Mortality and neurologic injury after surgical repair with hypothermic circulatory arrest in acute and chronic proximal thoracic aortic pathology: effect of age on outcome.

BACKGROUND: The goal of this study was to determine whether advanced age affects mortality and incidence of neurological injury in patients undergoing surgical repair with hypothermic circulatory arrest in acute and chronic thoracic aortic pathology. METHODS AND RESULTS: A university center audit was done of 523 consecutive patients (median age, 64 years; interquartile range, 56-71 years) between 2005 and 2010. Mortality in acute type A aortic dissection (207 patients) was 9.7%, and in chronic ascending aortic aneurysms (316 patients) was 2.2% (P<0.001). Neurological injury was observed in 16.9% of patients with acute type A aortic dissection (chronic ascending aortic aneurysms, 7.9%; P=0.002). Multivariable regression analysis revealed hypothermic circulatory arrest >40 minutes (odds ratio [OR], 4.21; 95% confidence interval [CI], 1.60-11.06; P=0.004) and redo surgery (OR, 3.44; 95% CI, 1.11-10.64; P=0.03) but not age (OR, 1.98; 95% CI, 0.73-5.38; P=0.18) as independent predictor of mortality. Emergency surgery (OR, 3.27; 95% CI, 1.31-8.15; P=0.01) and extracardiac arteriopathy (OR, 2.38; 95% CI, 1.26-4.50; P=0.008) but not age (OR, 1.80; 95% CI, 0.93-3.48; P=0.08) were independent predictors of neurological injury. CONCLUSIONS: Age is not associated with increased risk for mortality and neurological injury in patients undergoing surgical repair for acute and chronic thoracic aortic pathology with hypothermic circulatory arrest. Extended hypothermic circulatory arrest times, reflecting the extent of disease, and redo surgery predict mortality, whereas emergency surgery and extracardiac arteriopathy predict neurological injury.

Temporary neurological dysfunction after surgery of the thoracic aorta: a predictor of poor outcome and impaired quality of life.

BACKGROUND: Transient neurological dysfunction (TND) consists of postoperative confusion, delirium and agitation. It is underestimated after surgery on the thoracic aorta and its influence on long-term quality of life (QoL) has not yet been studied. This study aimed to assess the influence of TND on short- and long-term outcome following surgery of the ascending aorta and proximal arch. METHODS: Nine hundred and seven patients undergoing surgery of the ascending aorta and the proximal aortic arch at our institution were included. Two hundred and ninety patients (31.9%) underwent surgery because of acute aortic dissection type A (AADA) and 617 patients because of aortic aneurysm. In 547 patients (60.3%) the distal anastomosis was performed using deep hypothermic circulatory arrest (DHCA). TND was defined as a Glasgow coma scale (GCS) value <13. All surviving patients had a clinical follow up and QoL was assessed with an SF-36 questionnaire. RESULTS: Overall in-hospital mortality was 8.3%. TND occurred in 89 patients (9.8%). As compared to patients without TND, those who suffered from TND were older (66.4 vs 59.9 years, p<0.01) underwent more frequently emergent procedures (53% vs 32%, p<0.05) and surgery under DHCA (84.3% vs 57.7%, p<0.05). However, duration of DHCA and extent of surgery did not influence the incidence of TND. In-hospital mortality in the group of patients with TND compared to the group without TND was similar (12.0% vs 11.4%; p=ns). Patients with TND suffered more frequently from coronary artery disease (28% vs 20.8%, p=ns) and were more frequently admitted in a compromised haemodynamic condition (23.6% vs 9.9%, p<0.05). Postoperative course revealed more pulmonary complications such as prolonged mechanical ventilation. Additional to their transient neurological dysfunction, significantly more patients had strokes with permanent neurological loss of function (14.6% vs 4.8%, p<0.05) compared to the patients without TND. ICU and hospital stay were significantly prolonged in TND patients (18+/-13 days vs 12+/-7 days, p<0.05). Over a mean follow-up interval of 27+/-14 months, patients with TND showed a significantly impaired QoL. CONCLUSION: The neurological outcome following surgery of the ascending aorta and proximal aortic arch is of paramount importance. The impact of TND on short- and long-term outcome is underestimated and negatively affects the short- and long-term outcome.

