs. 32±15mg/dl) and creatinine levels (1.6±0.3 vs. 1.4±0.5mg/dl) as well as the requirement for temporary renal replacement therapy (6/56;11% vs. 30/345;9%) were not significantly higher in patients with ACP times ≥ 60 min as compared to the entire group. At late follow-up (4.2±3.7 years, 98% complete), 278 patients (81%) were still alive.
Conclusion: Selective ACP in combination with mild hypothermia offered sufficient cerebral as well as visceral organ protection in our patient cohort. Thus, current data suggest that this standardised perfusion and temperature management protocol can safely be applied to complex aortic arch surgery requiring up to 90 minutes of isolated ACP times.
