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Ann Thorac Surg 2002;74:S1786-S1788
© 2002 The Society of Thoracic Surgeons
a Center for Aortic Surgery and Marfan Syndrome and Connective Tissue Disorder Clinic, Department of Cardiovascular Surgery, The Cleveland Clinic Foundation, Cleveland, Ohio, USA
* Address reprint requests to Dr Svensson, Center For Aortic Surgery, Marfan and Connective Tissue Disorder Clinic, The Cleveland Clinic Foundation, 9500 Euclid Ave, F25, Cleveland, OH, 44195, USA
e-mail: svenssl{at}ccf.org
Presented at the Aortic Surgery Symposium VIII, May 2–3, 2002, New York, NY.
Abstract
BACKGROUND: Herein are described recent developments in aortic surgery techniques and the improved results.
METHODS: Of 403 ascending and aortic arch operations, 68 patients underwent minimally invasive aortic surgery including 23 for aortic dissection, 5 for Marfan syndrome, 29 reoperations, and 39 with hypothermic arrest. Blood conservation methods were used in 187 of the 403 patients (46.5%). Aortic valve procedures were used in 267 (66.2%), including 51 (12.7%) valve-preserving operations. A protocol for stroke and neurocognitive deficit prevention was used in an attempt to prevent neurologic deficits. Data were prospectively collected and included new neurocognitive events either by formal testing (n = 35) or by informal questioning.
RESULTS: Stroke occurred in 2.0% (8 of 403); clinical gross neurocognitive deficits in 2.5% (10 of 403) with a 98% 30-day survival. For those patients undergoing the minimally invasive operation 1 hospital death occurred (98.5% survival). Homologous operative transfusions were required in only 12% of blood conservation patients (23 of 187) and their postoperative intubation time, intensive care unit (ICU) stay, and hospital stay were significantly shorter (p < 0.04).
CONCLUSIONS: Minimally invasive surgery is particularly useful for reoperations. The blood conservation methods appear to be beneficial and the number of neurologic deficits is low with the current protocol.
The field of ascending and aortic arch surgery has continued to evolve with the introduction of new techniques and technologies [1–15]. This report updates our experience with minimally invasive aortic surgery, blood conservation techniques, and stroke and neurocognitive outcome with a brain protection protocol.
Material and methods
From July 25, 1991 to September 25, 2001, 403 patients underwent ascending aorta and or aortic arch operations. The mean age was 61.6 years and 267 (66.2%) patients were male. A minimally invasive incision, mostly a J incision was used in 68 (17%) [10]. An aortic valve procedure was performed in 267 (66.2%) including 51 valve-preserving, remodeling [9], or David type reimplantation operations; coronary artery bypass in 138 (34%); and arch operations in 199 (49%).
Blood conservation techniques were used in 187 (46.5%) [11]. This entailed patients donating 1 unit of autologous blood and fresh frozen plasma weekly before surgery (usually 3 to 4 units in total), and donating platelets 3 to 6 days before surgery. During the operation before starting cardiopulmonary bypass, platelet rich plasma was obtained, and after operation chest tube drainage was reinfused [11]. Patients who had emergency or urgent surgery did not donate autologous blood preoperatively because of time constraints. A cell saver was, however, routinely used for all participants.
For the prevention of stroke and neurocognitive deficits a protocol as shown in Table 1 was used [15]. Stroke was defined as any neurologic deficit with which a patient awoke including coma and delayed awakening from surgery. Any patient with a deficit was seen by a neurologist and underwent computed tomography or magnetic resonance imaging scans of the brain. Clinical gross neurocognitive deficits were defined as those detected by formal testing (n = 35), or by informal questioning of patients or families 2 to 3 weeks after operation.
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Stroke occurred in 8 patients (2.0%): 3 were permanent and 5 transient. The 30-day survival was 98% (395 of 403) including 2 deaths after hospital discharge from documented ventricular tachycardia and failed resuscitation. Among the patients who underwent minimally invasive surgery, there was 1 hospital death (98.5% survival) and 2 strokes, the one from carotid malperfusion from dissection and the other from aprotinin-related left atrial thrombus formation.
For the blood conservation patients the mean hematocrit values before donation and after donation were 38.5 (SD 6.6) and 35.7 (SD 5.2), respectively (p < 0.0001). For those patients who did not donate blood before surgery, the mean hematocrit was 36.6 (SD 5.5). In the patients who preoperatively donated autologous blood products, the average number of autologous units of blood used was 2.8 (range 1 to 5); fresh frozen plasma, 3.0 (range 1 to 6); and collected platelets, 6.7 (range 1 to 20). Intraoperatively platelet-rich plasmapheresis in the patients who had preoperatively donated autologous blood was an average of 1171.4 mL (range 300 mL to 1,900 mL). The average number of cell-saver units collected intraoperatively was 4.0 U (range 1 U to 46 U).
