Circulation
`
`VOLUME 66
`
`NUMBER 2
`
`*
`
`«
`
`AUGUST 1982
`
`»
`
`PART Il
`
`
`
`american
`“Heart
`Association
`
`89
`!
`
`Number
`
`Monograph
`
`I
`
`R (
`
`,
`
`|
`
`Cardiovascular Surgery 1981
`
`:
`uo oF NEBRASKA
`3
`ble lk Life!
`
`JUL 28 1982
`
`PERIODICALS
`
`,
`
`,
`
`Council on Cardiovascular Surgery
`
`American Heart Association
`Scientific Sessions
`
`Floyd D. Loop, M.D.
`
`Guest Editor
`
`MEDTRONIC 1011
`
`Published by the
`
`American Heart Association
`
`73-075A
`
`4,
`
`@P
`
`MEDTRONIC 1011
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`

`

`Number 89
`
`Cardiovascular
`
`Surgery
`1981
`
`COUNCIL ON CARDIOVASCULAR SURGERY
`
`AMERICAN HEART ASSOCIATION
`
`SCIENTIFIC SESSIONS
`
`Datias, Texas, NOVEMBER 16-19, 1981
`
`Edited by
`Floyd D. Loop, M.D.
`Cleveland, Ohio
`
`THE AMERICAN HEART ASSOCIATION, INC., DALLAS
`1982
`
`

`

`COUNCIL ON CARDIOVASCULAR SURGERY
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`American Heart Association
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`CHAIRMAN: Mortimer J. BuckLey, M.D.
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`MEMBERS: FrepericK O. Bowman, Jr., M.D.
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`Donacp B. Dory, M.D.
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`Grapy L. HALLMAN, M.D.
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`NicuoLas T. Koucuouxkos, M.D.
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`Noet Mitis, M.D.
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`QUENTIN STILES, M.D.
`
`©
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`1982
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`Copyright
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`copyrighted
`CircULATION Vol. 66, August 1982, Pages
`An Official Journal of the
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`I-I to I-226
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`CIRCULATION
`
`An
`
`Official Journal of the American Heart Association, Inc.
`7320 Greenville Ave., Dallas, Texas 75231
`
`Elliot
`
`EDITOR-IN-CHIEF
`Rapaport, M.D., San Francisco, California
`
`ASSOCIATE EDITORS
`Melvin D. Cheitlin, San Francisco, California
`Joel S. Karliner, San Francisco, California
`William W. Parmley, San Francisco, California
`Melvin M. Scheinman, San Francisco, California
`
`Managing Editor
`A. Inman
`Margaret
`Assistant Editor
`
`Stephen Ordway
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`GUEST EDITOR
`Floyp D. Loop, M.D.
`
`
`to CIRCULATIONare
`published occasionally and may
`Supplements
`be bound with each volume. The first supplement begins with
`page I-1. The second supplement would begin with pageI-1. Volume
`index issues include a
`index whenever
`separate supplement
`supple-
`ments have been published.
`
`
`
`PUBLICATIONS COMMITTEE, AMERICAN HEART ASSOCIATION
`Rosert M. BERNE, Chairman
`Charlottesville, Virginia
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`Mary Jo BurGeEss
`Francois M. ABBOUD
`Salt Lake City, UT
`lowa City, IA
`Harriet P. DusTAN
`JoHN T. BAKER
`Birmingham, AL
`Chicago, IL
`JoHN W. Evers
`H.J.M. BARNETT
`London, Ontario, Canada Chicago, IL
`Epwin L. BIERMAN
`Tuomas P. GrauaM, JR.
`Nashville, TN
`Seattle, WA
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`Louis MANSFIELD
`Seattle, WA
`FRANK I. MARCUS
`Tucson, AZ
`ALBERT J. MILLER
`Chicago, IL
`Rosert A. O’RouRKE
`San Antonio, TX
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`SHAHBUDIN H. RAHIMTOOLA
`Los Angeles, CA
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`San Francisco, CA
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`Epwin W. SALZMAN
`Boston, MA
`FRANK M. Yatsu
`Portland, OR
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`Published at the Publication Office, American Heart Association, Inc., 7320 Greenville Ave., Dallas, Texas 75231. Staff:
`Publishing, Franck P. Cushner; New York Office, William J. Asmann; Circulation, Barbara Stephens; Production, Vicki
`Turner.
`
`