Large area of the false lumen favors secondary dilatation of the aorta after acute type A aortic dissection.

BACKGROUND: Since 1994 patients with acute aortic dissection type A (AADA) are followed-up in our outpatient clinic. Early diagnosis of secondary dilatation of the diseased aorta is crucial to reduce late mortality in these patients. Aim of the present study is to asses the impact of a large volume in the false lumen of the diseased downstream aorta on secondary dilatation. METHODS AND RESULTS: 134 patients of 264 patients who underwent surgery for AADA (between January 1994 and June 2003) are followed-up at our outpatient clinic since 1994. 84 patients (62.7%) fulfilled the inclusion criteria. Areas of the true and the false lumens of the aorta were analyzed and a logistic regression was calculated at 5 levels of the aorta for each patient. Patients were divided in 3 groups: group 1 included 34 patients (40.5%) without progression, group 2 had 34 patients (40.5%) with slight progression, and group 3 had 16 patients (19.0%) with important progression, requiring surgery in all patients. In 87.5% of the patients the area of the original lumen was <0% in group 3, compared with 11.8% in group 2 and 8.8% in group 1 in relation to the total area of the aorta 6 months after surgery (P<0.001). CONCLUSIONS: A large false lumen, with an area of the true lumen <30% 6 months after surgery, is the strongest predictor for secondary dilatation of the diseased downstream aorta.

Effects of deep hypothermic circulatory arrest on outcome after resection of ascending aortic aneurysm.

BACKGROUND: Aneurysm of the ascending aorta is a common finding especially in patients with aortic valve diseases. The aim of this study was to analyze early and midterm outcome in patients operated on for aneurysm of the ascending aorta with or without the use of deep hypothermic circulatory arrest (DHCA). METHODS: Between January 1996 and December 2000, 133 of 410 patients with thoracic aortic pathology were operated on for an aortic aneurysm limited mainly to the ascending aorta. Early and midterm outcomes were assessed and quality of life (QOL) evaluated using the Short-Form 36 Health Survey Questionnaire (SF-36). RESULTS: Sixty patients (group 1) were operated on with DHCA and 73 patients (group 2) without DHCA. In-hospital mortality was identical in both groups (9.6% versus 6.7%; p = not significant) whereas postoperative transient neurologic events were significantly more frequent in group 1 (6.7% versus 0%; p < 0.05). Midterm clinical outcome was not different between groups but QOL showed significant impairment in daily functional physical and emotional activity in group 1 patients compared with group 2 and an age-matched standard population. CONCLUSIONS: The risk of transient neurologic complications is significantly increased with the use of DHCA and QOL is impaired without benefits in the long-term outcome especially among older patients.

Quality of life after interventions on the thoracic aorta with deep hypothermic circulatory arrest.

OBJECTIVE: Assessment of quality of life (QL) in patients undergoing major surgical procedures is of increasing interest. We focused on surgery of the thoracic aorta requiring deep hypothermic circulatory arrest (DHCA). Aim of this study was to assess QL after thoracic aortic surgery with DHCA, using the Short Form 36 Health Survey (SF-36) questionnaire. METHODS: Between 01/94 and 12/99 212 (59.1%) out of a total of 359 interventions on the thoracic aorta were performed under DHCA, with an early mortality of 13.7% (28 patients). During an average follow-up of 3.2+/-1.3 years, 27 patients died (15.2%) and five patients (2.8%) were lost. A total of 145 patients (81.9%) had a complete follow-up. RESULTS: 125 of the 145 SF-36 questionnaire handed out were answered correctly (86.2%). In relation to a standard population (z=0), the most important deficits were found in physical function (z=-0.53) and role limitations because of physical health (z=-0.42). Good results were found regarding the aspect of pain (z=0.28), social functioning (z=0.02) and vitality (z=-0.02). Overall QL in patients having been operated for aortic aneurysm was better than for patients with acute type A-dissection. CONCLUSION: Despite restrictions in physical functioning and role limitation because of physical health, QL in patients after interventions on the thoracic aorta with DHCA is fairly good and, for patients being operated for aortic aneurysm, comparable to an age-matched standard population. Patients having being operated electively for aortic aneurysm enjoyed a better QL than patients having been operated emergently for acute type A dissection.