The average number of homologous red cell units used was 4.8 (range 1 to 70); fresh frozen plasma, 5.8 U (range 1 to 78); platelets, 10.5 (range 5 to 74), and cryoprecipitate 16.9 (range 10 to 110). However, the use of homologous blood products analyzed according to whether patients donated autologous blood products preoperatively were as follows: red blood cell units—with and without autologous donation—2.6 versus 5.2 (p = 0.001); fresh frozen plasma units, 3.5 versus 6.1 (p = 0.005); platelet units, 8.7 versus 10.7 (p = 0.053); and cryoprecipitate units, 10.0 versus 18.2 (p = 0.097).
For blood conservation patients the mean intubation time was 1.1 days (SD 0.95 days), ICU stay 2.4 days (SD 4.4 days), and postoperative stay 8.0 days (SD 5.5 days). For the patients managed in the standard way the respective times were significantly longer (p < 0.04): intubation 3.3 days (SD 9.4), ICU 4.4 days (SD 9.8), and postoperative stay 9.6 days (SD 8.9). Postoperative aminocaproci acid (Amicar; Xanodyne Pharmacal, Florence, KY) was given to 279 (69%) of patients and postpump aprotinin to 61 patients.
At the end of the procedure the aortic aneurysm was reapproximated loosely around the graft in 207 (51.4%), was wrapped around the graft to obtain hemostasis in 42 (10.4%), and a Cabrol fistula was created in 14 (3.5%).
On multivariable analysis the predictors of readmission after discharge were (p < 0.05): homologous operative blood product transfusion; units of homologous packed red blood cells transfused, preoperative New York Heart Association (NYHA) dyspnea class, and preoperative aortic valve regurgitation grade [15].
Clinical neurocognitive deficits occurred in 2.5% (10 and 403). The univariate predictors were (p < 0.05) degree of cooling, pump time, cooling time, day of extubation, and antegrade brain perfusion during hypothermic arrest. The multivariable predictors were (p < 0.05): NYHA preoperative dyspnea class, pump time, circulatory arrest time, day of extubation, and antegrade brain perfusion [15].
Comment
The minimally invasive approach continues to be a useful option for ascending and aortic arch operations with satisfying results that are no different from standard incisions. In addition the patients have less pain and a shorter hospital stay [10]. The minimally invasive approach is particularly useful for reoperation on the aorta and unless the patient requires a mitral valve procedure or distal coronary artery bypass, the J incision is the preferred approach for our reoperations [10].
The data also support continued use of autologous blood and blood conservation techniques for these complex operations [11]. Previously the use of autologous blood products was considerably less expensive although now that autologous blood products undergo full screening and viral testing, the cost differential is not as great. Nevertheless we continue to use blood conservation techniques at the Cleveland Clinic. As has been reported by Sundt and colleagues [12] we have noted a stroke related to aprotinin usage and thus hardly ever use aprotinin during cardiopulmonary bypass.
The definitions for neurocognitive deficits continue to be debated [13, 14]. For the previous prospective randomized study we reported that we chose to define this based on 51 neurocognitive tests [1, 11]. In this larger series of prospectively evaluated patients we included the patients who had formal testing but also had deficits based on informal questioning. Clearly this would underestimate some deficits but the results indicate that at least the majority of patients did not have any major deficits and were functioning well with our neurologic brain protection protocol [15]. We are at present unable to ascribe the low incidents of neurocognitive deficits or stroke to any one or two particular aspects in the stroke prevention protocol and surmise that many factors may contribute to the reduced levels of neurocognitive deficits and stroke. We do now, however, restrict antegrade or retrograde brain perfusion during hypothermic arrest to patients for whom we are planning to replace the entire aortic arch or are planning to perform an endarterectomy based on these and other data and publications [1, 3, 4, 6, 15].
References
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 T. M. Fleck, H. Koinig, M. Czerny, D. Hutschala, E. Wolner, M. Ehrlich, and M. Grabenwoger Impact of surgical era on outcomes of patients undergoing elective atherosclerotic ascending aortic aneurysm operations Eur. J. Cardiothorac. Surg., August 1, 2004; 26(2): 342 - 347. [Abstract] [Full Text] [PDF]
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