`

`Open Aortic Anastomosis: Improved Results in the
`Treatment of Aneurysms of the Aortic Arch
`James J. Livesay, M.D., DeNton A. Cootey, M.D., J. MicHaEL Duncan, M.D.,
`AND GEorGE J. REuL, M.D.
`Davip A. Orr, M.D., Wittiam E. Wacker, M.D., Pu.D.,
`
`SUMMARY Over a 7-monthperiod, 15 consecutive patients underwent resection and reconstruction of
`the transverse aortic arch for a
`variety of pathologic lesions using moderate systemic hypothermia (24°C)
`were
`developed to allow rapid repair. The
`and brief circulatory arrest. Simplified surgical techniques
`‘“‘open’’ aortic technique facilitated repair of arch aneurysms, aortic dissections and obstructive lesions of
`the arch tributaries. The mean cerebral ischemic time was 11.2 + 1.5 minutes (mean + sEmM). Moderate
`hypothermia afforded adequate cerebral and myocardial protection during circulatory arrest and short-
`ened the duration of extracorporeal bypass necessary for the cooling and rewarming phases (87 + 8
`a new method greatly reduced postoperative blood loss. Since these
`minutes). Dacron grafts preclotted by
`were
`adopted, 14 patients (93%) have survived aortic arch replacement, with mini-
`simplified techniques
`mal postoperative morbidity. One patient with severe
`preoperative left ventricular dysfunction died of
`can be performedsafely
`cardiac failure after operation. These results suggest that aortic arch replacement
`and with low operative risk.
`
`for tho-
`
`treatment wasfirst
`SINCE surgical
`proposed
`various
`racic aortic
`operative techniques
`aneurysms,'
`have been recommended for resection of aneurysms
`the aortic arch. However, resection of aortic
`involving
`arch aneurysms remains a
`that is
`complex procedure
`and
`often associated with
`high mortality
`morbidity
`rates. The
`for manage-
`optimal operative technique
`mentof this difficult group of aneurysms has not been
`established.
`
`were limited
`at lateral aortorrhaphy
`Early attempts
`to the treatment of localized saccular aneurysms, and
`of
`carried the risk of emboli from
`partial
`application
`the
`occlusion clamps during
`procedure.':? Temporary
`allowed circulatory diversion while the
`bypass grafts
`aneurysm was
`tedious proce-
`resected, but these long,
`required multiple arterial anastomoses and were
`dures
`technical difficulties from
`bleeding
`accompanied by
`and emboli.*° With the advent of
`cardiopulmonary
`more di-
`bypass, the aneurysm could be
`approached
`lines were used in
`rectly.° Multiple arterial
`perfusion
`the extracorporealcircuit for cerebral and visceral per-
`fusion. However, cerebral
`perfusion techniques may
`produce cerebral injury by underperfusion, overperfu-
`sion or emboli and are often cumbersome due to ob-
`struction of the operative field.’
`arrest
`with
`Deep hypothermia
`simplified
`circulatory
`to aneurysmsof the aortic arch and pro-
`the
`approach
`vided a
`field in which the
`dry, unobstructed operative
`to 12—16°C
`surgeon could work.*'° Deep hypothermia
`has been usedto preserve cerebral and cardiac
`integrity
`arrest. Al-
`of necessary circulatory
`during periods
`the effectiveness of this
`has been
`’
`technique
`though
`the last 5
`further experience during
`demonstrated,''
`years has revealed several
`problems.'* Prolongedper-
`are needed for the
`iods of
`cardiopulmonary bypass
`and
`of the procedure. The
`rewarming phases
`cooling
`interference of normal
`mechanisms by
`coagulation
`From the Division of Surgery, Texas Heart Institute, St. Luke’s
`Episcopal and Texas Children’s Hospitals, Houston, Texas.
`Address for correspondence: Denton A. Cooley, M.D., Texas Heart
`Institute, P.O. Box 20345, Houston, Texas 77025.
`Circulation 66 (suppl D, 1982.
`
`has
`prolonged bypass and hypothermia
`produced
`in some
`troublesome
`patients. Multiple organ
`bleeding
`has been observed
`system dysfunction
`postoperatively
`after a
`and hasraised
`technically satisfactory operation
`the level of
`with this
`doubts regarding
`protection
`technique.
`andresults used recent-
`Weevaluated the
`technique
`who underwent resection
`in 15 consecutive patients
`ly
`of the transverse aortic arch.
`
`Methods
`are
`The essential features of the
`operative technique
`illustrated in
`1. Aneurysms of the ascending
`figure
`aorta and the transverse aortic arch are
`approached
`a median sternotomy. Techniques of cannula-
`through
`have been
`tion and methods of
`'*
`hypothermic perfusion
`a sin-
`are cannulated using
`All patients
`described.'*
`return
`atrial cannula with arterial
`large,
`right
`gle,
`the femoral artery. Care is taken to ensure
`through
`of the femoral artery
`arterial cannulation and
`perfusion
`with the true lumen.
`in
`continuity
`induced with
`Moderate systemic hypothermia is
`core
`to 24°C. Additional myocardial cooling
`cooling
`so-
`can be accomplished by infusing
`cold
`cardioplegic
`the aneu-
`lution into the coronary ostia after
`opening
`arrest is accomplishedby
`rysm. Total circulatory
`first
`extracol-
`the arch vessels and then ceasing
`clamping
`are
`to both the arterial
`poreal bypass. Clamps
`applied
`©
`and venous
`lines to prevent introduction
`perfusion
`the aneurysm,
`circuit. After
`air into the bypass
`opening
`as necessary to visualize the
`blood is aspirated only
`transverse arch and proximal descending thoracic aol
`a
`ta. This provides
`dry, unobstructed operative field
`and facilitates a
`Attention to the origin of the arch vessels, relief of
`rapid repair.
`bypass, and re
`or
`arch obstruction by endarterectomy
`ofaortic dissection are
`possible during brief circU”
`pair
`arrest. The distal aortic anastomosis is then com
`latory
`an
`to the ‘‘open’’ aorta, using
`elliptical suture
`pleted
`line, and a
`long tongue of the Dacron graft is sewn
`!”
`beneath the aortic arch tributaries." In cases of aorll¢
`layers of the aortic wall are incol™
`dissection, the two
`porated in a
`single suture line, obliterating the fals¢
`
`1-122
`
`