What makes the difference between the natural course of a remaining type B dissection after type A repair and a primary type B aortic dissection?

OBJECTIVES: To analyse the outcome and need for intervention [surgery or thoracic endovascular aortic repair (TEVAR)] in patients after surgery for remaining type B dissection after type A repair and primary type B aortic dissection. METHODS: Within a 10-year period, 247 patients with remaining type B after type A, and 112 patients with primary type B aortic dissection were analysed. We assessed the clinical outcome as well as the need for intervention (surgery or TEVAR) within the aortic arch and the thoracoabdominal aorta as well as risk factors. RESULTS: The median follow-up was 23 months (interquartile range 5-52). There was a significant difference with regard to the status of the primary entry tear between patients after surgical repair of an acute type A aortic dissection and primary acute type B aortic dissection (patent vs. non-patent entry 35 vs. 83%, P < 0.001). The overall need for any kind of intervention (surgery or TEVAR) was 19%. Multivariate Cox regression analysis revealed a patent primary entry tear in patients after surgery for acute type A aortic dissection as an independent predictor for intervention (surgery or TEVAR) during follow-up [odds ratio (OR) 6.4; confidence interval (CI) 1.39-29.81, P = 0.017]. Multivariate Cox regression analysis did not reveal a patent primary entry tear in patients after acute type B aortic dissection as an independent predictor for intervention (surgery or TEVAR) during follow-up (OR 0.67; CI 0.27-1.69, P = 0.671). Finally, the thrombosis status of the false lumen was not an independent predictor for intervention (surgery or TEVAR) either in patients after surgery for acute type A aortic dissection (OR 3.46; CI 0.79-15.16, P = 0.100) or in patients after acute type B aortic dissection (OR 0.77; CI 0.31-1.93, P = 0.580). CONCLUSIONS: A remaining type B dissection after type A repair and a primary type B aortic dissection represent two distinct pathophysiological entities with regard to late outcome. The need for any kind of intervention in the thoracoabdominal aorta is significantly higher in primary type B aortic dissections. A remaining patent primary entry tear independently predicts the need for intervention (surgery or TEVAR) in patients after surgery for acute type A aortic dissection and, thereby, remains the main target of initial therapy. The thrombosis status of the false lumen seems to be of secondary importance.

Long-term results after operations for active infective endocarditis in native and prosthetic valves.

BACKGROUND: The objective of this study was to evaluate the midterm results of patients who underwent operations for active infective endocarditis. METHODS: Within a 10-year period, 141 patients with active infective endocarditis received surgical therapy. We assessed outcome, freedom from reinfection, and freedom from reintervention. Prosthetic valve endocarditis was included in this series. RESULTS: Surgical strategies included valve replacement with a tissue valve in 62% of patients and valve repair in 29% of patients. In 29% of patients, reconstruction of the aortomitral continuity, left ventricular outflow tract, or sinus of Valsalva was preferably performed with 1 or more bovine pericardial patches. In-hospital mortality was 11% and postoperative stroke rate was 7%. Multivariate logistic regression revealed multivalve involvement (p=0.052; odds ratio [OR], 5.84; 95% confidence interval [CI], 0.98-34.57), preoperative neurologic impairment (p=0.006; OR, 9.71; 95% CI, 1.92-49.09), and European system for cardiac operative risk evaluation (EuroSCORE) in quartiles (p=0.023; OR, 2.88; 95% CI, 1.15-7.17) to be independent predictors for in-hospital death. One-year and 5-year actuarial survival was 77% and 69%, respectively. One-year and 5-year actuarial freedom from reinfection was 100% and 90%, respectively. Freedom from reoperation at 5 years was 100%. Five-year survival was 74% for single-valve endocarditis and 46% for multivalve endocarditis (p<0.001). One-year freedom from reinfection was 100% for both single-valve and multivalve endocarditis; 5-year freedom from reinfection was 95% for single-valve endocarditis versus 67% for multivalve endocarditis (p=0.049). CONCLUSIONS: Despite a high early mortality during the first year, surgical intervention for active infective endocarditis provided excellent results with regard to freedom from reinfection and reoperation. A strategy of extensive debridement, reconstruction of destroyed cardiac structures using xenopericardium, followed by valve replacement or repair is highly effective and shows favorable long-term outcomes.

