Ann Thorac Surg 2008;85:1781-1782. doi:10.1016/j.athoracsur.2007.11.003
© 2008 The Society of Thoracic Surgeons
Case Reports
Total Arch Replacement Under Normothermic Beating Heart Surgery
Jui-Chih Chang, MD*,
Shen-Feng Chao, MD*,
Bee-Song Chang, MD
Division of Thoracic and Cardiovascular Surgery, Buddhist Tzu Chi General Hospital, Hualien, Taiwan
Accepted for publication November 2, 2007.
* Address correspondence to Dr Chao, Division of Thoracic and Cardiovascular Surgery, Buddhist Tzu Chi General Hospital, No. 707, Sec. 3, Chong Yang Rd, Hualian, Taiwan (Email: sfchao{at}tzuchi.com.tw).
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Abstract
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The authors propose a new method for total arch replacement under normothermic beating heart surgery. The surgical procedure was performed with no time limit. The cardiopulmonary bypass was terminated without using inotropic agents. The patient regained consciousness in postoperative hour 8 without any neurologic deficit. This new strategy avoids the potential devastating side-effects associated with deep hypothermic circulatory arrest and myocardial stunning.
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Introduction
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Treatment of aortic arch aneurysm and dissection represent a continuing challenge. The outcome in recent years has improved due to better strategies for cerebral and myocardial protection. Antegrade selective cerebral perfusion with the combination of deep hypothermic circulatory arrest is the most commonly used method. We report a case with a new technique of cerebral and myocardial protection for total arch replacement.
A 64-year-old man was diagnosed with an intramural hemorrhage aortic dissection at the aortic arch and a proximal thoracic aortic aneurysm (Fig 1). He received an elective surgery of the total arch with a proximal descending aorta replacement.
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Fig 1. (Left) An intramural hemorrhage aortic dissection (arrow) at the aortic arch and (right) a proximal thoracic aortic aneurysm.
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Arterial monitor lines were set up at the left radial artery and the right dorsalis pedis artery. For exposure of the entire arch and descending aorta, a trans-sternal (clamshell) bi-thoracotomy was created through the fourth intercostals space. To set up the extracorporeal circulation, a 20-French cannula was inserted into the right axillary artery through an 8-mm prosthesis graft. A 21-French arterial cannula and venous cannulas were introduced into the left common femoral artery and vein. A 32-French venous cannula was placed through the right atrium. Extracorporeal circulation with axillary-atrial and femo-femoral bypass was started. The body temperature was kept in normothermia.
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Step 1
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The distal arch and distal descending aorta were cross clamped. The perfusion pressure of the left radial and the right dorsalis pedis was maintained at greater than 70 mm Hg. The proximal descending thoracic aneurysm was incised longitudinally. The descending aorta was transected at the healthy level. The distal end of the vascular graft (Hemashield Platinum, 30 mm in diameter; Boston Scientific Corp, Natick, MA) was anastomosed end-to-end to the descending aorta (Fig 2A). The descending aortic cross clamp was released. Air was then evacuated from the graft.
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Fig 2. Schematic drawing of the arterial route of cardiopulmonary bypass circuit and the steps of the procedure. (A) Step 1, (B) step 2.
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Step 2
A 7-French antegrade coronary perfusion cannula connected to the axillary cannula was set up at the aortic root. The ascending aorta was cross clamped. Coronary perfusion was continuously maintained with systemic warm blood. The heart was kept beating without distension. The brachiocephalic arteries were all cross clamped. The perfusion pressure of the left radial and the right dorsalis pedis artery was continuously maintained at greater than 70 mm Hg. A cuff of aortic tissue containing the brachiocephalic arteries was prepared. The cross clamp on the left common carotid artery was released and a strong backflow was noted. The cross clamp was then reapplied. The graft was anastomosed end-to-side to the cuff of the brachiocephalic arteries (Fig 2B). The cross clamps at the brachiocephalic arteries and descending aortic graft were released. The air was then removed from the graft and the proximal graft was cross clamped.
Step 3
The femo-femoral bypass was stopped. The systemic bypass was depended on only axio-atrial bypass. The ascending aorta was transected to the healthy level. The proximal end of the graft was made end-to-end anastomosis to the proximal ascending aorta.
The cardiopulmonary bypass was terminated without using inotropic agents. Total bypass time was 158 minutes. A postoperative transesophageal echocardiography demonstrated the same contractility and movement of heart chambers as were shown preoperatively. The patient woke up in postoperative hour 8, without any neurological deficit. The total hospital length of stay was 16 days.
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Comment
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Antegrade selective cerebral perfusion with combination of deep hypothermic circulatory arrest is the most commonly used method for cerebral protection during total aortic arch replacement [1]. But deep hypothermic circulatory arrest is associated with a definitive risk for neuropsychological deficits [2]. Touati and colleagues [3] reported a good result with normothermia for aortic arch replacement, but their method requires intermittent retrograde cardioplegia perfusion.
In our method, the patient is kept in normothermia and the heart is kept beating with continuous antegrade coronary perfusion; this avoids any neuropsychological deficits, as well as preventing myocardial stunning. A major benefit is that the surgeon can then perform the procedure without a time limit. As the antegrade coronary perfusion cannula is set up at the aortic root, this method is suitable only for aortic arch aneurysms and dissections not involving the proximal aorta.
In conclusion, total arch replacement under normothermic beating heart surgery is a good alternative for aortic arch aneurysm and dissection not involving the proximal ascending aorta. It avoids the potential devastating side-effects associated with deep hypothermic circulatory arrest and myocardial stunning. We believe that this is the first report of a total aortic arch replacement under normothermic beating heart surgery.
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Footnotes
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* The first two authors contributed equally to this work. 
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References
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- Kazui T, Yamashita K, Washiyama N, et al. Aortic arch replacement using selective cerebral perfusion Ann Thorac Surg 2007;83:S796-S798.[Abstract/Free Full Text]
- Reich DL, Uysal S, Sliwinski M, et al. Neuropsychologic outcome after deep hypothermic circulatory arrest in adults J Thorac Cardiovasc Surg 1999;117:156-163.[Abstract/Free Full Text]
- Touati GD, Roux N, Carmi D, et al. Totally normothermic aortic arch replacement without circulatory arrest Ann Thorac Surg 2003;76:2115-2117.[Abstract/Free Full Text]
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Abstract
Introduction