`

`OPEN AORTIC ANASTOMOSIS/Livesay
`
`etal.
`
`1-123
`
`
`
`-
`
`TLE
`7
`
`Ficure |. Surgical technique for resection
`and graft replacement ofdissecting aneurysm
`aorta andtransverse
`involving the ascending
`aortic arch using moderate hypothermia with
`arrest.
`circulatory
`
`males, ages 24-77 years (mean 58
`years). Fourteen
`had aneurysmsthat involved the transverse
`patients
`aortic arch; the cause was atherosclerosis in seven
`pa-
`medial necrosis in seven
`tients and
`(table 1). A
`cystic
`saccular aneurysm arising in the transverseaortic
`large
`In one
`arch was found in two
`the
`patient,
`patients.
`youngest of our
`an unusual
`of the
`series,
`hyperplasia
`of the aorta
`intimal and medial
`produced signifi-
`layers
`aorta and transverse
`cant stenosis of the
`ascending
`aortic arch.
`a
`prominent feature in 10 pa-
`Aortic dissection,
`was classified (DeBakey) type I in six and type
`tients,
`II in four.'® Three patients had acute aortic dissection.
`obstruc-
`of the dissection
`Distal propagation
`produced
`tion of the innominatearteryor left carotid artery in six
`extension of the dissection re-
`patients and
`proximal
`in six. Three
`sulted in aortic valvular insufficiency
`patients had the classic findings of Marfan’s syn-
`drome. Associated factors that increased the
`complex-
`included concomitant
`ity and risk of the
`procedure
`severe left
`coronary artery disease in five patients,
`recurrent an-
`in two
`ventricular dysfunction
`patients,
`The Pathologic Process and Operative Findings in 15
`TABLE 1.
`Patients with Aortic Arch Lesions
`
`Operative findings
`
`Aneurysm
`7
`
`Dissec-
`tion
`
`4
`
`7
`
`—_
`
`6 (3*)
`—
`
`Aortic
`obstruc-
`tion
`a
`
`1
`
`l
`
`Pathologic process
`Atherosclerosis
`=
`(n
`7)
`Cystic medial necrosis
`=
`(n
`7)
`
`(n
`1)
`=
`2
`14
`10
`Total (n
`15)
`*Acute dissection.
`
`Intimal hyperplasia=
`
`~
`
`a
`
`--FT
`3
`(EY
`\\
`
`or
`lumen.
`the
`inside the
`Invaginating
`telescoping
`graft
`true lumen is advisable. A long (120-cm) 2-0 or 3-0
`placed with care to minimize
`suture is
`polypropylene
`are
`from suture holes. Saccular aneurysms
`bleeding
`with a Dacron patch
`sewn from within the
`repaired
`aortic lumen.
`debris are eliminated by slowly
`Air and
`particulate
`As the blood level
`resuming cardiopulmonary bypass.
`rises, filling the aorta, and after all air has been re-
`a
`to the
`moved from the aortic arch,
`clamp is applied
`on the arch vessels is then released,
`graft. The
`clamp
`is per-
`Intracardiac repair
`restoring cerebral perfusion.
`formed and the proximal aortic anastomosis is com-
`pleted during systemic rewarming. With associated
`the
`and annuloaortic ectasia,
`aortic valve pathology
`replaced with a
`conduit that
`aortic valve is
`composite
`contains a
`Bjérk-Shiley valve, and coronary ostial
`In the presence of signifi-
`reimplantation is required.
`cant
`coronary occlusive disease, concomitant coronary
`a
`bypass is performed. After rewarmingto
`temperature
`of
`36-37°C, cardiopulmonary bypass is discontinued.
`Graft Preparation
`low-porosity Veri-soft woven Dacron
`A
`graft
`as
`previously de-
`(Meadox Medicals, Inc.) is prepared
`Platelet-rich plasma is obtained by centrifug-
`Scribed.'>
`‘ng SO mlofthe patient’s heparinized blood andis used
`to soak the graft. The graft is then placed in a steam
`cov-
`autoclave for 5 minutes. This method effectively
`€rs
`the fabric with a thick proteinaceous coating, elimi-
`Nates bleeding throughthe interstices of the graft, and
`suture lines.
`Mlnimizes postoperative bleeding along
`
`Results
`October 1980 to
`May 1981, 15 consecutive
`From
`underwentoperationsfor lesions involving the
`Patients
`aortic arch. Twelve were males and three were fe-
`
`