Autotransfusion system or integrated automatic suction device in minimized extracorporeal circulation: influence on coagulation and inflammatory response.

OBJECTIVE: To measure surrogate markers of coagulation activation as well as of the systemic inflammatory response in patients undergoing primary elective coronary artery bypass grafting (CABG) using either the so-called Smart suction device or a continuous autotransfusion system (C.A.T.S.®). METHODS: Fifty-eight patients being operated with a miniaturized circuit (minimal extracorporeal circuit, MECC) were prospectively randomized to using a so-called Smart suction device or a routine continuous autotransfusion system (C.A.T.S.®) for collection of mediastinal shed blood. The coagulation response was measured by thrombin-antithrombin complex (TAT) and D-dimer. The inflammatory response was measured by Interleukin 6 (IL-6) and complement factor 3a (C3a) at three different time points, before surgery, 2h after surgery, as well as 18 h after surgery. RESULTS: No serious adverse cardiovascular event was observed. Serum levels of TAT significantly differed between both groups 2h after surgery (Smart suction 16.12 ± 13.51 µg l⁻¹ vs C.A.T.S® 9.83 ± 7.81 µg l⁻¹, p = 0.040) and returned to baseline values after 18 h in both groups. Serum levels of D-dimer showed a corresponding pattern with a peak 2h after surgery (Smart suction 1115 ± 1231 ng ml⁻¹ vs C.A.T.S.® 507 ± 604 ng ml⁻¹, p = 0.025). IL-6 levels also significantly differed between both groups 2h after surgery (Smart suction 186 ± 306 pg ml⁻¹ vs C.A.T.S.® 82 ± 71 pg ml⁻¹, p = 0.072). No significant changes in serum levels of C3a over time could be observed. CONCLUSIONS: Despite no differences in the clinical course of patients with either Smart suction or C.A.T.S.® being observed, surrogate markers of coagulation and inflammation seem to be less pronounced in patients where cardiotomy blood is not being directly reinfused. As such, C.A.T.S.® should be preferred in routine CABG, as long as no extensive volume substitution is anticipated.

Results after thoracic endovascular aortic repair in penetrating atherosclerotic ulcers.

BACKGROUND: Results after thoracic endovascular aortic repair in penetrating atherosclerotic ulcers are uncertain. METHODS: From 1997 to 2010, 72 patients (median age, 67 years) presented with penetrating atherosclerotic ulcers (symptomatic, 58%; rupture, 36%). Median logistic EuroSCORE (European System for Cardiac Operative Risk Evaluation) was 32. Mean follow-up was 42 months (range, 19 to 56 months). In-hospital mortality, occurrence of endoleaks, reinterventions, and survival were recorded. RESULTS: In hospital mortality was 4%. The primary success rate was 100%. Actuarial survival rates at 1, 5, and 10 years were 93%, 72%, and 60%. The early type I and III endoleak rate was 2.7%. The late type I and III endoleak rate was 4%. One late surgical conversion was performed. Aortic-related actuarial survival was 100% at 1 year and 98.6% at 5 and 10 years. Age older than 75 years (odds ratio, 8.928; 95% confidence interval, 2.05 to 38.93) was an independent predictor of survival. During follow-up, 21% of patients underwent a cardiovascular intervention. CONCLUSIONS: Results after thoracic endovascular aortic repair in patients with penetrating atherosclerotic ulcers are excellent for early and late type I and III endoleak formation and aortic-related survival. Patients are mainly limited by age and by the aggressive underlying obliterative atherosclerotic process.

