Reoperation of the aortic arch with total replacement during selective antegrade cerebral perfusion with moderate systemic hypothermia (28°C): Experience in 23 consecutive patients

Objectives: Total aortic arch replacement as redo surgery is a rare and challenging procedure. There is no standardized protocol for cerebral and visceral organ protection and outcomes thus far are more anecdotic. We describe herein our institutional experience employing selective antegrade cerebral perfusion (ACP) with moderate hypothermic circulatory arrest (28°C).

Methods: Between October 2003 and August 2011, 23 Patients underwent aortic arch re-replacement. Initial surgery (hemiarch replacement: n=22; total arch replacement: n=1) was performed between 1967 and 2009 for acute type A dissection (n=14), degenerative aneurysm (n=6), penetrating ulcer (n=2), and aortic coarctation (n=1). The interval between initial and redo surgery was 9±18 years. Mean age at the time of redo surgery was 61±12 years, 17 patients (74%) were men. The indications for re-operation included progression of the intimal tear (n=13), aneurysmal dilatation (n=6), and pseudo aneurysm formation arising from the distal suture line (n=4).

Results: Complete arch replacement was performed in all patients. Additional aortic valve reconstruction or replacement was performed in 9 patients (39%). Cardiopulmonary bypass time was 204±89min, myocardial ischemic time 134±23min, selective ACP time 62±18min, and the deepest body temperature reached 28±2°C. In 4 patients (17%) re-exploration for bleeding had to be performed. Mean ventilation time was 36±22 hours and intensive care unit stay was 4±7 days. We observed new postoperative permanent neurologic deficits in one patient (4%) and transient neurologic deficits in 2 patients (8%). Operative mortality was 4% (n=1). At late follow-up (3.8±3.2 years, 100% complete), 19 patients (83%) were still alive.

Conclusions: Current data suggest that our institutional perfusion and temperature management protocol can safely be applied to total aortic arch replacement even in the setting of a redo surgery. Postoperative bleeding remains a surgical challenge although deep hypothermia is avoided. Despite these encouraging data, we aim to perform total arch replacement with an elephant trunk during initial surgery whenever possible.