`

`1-124
`
`CIRCULATION
`
`VoL 66, SupeL I, AuGustr 1982
`
`TaBLe 2. Surgical ManagementofAortic Arch Aneurysmsin 15
`Patients
` n
`aorta and transverse aortic arch
`Ascending
`Dacron graft replacement
`Dacron patch angioplasty
`False lumen (dissection) obliterated
`Aortic arch tributaries
`
`2
`
`9
`
`13
`
`to use a
`cases, we
`directedfirst
`staged approach
`prefer
`at the most
`life-threatening problem. Usually, this is
`ofaortic insufficien-
`aorta. The presence
`the ascending
`aortic dissection or coronary insufficien-
`cy, proximal
`cy are
`strong indicationsfor directing operation toward
`a
`that segmentfirst. In the present series,
`43-year-old
`with an en-
`female with Marfan’s syndrome presented
`larging ascending aortic aneurysm, aortic insufficiency
`from distal dissection involving the
`and back pain
`arch, descending thoracic aorta and abdominal aorta
`wasaortic valve replace-
`(fig. 4). The initial procedure
`ment with a
`composite graft, coronary artery reimplan-
`tation andaortic arch reconstruction. Two weekslater,
`wasresected.
`the descending thoracic aneurysm
`are
`The results of surgery for this group of patients
`summarized in table 3. The overall survival was 93%
`a
`One patient,
`70-year-old male, died
`(14 patients).
`after repair of a saccular aneurysm of the transverse
`He had
`aortic arch and
`quadruple coronary bypass.
`coronary artery disease and severeleft ventricular dys-
`fraction of 25%). The
`function (preoperative ejection
`could not be weaned from cardiopulmonary
`patient
`bypass and died of low-output cardiacfailure.
`was minimalin this group
`Postoperative morbidity
`In contrast to the postoperative complica-
`of patients.
`there
`tions in patients undergoing deep hypothermia,
`of vital or-
`was a remarkable absence of dysfunction
`were
`13 (93%)
`gans. Among
`14 surviving patients,
`the
`immediately after the proce-
`normal
`neurologically
`dure. Onepatient had a
`right cerebral stroke after arch
`resection of an atherosclerotic aneurysm using hypo-
`arrest (24.3°C, 7
`thermia and temporary circulatory
`minutes). The distribution of the infarction, the nature
`of the aneurysm, and the short duration of arrest sug-
`an embolic cause. The patient made a
`nearly
`gested
`mild residual weakness
`complete recovery, with only
`was
`neuro-
`of the left arm. A second patient
`initially
`aortic arch recon-
`normal after undergoing
`logically
`innominate artery endarterectomy and by-
`struction,
`andaortic valve replacementfor a recurrent type
`pass,
`I aortic dissection involving the innominateartery. On
`the third postoperative day, however, the patient had a
`a recurrent dissection
`left cerebral stroke, suggesting
`or embolus involving
`the left carotid artery.
`Pretreatment of Dacron grafts and rapid correction
`of coagulation abnormalities have eliminated most
`
`Endarterectomy
`
`Bypass
`Aortic valve
`Aortic valve replacement
`Composite graft
`Coronary arteries
`Coronary artery bypass
`Coronary reimplantation
`
`3
`
`1
`
`7
`
`4
`
`3
`
`and ob-
`
`eurysm after prior operation in two
`patients,
`vena cava in one
`struction of the superior
`patient.
`used for resection and re-
`The operative procedures
`construction of lesions of the aortic arch in 15
`patients
`are listed in table 2.
`of the
`the
`complexity
`Despite
`cardiac arrest time was
`only 42 minutes
`procedures,
`(range 23-73 minutes). Moderate systemic hypother-
`mia with nasopharyngeal temperature of 24.1°C (range
`for
`cerebral
`22.9-26°C) provided adequate
`protection
`The
`of circulatory interruption.
`brief periods
`‘‘open’’
`distal aortic anastomosis facilitated a
`rapid, precise
`repair of lesions of the transverse aortic arch. The
`circulatory arrest time was 11.2 minutes (range
`mean
`6-27 minutes), and the total duration of
`cardiopulmo-
`was 87 minutes (range 64-181 minutes),
`nary bypass
`of cooling and rewarming.
`including the period
`arrest and the ‘‘open’’ aortic technique
`Circulatory
`enabled direct visualization of obstructive lesions in-
`the aortic arch and its tributaries. In one pa-
`volving
`aortic endar-
`tient with intimal and medial hyperplasia,
`a
`‘‘cast’’ of the aortic
`terectomy produced
`complete
`arch
`(fig. 2). Whenaortic dissection propagatesdistal-
`to involve archtributaries, arterial obstruction can
`ly
`or
`be relieved by endarterectomy
`bypass (fig. 3).
`Aneurysms may involve the aorta at
`multiple sites,
`In such
`with aortic dissection.
`in
`patients
`especially
`
`Figure 2.
`Treatment ofpatient with diffuse
`hyperplasia ofthe transverse aorticarch. (A)
`loca
`Aortogram before operation showingthe
`tion andextent ofdisease. (B) Diagram ofhy:
`ive
`perplasia of the aortic wall and the operat
`( C)
`specimen after aortic endarterectomy.
`Diagram of reconstruction ofthe transverse
`aortic arch,
`
`
`
`