Persistent sensitivity disorders at the radial artery and saphenous vein graft harvest sites: a neglected side effect of coronary artery bypass grafting procedures.

OBJECTIVE: The use of radial artery conduits in coronary artery bypass grafting (CABG) surgery is associated with improved long-term patency and patient survival rates as compared with saphenous vein conduits. Despite increasing popularity, relative incidence of local harvest-site complications and subjective perception of adverse long-term sequelae remain poorly described. METHODS: To allow for direct comparison, we investigated a consecutive series of patients in whom both the radial artery and the saphenous vein had been harvested for isolated CABG during a 36-month period. Patients were identified from a prospective database that collects baseline clinical information. The patients' own perceptions were assessed by a standardized direct telephone survey regarding any persistent functional impairment from their arm and leg operation sites. RESULTS: Out of 1756 CABG patients during the study period, 168 (10%) were eligible (78% men, median age: 60.1 ± 9.6 years, range: 29.6-82.4 years). Of these, 123 (73%) could be contacted and interviewed at a median follow-up time of 2.5 ± 0.9 years. Surgical wound complications at harvest sites (arms and legs) had occurred in 3% and 12%, respectively, and persistent symptoms (arms and legs) were self-reported as follows: chronic pain (5% and 8%), numbness (32% and 34%) and paresthesia/dysesthesia (14% and 7%). Overall, 39% of the patients reported persistent discomfort at the arm and 39% at the leg. Both sites were simultaneously affected in 21% (P = n.s., paired testing). Logistic regression modeling showed that patients with adverse long-term sequelae were younger (P < 0.005), had a higher body mass index (P < 0.05) and a lower EuroSCORE (P < 0.001) at the time of operation (EuroSCORE, European System for Cardiac Operative Risk Evaluation). Perioperative wound complications, however, did not predict persistence of symptoms. CONCLUSIONS: Persistent harvest-site discomfort occurs with astonishing frequency after CABG surgery and affects arms and legs equally. Although usually considered a minor complication, long-term limitation to quality of life may be substantial, particularly in younger and relatively healthy patients. Thus, harvest-site discomfort clearly belongs to the list of possible post-CABG complications of which patients need to be aware.

Antegrade cerebral protection in thoracic aortic surgery: lessons from the past decade.

OBJECTIVE: Prolonged deep hypothermic circulatory arrest (DHCA) adversely affects outcome and quality of life in thoracic aortic surgery. Several techniques of antegrade cerebral perfusion are routinely used: bilateral selective antegrade cerebral protection (SACP) by introducing catheters in the innominate and left carotid artery, unilateral perfusion through the right axillary antegrade cerebral perfusion (RAACP) or a combination of right axillary perfusion with an additional catheter in the left carotid artery (RAACCP), resulting also in bilateral perfusion. The aim of the present study was to analyse the impact of the different approaches on the quality of life (QoL). METHODS: The data of 292 patients who underwent surgery of the thoracic aorta using DHCA at our hospital between January 2004 and December 2007 have been analysed and a follow-up was performed focussing on QoL, assessed with the Short Form-36 Health Survey Questionnaire (SF-36). Results were analysed according to the type of cerebral perfusion and the duration of DHCA. RESULTS: Patients' characteristics were similar in all groups. Of the total, 3.4% patients underwent DHCA (average 8.3+/-6.4 min) without ACP, 45.9% underwent SACP (average DHCA of 15.6+/-7.1 min), 40.4% had RAACP (average DHCA of 28.1+/-11.6 min) and 9.4% bilateral perfusion (RAACCP) (average DHCA of 43.1+/-16.7 min). The average follow-up was 23.2+/-15.1 months. QoL was preserved in all groups. For DHCA above 40 min, bilateral ACP provides superior midterm QoL than unilateral RAACP (average SF-36 95.1+/-44.4 vs 87.6+/-31.3; p=0.072). CONCLUSIONS: When midterm QoL is assessed, bilateral SACP provides the best cerebral protection for prolonged DHCA (>40 min).

