Aortic arch reconstruction in surgical treatment of ascending aortic aneurysms and dissections

Abstract

Aim. The study focused on the analysis of short-term results of aortic arch reconstruction in patients undergoing open heart surgery for ascending aortic aneurysms and dissections, comparison of intra-operative brain protection methods and verification of predictors of complications.Methods. 84 patients (mean age 55.5 ± 11.5 years, 72.6 % (61) males) with ascending aortic aneurysms and Stanford type A ascending aortic and arch dissections underwent surgery over a period from January, 2013, to March, 2015. Patients were divided into 3 groups. The 1st group included patients with ascending aortic aneurysm combined with aortic dilatation at the level of innominate artery >4.0 cm (n = 41). The 2nd group consisted of patients with Stanford type A acute ascending aortic and arch dissection (n = 25). In the 3rd group there were patients with type A chronic ascending aortic and arch dissection (n = 18). No significant differences between the groups were observed. Mean values of the maximum ascending aortic diameter did not differ significantly and were 59.6, 58.4 and 62.4 mm in the 1st, 2nd and 3rd groups, respectively. 3 patients from the 2nd group presented with acute heart failure, 6 – acute myocardial infarction, and 3 – stroke. Higher values of pressure gradient on the aortic valve were registered in the 1st group, as compared to those in the 2nd and 3rd groups (mean value of the peak gradient was 4.5, 8.1 and 12.4 mm Hg, respectively). EuroSCORE II value in the 1st , 2nd and 3rd groups was 9.4 %, 17.7 % and 5.8 %, respectively. Results. Overall hospital mortality was 1.2 %: 1 patient with acute type A aortic dissection and later dissection of innominate artery developed stroke and died due to multiple organ failure. More prolonged cardiopulmonary bypass time and aortic cross-clamp time were required for patients with acute ascending aortic dissections, but the total surgery time and circulatory arrest time differed significantly only in the 2nd and 3rd groups. Lengthy inotropic support, ventilation time and total ICU stay, as well as a higher rate of neurologic disorders in patients with aortic dissections in comparison with patients with aneurysms were observed. We verified correlation of the urgent type of surgery, acute type A aortic dissection, including arch and descending thoracic aortic dissection, also with dissection of cervicocerebral arteries, with a more complicated hospital period, increased inotropic support and prolonged duration of stay in the intensive care unit.Conclusion. Hemiarch repair of aortic arch dilatation in case of ascending aortic replacement is an effective and safe method of treatment of extended ascending aortic aneurysms and dissections. Unilateral anterograde cerebral perfusion with simultaneous crossclamping of contralateral common carotid artery allows to maintain effective cerebral protection in conditions of moderate hypothermia and duration of circulatory arrest for at least 30-40 minutes. Adverse prognostic factors are urgent surgery, ascending aortic, arch and descending thoracic aortic dissection, prolonged extracorporeal circulation and myocardial ischemia, and disuse of the axillary artery for cannulation.Received 6 October 2016. Accepted 24 November 2016.Funding: The study was carried out within the government’s task for 2015-2017, “Cardiovascular pathologies”, theme No. 4 “Research on genome and cellular mechanisms of formation of aorta and aortic valve pathology and development of new methods for its treatment including hybrid technologies”.Conflict of interest: The authors declare no conflict of interest.Author contributionsMaterial acquisition and analysis: Gordeev M.L., Uspenskiy V.E., Bakanov A.Y., Volkov V.V., Ibragimov A.N., Scherbinin T.S., Irtyuga O.B., Naimushin A.V. Article writing: Gordeev M.L., Uspenskiy V.E., Bakanov A.Y. Review & editing: Gordeev M.L., Naimushin A.V.AcknowledgmentThe authors express their gratitude for support in diagnostics and management of patients with aortic abnormalities to I. V. Basek, PhD, Head of X-Ray CT Department, and to the employees of X-ray CT Department; to D.A. Zverev, PhD, Head of X-ray Endovascular Surgery Research Lab and the employees of X-ray Endovascular Surgery Departments; O.M. Moiseyeva, Doc. Sci. (Medicine), Head of Noncoronarogenic Heart Diseases Department and her employees, as well as to the employees of Anesthesiology & Resuscitation and Cardiovascular Surgery Departments.