Ann Thorac Surg 2008;86:1399-1400. doi:10.1016/j.athoracsur.2008.04.032
© 2008 The Society of Thoracic Surgeons
Correspondence
Hypothermic Circulatory Arrest in the Treatment of Descending Thoracic and Thoracoabdominal Aortic Disease
Chris K. Rokkas, MDa,
Nicholas T. Kouchoukos, MDb
a Department of Cardiothoracic Surgery, University of Athens School of Medicine, "Attikon" Hospital, 1 Rimini St, Haidari, Athens, 12462 Greece
b Missouri Baptist Medical Center, 3009 N Ballas Rd, St. Louis, MO 63131
(Email: ckrokkas{at}yahoo.com; ntkouch{at}aol.com).
To the Editor:
We read with interest the article by Coselli and colleagues [1] on the safety and efficacy of hypothermic circulatory arrest (HCA) in the operative treatment of descending thoracic and thoracoabdominal aortic aneurysms. We congratulate them for achieving these results in a challenging group of patients. The authors did not use HCA on a routine basis for patients with extensive thoracic or thoracoabdominal aortic disease, but selectively in patients whose anatomy and pathology prevented safe clamping of the proximal aorta or in those whose replacement of part or all of the aortic arch was necessary. They reported a 29% operative mortality rate for 102 patients who underwent emergent or urgent operations, and an 11% mortality for 9 patients with elective repairs. One patient, who presented with acute dissection superimposed on a previous chronic deBakey type I dissection and a previous Crawford extent IV thoracoabdominal aortic repair, developed early and permanent postoperative paraplegia.
The prevalence of spinal cord ischemic injury is higher among patients requiring emergent or urgent operations for acute aortic pathology when adjuncts other than hypothermia are used for spinal cord protection [2]. Coselli's results confirm the protective effect of hypothermia in this setting reported by us and by others [3, 4]. However, the authors imply that this low rate of spinal cord ischemic injury is achieved at the cost of a high mortality rate, and thus that HCA should be reserved for high-risk patients or for patients unsuitable for other techniques.
Mortality in patients undergoing emergent or urgent operations on the descending thoracic or thoracoabdominal aorta is high regardless of the operative strategy used [2, 3]. In our reported series of 192 patients, 90-day mortality was 40% for 20 patients who required emergent operations, and 12.5% for patients undergoing elective repair [5]. Our experience suggests that although the prevalence of immediate postoperative paraplegia may not be substantially lower with HCA than with other techniques in elective cases, the prevalence of delayed paraplegia is lower. In view of this, it is reasonable to consider using HCA in patients who are undergoing elective repairs and who are at substantial risk for spinal cord ischemic injury.
Unless this technique is used often, the results are likely to be suboptimal. When used routinely, its emergent use may result in improved outcomes as compared with selective use on an emergent basis only. We advocate and continue to use deep hypothermic perfusion and full cardiopulmonary bypass with or without intervals of HCA for all patients who require extensive operations on the descending thoracic and thoracoabdominal aorta.
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References
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- Coselli JS, Bozinovski J, Hons CC. Hypothermic circulatory arrest: safety and efficacy in the operative treatment of descending and thoracoabdominal aortic aneurysms Ann Thorac Surg 2008;85:956-964.[Abstract/Free Full Text]
- Crawford ES, Crawford JL, Safi HJ, et al. Thoracoabdominal aortic aneurysms: preoperative and intraoperative factors determining immediate and long-term results of operations in 605 patients J Vasc Surg 1986;3:389-404.[Medline]
- Kouchoulos NT, Masetti P, Rokkas CK, Murphy SF, Blackstone EH. Safety and efficacy of hypothermic cardiopulmonary bypass and circulatory arrest for operations on the descending thoracic and thoracoabdominal aorta Ann Thorac Surg 2001;72:699-708.[Abstract/Free Full Text]
- Fehrenbacher J, Hart D, Huddleston E, et al. Optimal end-organ protection for thoracic and thoracoabdominal aortic aneurysm repair using deep hypothermic circulatory arrest Ann Thorac Surg 2007;83:1041-1046.[Abstract/Free Full Text]
- Kouchoukos NT, Masetti P, Rokkas CK, Murphy SF. Hypothermic cardiopulmonary bypass and circulatory arrest for operations on the descending thoracic and thoracoabdominal aorta Ann Thorac Surg 2002;74:1885-1887.
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