Midterm results of thoracic endovascular aortic repair in patients with aneurysms involving the descending aorta originating from chronic type B dissections.

BACKGROUND: Midterm results of TEVAR (thoracic endovascular aortic repair) in patients with aneurysms involving the descending aorta originating from chronic type B dissections are not known. METHODS: Between 2004 and 2009, 14 patients with a median age of 63 years (79% male) with this pathology were treated. Seven patients underwent supraaortic transpositions in various extents prior to TEVAR in order to gain a sufficient proximal landing zone. RESULTS: Median time from dissection to treatment was 19 months (4 to 84 months). All patients had an uneventful in-hospital course. The median covered length of the aortic arch and descending aorta was 190 mm (100 to 250 mm). Primary success rate defined as absence of type Ia endoleakage was 86%. No patient, where visceral or renal vessels originated from the false or from both lumina sustained ischemic injury by TEVAR. The median follow-up period is 34 months to date (6 to 64 months). Aortic-related morbidity and mortality during follow-up was low (14%). CONCLUSIONS: Midterm results of TEVAR in patients with aneurysms involving the descending aorta originating from chronic type B dissections are good. The self-expanding capability of the stent grafts is sufficient over time. However, extensive coverage of the descending aorta is warranted to achieve success. Further studies are needed to extend our knowledge in this particular subgroup of patients.

Excellent outcome after surgical treatment of massive pulmonary embolism in critically ill patients.

OBJECTIVE: Treatment of central and paracentral pulmonary embolism in patients with hemodynamic compromise remains a subject of debate, and no consensus exists regarding the best method: thrombolytic agents, catheter-based thrombus aspiration or fragmentation, or surgical embolectomy. We reviewed our experience with emergency surgical pulmonary embolectomy. METHODS: Between January of 2000 and March of 2007, 25 patients (17 male, mean age 60 years) underwent emergency open embolectomy for central and paracentral pulmonary embolism. Eighteen patients presented in cardiogenic shock, 8 of whom had cardiac arrest and required cardiopulmonary resuscitation. All patients underwent operation with mild hypothermic cardiopulmonary bypass. Concomitant procedures were performed in 8 patients (3 coronary artery bypass grafts, 2 patent foramen ovale closures, 4 ligations of the left atrial appendage, 3 removals of a right atrial thrombus). Follow-up is 96% complete with a median of 2 years (range, 2 months to 6 years). RESULTS: All patients survived the procedure, but 2 patients died in the hospital on postoperative days 1 (intracerebral bleeding) and 11 (multiorgan failure), accounting for a 30-day mortality of 8% (95% confidence interval: 0.98-0.26). Four patients died later because of their underlying disease. Pre- and postoperative echocardiographic pressure measurements demonstrated the reduction of the pulmonary hypertension to half of the systemic pressure values or less. CONCLUSION: Surgical pulmonary embolectomy is an excellent option for patients with major pulmonary embolism and can be performed with minimal mortality and morbidity. Even patients who present with cardiac arrest and require preoperative cardiopulmonary resuscitation show satisfying results. Immediate surgical desobstruction favorably influences the pulmonary pressure and the recovery of right ventricular function, and remains the treatment of choice for patients with massive central and paracentral embolism with hemodynamic and respiratory compromise.

Technical advances improved outcome in patients undergoing surgery of the ascending aorta and/or aortic arch: ten years experience.

BACKGROUND: Several technical advances in thoracic aortic surgery, such as the use of antegrade cerebral perfusion, avoidance of cross-clamping and the application of glue, have beneficially influenced postoperative outcome. The aim of the present study was to analyse the impact of these developments on outcome of patients undergoing surgery of the thoracic aorta. METHODS AND RESULTS: Between January 1996 and December 2005, 835 patients (37.6%) out of 2215 aortic patients underwent surgery on the thoracic ascending aorta or the aortic arch at our institution. All in-hospital data were assessed. Two hundred and forty-one patients (28.8%) suffered from acute type A dissection (AADA). Overall aortic caseload increased from 41 patients in 1996 to 141 in 2005 (+339%). The increase was more pronounced for thoracic aortic aneurysms (TAA) (+367.9%), than for acute type A aortic dissections (+276.9%). Especially in TAA, combined procedures increased and the amount of patients with impaired left ventricular function (EF <50%) raised up from 14% in 1996 to 24% in 2005. Average age remained stable. Logistic regression curve revealed a significant decrease in mortality (AADA) and in the overall incidence of neurological deficits. CONCLUSIONS: Technical advances in the field of thoracic aortic surgery lead to a decrease of mortality and morbidity, especially in the incidence of adverse neurological events, in a large collective of patients. Long-term outcome and quality of life are better, since antegrade cerebral perfusion has been introduced.

