Evolving Knowledge About Age and Hypothermic Circulatory Arrest in Aortic Surgery

Abstract

Listen

Translate article

In ascending aortic surgery, progress in surgical and perfusion technology is continuous and quiet and does not produce frequent reports of short-term success. Changes in strategy show their effects years after their implementation, and may then be recommended to the broad community to adapt therapeutic strategy and thus to improve overall outcome. An example is the report by the Berne group1 in the current issue of Circulation on the effect of age on mortality and neurological injury in patients after surgical repair with hypothermic circulatory arrest in acute and chronic proximal thoracic pathology. Traditionally, age has been associated with a higher risk for both mortality and neurological injury, as has been shown by large databases such as the International Registry of Acute Aortic Dissection (IRAD).2 As a consequence, some centers refuse surgery in elderly patients because of dismal results, especially loss of quality of life, which has emerged as one of the most important surrogates for treatment success.3 Article see p 1407 However, the aforementioned reports stem from a time when deep hypothermic circulatory arrest was used as the only adjunctive technique for brain protection. Improvements in modern surgical therapy of aortic aneurysms include several important changes: subclavian artery perfusion, heparin-coated circuits for cardiopulmonary bypass, and most important, antegrade cerebral perfusion via the subclavian artery or selective perfusion catheters of supraaortic branches. Antegrade cerebral perfusion allows operating on the aortic arch in moderate hypothermia, thus reducing the side effects of deep hypothermia (eg, coagulopathy, inflammatory reactions). Additionally, concomitant treatment of the descending thoracic aorta with an open placement of a stent graft enables even more extensive repair of pathologies of the entire thoracic aorta. Commercially available trifurcated prostheses facilitate surgical aortic arch repair …