`

`B 3/16/81
`
`et al.
`OPEN AORTIC ANASTOMOSIS/Livesay
`3/18/81
`C 3/16/81
`
`1)
`
`
`
`
`
`
`postoperative bleeding problems. The mean
`postoper-
`was
`ative bloodloss for the first 24 hours in 13
`—
`patients
`1152 + 245 ml
`low
`(fig. 5). The average postoper-
`was 2.6 units of blood.
`ative transfusion
`requirement
`One patient of the Jehovah’s Witness faith underwent
`successful resection of the aortic arch without blood
`for
`replacement. One
`patient required reexploration
`and was found to have an occult
`excessive
`bleeding
`tear in the left subclavian artery from a
`injury.
`
`cross-clamp
`
`Discussion
`a
`of the aortic arch have long posed
`Aneurysms
`formidable surgical challenge, because resection in-
`ofcirculation through this channel
`Volves
`interruption
`and requires preservation of cerebral and myocardial
`Integrity. Techniques used in the past often have re-
`sulted in long, tedious operations with uncertain pro-
`tection of vital organs and a
`high risk of mortality and
`morbidity.
`The application of deep hypothermia with circula-
`tory arrest has greatly simplified the surgical approach
`{0 lesions of the aortic arch, and improved surgical
`'?:'7-'8
`were-
`Tesults have been
`In 1978,
`reported.*"'”:
`Ported our initial
`with this
`technique; five
`experience
`of six patients survived aortic arch replacement." In
`
`recurrent aortic
`Figure 3. Treatment for
`dissection, right carotid occlusion, and aortic
`insufficiency. (A) Aortogram before first oper-
`ation
`showing aortic dissection involving the
`innominate artery.
`(B) Aortogram after first
`recurrent aortic dissection
`operation showing
`with right carotid obstruction.
`(C) Diagram
`before reoperation showing the extent
`ofaortic
`dissection.
`(D) Diagram after
`reoperation
`showing aortic arch reconstruction,
`innomi-
`and
`nate artery endarterectomy
`bypass, aortic
`andobliteration of the false
`valve replacement
`lumen.
`
`Griepp'’ reported that 10 of 14 pa-
`1980, Ergin and
`tients survived arch resection
`using deep hypothermic
`including nine of 10
`arrest,
`patients operated upon
`We reviewed our continued experience
`electively.'?
`over a
`with this
`in 20 pa-
`technique
`4-year period
`tients.'? An overall operative mortality of 50% (10 of
`patients) has led us to reassess our methods of
`20
`were
`arrest. Three specific complications
`hypothermic
`identified:
`postoperative bleeding, dysfunction of vital
`organs and uncertain
`preservation of cerebral and myo-
`cardial
`integrity.
`Hypothermia depresses normal coagulation mecha-
`nisms, and
`de-
`*°
`prolonged cardiopulmonary bypass
`pletes factors necessary for
`Continued
`coagulation.'?
`to
`exposure of the preclotted graft
`heparinized blood
`on
`of
`during necessary periods
`bypass
`rewarming
`washes fibrin from the surface of the
`graft and pro-
`motes
`suture lines. The tech-
`from its long
`bleeding
`of Bethea and Reemtsma’! has been modified to
`nique
`for
`hypothermic conditions.'> These
`prepare grafts
`plasma-soaked grafts prepared by autoclave have
`greatly reduced the amount of
`postoperative bleeding
`after thoracic aortic
`replacement.
`a
`Despite
`technically satisfactory operation,
`have
`major organ system dysfunction
`patients
`arrest.
`deep hypothermic
`Hepatic dysfunction,
`
`some
`
`after
`renal
`
`Ficure 4. Treatment of patient with Mar-
`fan's syndrome, aortic aneurysm, dissection
`andvalvular insufficiency. (A) Aortogram and
`scan
`before oper-
`computerized tomographic
`ation showing ascending aortic (AA) and de-
`scending aortic (DA) aneurysms. (B) Diagram
`before operation showing the extent
`ofdisease.
`(C) Aortogram after resection of ascending
`andtransverse arch aneurysm showing residu-
`al dissection of descending thoracicaorta. (D)
`Diagram after staged reconstruction,
`
`
`
`
`
`