Arterial access through the right subclavian artery in surgery of the aortic arch improves neurologic outcome and mid-term quality of life.

BACKGROUND: We have shown that selective antegrade cerebral perfusion improves mid-term quality of life in patients undergoing surgical repair for acute type A aortic dissection and aortic aneurysms. The aim of the study was to assess the impact of continuous cerebral perfusion through the right subclavian artery on immediate outcome and quality of life. METHODS: Perioperative data of 567 consecutive patients who underwent surgery of the aortic arch using deep hypothermic circulatory arrest have been analyzed. Patients were divided into three groups, according to the management of cerebral protection. Three hundred eighty-seven patients (68.3%) had deep hypothermic circulatory arrest with pharmacologic protection with pentothal only, 91 (16.0%) had selective antegrade cerebral perfusion and pentothal, and 89 (15.7%) had continuous cerebral perfusion through the right subclavian artery and pentothal. All in-hospital data were assessed, and quality of life was analyzed prospectively 2.4 +/- 1.2 years after surgery with the Short Form-36 Health Survey Questionnaire. RESULTS: Major perioperative cerebrovascular injuries were observed in 1.1% of the patients with continuous cerebral perfusion through the right subclavian artery, compared with 9.8% with selective antegrade cerebral perfusion (p < 0.001) and 6.5% in the group with no antegrade cerebral perfusion (p = 0.007). Average quality of life after an arrest time between 30 and 50 minutes with continuous cerebral perfusion through the right subclavian artery was significantly better than selective antegrade cerebral perfusion (90.2 +/- 12.1 versus 74.4 +/- 40.7; p = 0.015). CONCLUSIONS: Continuous cerebral perfusion through the right subclavian artery improves considerably perioperative brain protection during deep hypothermic circulatory arrest. Irreversible perioperative neurologic complications can be significantly reduced and duration of deep hypothermic circulatory arrest can be extended up to 50 minutes without impairment in quality of life.

Does aortic crossclamping during the cooling phase affect the early clinical outcome of acute type A aortic dissection?

OBJECTIVES: The purpose of this study is to evaluate the effects of crossclamping the ascending aorta in acute type A aortic dissection during the cooling phase for deep hypothermic arrest on early clinical outcome. METHODS: The records of 275 consecutive patients who underwent surgery for acute type A aortic dissection were reviewed. Ten patients have been excluded. Overall, 265 patients who underwent surgery under deep hypothermia and circulatory arrest in the "open technique" were divided retrospectively into two groups: those who underwent surgery with crossclamping of the ascending aorta during the cooling phase at the begin of the procedure (group 1, n = 191; 72.1 %) and those in whom the aorta was not clamped (group 2, n = 74; 27.9 %). RESULTS: Preoperative characteristics were similar in both groups. In group 1, femoral artery cannulation, composite graft repair, and aortic arch replacement were significantly more frequent. In-hospital mortality was 15.2 % in group 1 and 17.6 % in group 2 (P = not significant). Neurologic deficits were observed in 9.4% in group 1 and in 10.8% in group 2 (= not significant). There were no significant differences in clinical outcome between the two groups of patients. CONCLUSIONS: This study demonstrates that both options, aortic crossclamping or noclamping, may be used during the induction of deep hypothermia to repair acute type A aortic dissections with similar early clinical outcome. For the selection of the most appropriate technique, we recommend case by case evaluation, weighing the potential risks and benefits of aortic crossclamping.