`

`1-126
`
`CIRCULATION
`
`Vor 66, Supp.
`
`I, AuGusr 1989
`
`TABLE 3. Surgical Results of Aortic Arch Replacement
`Patients
`n
`
`%
`
`in 15
`
`Since adoption of these techniques, results have im-
`in this difficult group of patients. The
`proved greatly
`and the duration of
`length of operation
`cardiopul-
`monary bypass have been shortened. Postoperative
`been significantly reducedto
`has
`of
`the level
`bleeding
`The complications of
`.
`.
`other intracardiac procedures.
`3
`.
`;
`seen with deep hypo.
`major organ system dysfunction
`thermia have not been observed with moderatelevels
`Morbidity
`Neurologic deficit
`hypothermia. Morbidity has been minimalafter op-
`of
`eration. Most important, 14 of 15 patients (93%) sur-
`Myocardial infarction
`vived. These improved results demonstrate
`aortic
`can
`Pulmonary insufficiency
`that
`be safely accomplished by
`Postoperative bleeding
`arch replacement
`:
`simplified techniques, with an
`acceptably low opera-
`0
`Renal or
`0
`hepatic dysfunction
`tive risk
`
`Results
`Survival
`-
`30-day mortality
`
`.
`
`14
`
`|
`
`2
`1
`\
`1
`
`93
`
`iL
`
`13
`7
`7
`7
`
`have beenreport-
`failure and pulmonary complications
`in
`with deep hypothermia
`ed. Similar complications
`4
`Ergin and Griepp'”
`adults have also been
`reported.”
`edema
`noted almost routine postoperative pulmonary
`In addition, the degree of cerebral
`in their patients.'’
`has
`and myocardial protection with deep hypothermia
`These complications may berelat-
`been unpredictable.
`ed to methods of cooling and rewarming with
`the rapidity of which may pro-
`hypothermic perfusion,
`duce temperature gradients, tissue edema, cellular in-
`jury and formationof free gaseous emboli in the blood.
`Wehave modified our
`to
`moder-
`provide
`technique
`systemic hypothermia (23—24°C) and to
`ate levels of
`a
`arrest.
`rapid repair using brief circulatory
`expedite
`cere-
`afford adequate
`Moderate levels of
`hypothermia
`and reduce the duration
`bral and myocardial protection
`of
`and rewarming phases
`for the cooling
`of
`perfusion
`an
`arrest
`unobstructed,
`bypass. Circulatory
`provides
`fa-
`field. The ‘‘open’’ aortic technique
`dry operative
`cilitates direct repair of obstructive lesions, dissec-
`ofthe aortic arch. A
`tions, and aneurysms
`single ellip-
`tical anastomosis can be
`to the ‘‘open’’
`performed
`distal aorta at the level of the arch tributaries, usually
`in less than 15 minutes.
`*
`
`5
`
`No.ofPatients
`
`S
`
`wo
`
`Nh
`
`_ 500 1000 1500 2000 2500 3000”
`
`10,000
`
`Post Operative Blood Loss
`
`(cc/24 hrs)
`* Mean Blood Loss 1152 +245cc/24 hrs.
`
`Ficure 5.
`resection.
`
`Postoperative blood loss
`
`after aortic arch
`
`Acknowledgment
`Wethank Bill Andrewsforhis illustrations and Marianne Kneippfor
`her editorial assistance.
`
`References
`1. Cooley DA, DeBakey ME: Surgical considerationsofintrathoracic
`aneurysmsofthe aorta and great vessels. Ann Surg 135: 660, 1952
`2. Bahnson HT: Considerations in the excision of aortic aneurysms.
`Ann Surg 138: 377, 1953
`3. Cooley DA, Mahaffey DE, DeBakey ME: Total excision ofthe
`aortic arch for aneurysm. Surg Gynecol Obstet 101: 667, 1955
`4. Creech O, DeBakey ME, Mahaffey DE: Total resection ofthe
`aortic arch. Surgery 40: 817, 1956
`5. Muller WH, Warren DW, Blanton FS: A methodforresection of
`aortic arch aneurysm. Ann Surg 151: 225, 1960
`6. DeBakey ME, Crawford ES, Cooley DA, Morris GC: Successful
`resection of a fusiform aneurysm ofaortic arch with replacement
`by homograft. Surg Gynecol Obstet 105: 657, 1957
`7. Crawford ES, Saleh SA, Schuessler JS: Treatment of aneurysm of
`transverse aortic arch. J Thorac Cardiovasc Surg 78: 383, 1979
`8. Nicks R: Aortic arch aneurysmresection and replacement: protec-
`tion of the nervous system. Thorax 27: 239, 1972
`9. Gschnitzer F: Resektion eines luetischen Aortenbogenaneurysmas
`im Linksherzbypass mit tiefer Hypotherme und Kreislaufstillstand.
`Thoraxchirurgie 21: 87, 1973
`10. Pierangeli A, Coli G, Donati A, Galli R, Mikus P, Turinetto B:
`and
`Treatment of aortic arch aneurysms with deep hypothermia
`circulatory arrest. J Cardiovasc Surg (Torino) 16: 409,
`1975
`11. Griepp RB, Stinson EB, Hollingsworth JF, Buehler D: Prosthetic
`replacementofthe aortic arch. J Thorac Cardiovasc Surg 70: 1051,
`1975
`12. Ott DA, Frazier OH, Cooley DA: Resectionofthe aortic arch using
`deep hypothermia and temporary circulatory arrest. Circulation 5
`(suppl I): 1-227, 1978
`13. Cooley DA, Ott DA, Frazier OH, Walker WE: Surgical treatment
`of aneurysms ofthe transverse aortic arch: experience with 2
`patients using hypothermic techniques. Ann Thorac Surg 32: 260,
`1981
`14. Cooley DA, Livesay JJ: Technique of*‘open’’ distal anastomoss
`andtransverse arch resection. Cardiovasc Dis Bu
`for ascending
`Texas Heart Inst 8: 421, 1981
`15. Cooley DA, Romagnoli A, Milam JD, Bossart MI: A method of
`woven Dacrongrafts to prevent interstitial hemorrhage:
`preparing
`Cardiovasc Dis Bull Texas Heart Inst 8: 48, 1981
`16. DeBakey ME, Henley WS, Cooley DA, Morris GC Jr, Crawford
`ofthe
`ES, Beall AC: Surgical managementofdissecting aneurysms
`aorta. J Thorac Cardiovasc Surg 49: 130, 1965
`17. Ergin MA, Griepp RB: Progressin treatment of aneurysms ofthe
`aortic arch. World J Surg 4: 535, 1980
`18. Crawford ES, Saleh SA: Transverse aortic arch aneurysm: 1"
`new modifications ofaortlt
`provedresults oftreatment employing
`reconstruction and hypothermic cerebral circulatory arrest. A
`i
`Surg 194: 180, 1981
`yt
`19. Biérck G, Johansson BW, Nilson IM: Bloodcoagulationstudies
`hibernating and nonhibernating state and in dogs:
`hedgehogs, in a
`
`

`

`CLOSURE OF AORTIC ANNULUS MYCOTIC ANEURYSMS/Bailey
`
`et al.
`
`1-127
`
`and normothermic. Acta Physiol Scand 56: 334, 1962
`hypothermic
`90. Phillips LL, Malm JR, Deterling RA Jr: Coagulation defects fol-
`lowing extracorporeal circulation. Ann Surg 157: 317, 1963
`41. Bethea MC, Reemtsma K: Graft hemostasis: an alternative to pre-
`clotting. Ann Thorac Surg 27: 374, 1979
`22. Blondeau P, d’Allaines C, Piwnica A, Carpentier A, Dubost C:
`avecarrét circula-
`Indications actuelles de I’hypothermie profonde
`
`toire en
`chirurgie cardio-vasculaire de l’enfant et de l’adulte (nour-
`risson excepté). Ann Chir 34: 563, 1980
`23. Blondeau P, Nottin R, Dubost C: Choréoathétose grave compli-
`quant une
`hypothermie profonde. Ann Chir 34: 561, 1980
`24, ThevenetA: L’arrét circulatoire en
`hypothermie profonde dans la
`et de ses branches. Ann Chir 34:
`chirurgie de l’aorte thoracique
`573, 1980
`
`Dacron Patch Closure
`of Aortic Annulus Mycotic Aneurysms
`Warren W. BaiLey, M.D., Tom D. Ivey, M.D., AnD DonaLp W. MiLter, Jr., M.D.
`
`SUMMARY Six patients with large mycotic aortic annular aneurysmswere
`on over
`successfully operated
`a
`was facilitated in all six patients by closing theorifice of the
`3-year period. Aortic valve replacement
`abscess with a Dacron patch and then seating the prosthetic valve at the level of the aortic annulus. In each
`case, a
`was sutureddirectly to the patch. Nopatient hasclinical evidence
`portion of the prosthetic valve ring
`of a
`perivalvular leak 18-48 monthsafter operation. Onepatient required reoperation to close a ventricular
`septal defect caused by partial patch dehiscence. Dacron patch closure has been highly effective in our
`experience and is simpler than many other options.
`
`THE PRESENCEof a
`mycotic aneurysm extending
`into the aortic annulus in the patient with bacterial
`to
`endocarditis may require extraordinary techniques
`eradicate the infection and correct the
`hemodynamic
`abnormalities. Leaving the orifice of the aneurysm
`open, suture closure ofthe orifice, patch closure of the
`aneurysm, andtranslocation of the inserted prosthetic
`valve are methods of management.
`We summarize the course of six
`patients operated
`upon at the
`of
`Washington in Seattle from
`University
`January 1, 1978, to December31, 1980, each of whom
`had a
`large mycotic aneurysm involvingthe aortic an-
`wasfacilitated in all
`nulus. Aortic valve replacement
`Six patients by closing the orifice of the aneurysm with
`a
`prosthetic patch and then seating the prosthetic valve
`at the level of the natural aortic annulus.
`
`Material and Methods
`We reviewed the operative report for each patient
`at the Univer-
`underwentaortic valve replacement
`who
`between January 1, 1978, and December
`Sity Hospital
`31, 1980, either as an isolated or combined procedure.
`All six patients (five men and one woman)
`operated
`that interval in whom an annular abscess
`Upon during
`are includedin this report. The
`Was closed with a
`patch
`Patients were 25-57 years old. The annular abscess
`Complicated native valve endocarditis in five of the
`Patients and prosthetic valve endocarditis in one. The
`televant features of each ofthe six patients
`are shown
`'N table 1. Microorganisms that presumably infected
`_——
`
`From the Division of Cardiothoracic Surgery, Department of Sur-
`8ery, University of Washington School of Medicine, Seattle,
`ashington,
`for correspondence: Warren W. Bailey, M.D., Cardiotho-
`Address
`"cic Surgery, Department of Surgery, University of Washington
`Schoo] of Medicine, BB 435, RF-25, Seattle, Washington 98195,
`Circulation 66 (suppl I), 1982.
`
`the valve were cultured from the blood within 4 weeks
`of
`operationin five
`patients. Cultures of excised valve
`tissue were
`positive in two
`patients. The duration of
`postoperative antimicrobial therapy varied, and was
`determined by kind of infection and the patient’s
`course.
`Operation in each case included the use of standard
`and cold potas-
`cardiopulmonary bypass techniques
`was debrided
`sium cardioplegia. The abscess
`cavity
`andits orifice closed with a woven Dacron
`sewn
`patch
`with a continuous monofilament suture
`into place
`was inserted
`(figs. 1-3). An aortic
`xenograft prosthesis
`and attached to the
`remaining noninfected aortic annu-
`lus and to the
`at the level of the annulus with
`patch
`was madeto
`mattress sutures. No attempt
`interrupted
`tilt or
`to avoid
`displace the prosthetic valve ring
`across the Dacron
`patch.
`
`sewing
`
`All
`
`Results
`patients survived the operation, and all except
`6 had an uneventful convalescence. Patient 6
`patient
`a
`murmurand
`heart fail-
`developed
`systolic
`increasing
`ure 3 weeks afterinitial operation. Cardiac catheteriza-
`tion demonstrated a subaortic ventricular septal defect,
`but no
`At reopera-
`perivalvular aortic
`incompetence.
`tion (table 1), the lower margin of the patch used to
`close a
`abscess
`extending from the aortic annulus
`large
`into the interventricular septum had dehisced from the
`crest of the septum; inflammatory tissue was not pre-
`sent. The defect was
`successfully repaired.
`were active and free of cardiac symp-
`All patients
`operation. Persistent or re-
`toms 18-48 months after
`current infection has not occurred, and none ofthe
`patients has a murmur ofaortic valve
`incompetence.
`Discussion
`The surgical management of
`patients with infective
`
`