Circulation
`
`PART Il » VOLUME 66 * NUMBER 2 « AUGUST 1982
`
`R (
`
`
`american
`
`“Heart
`! Association
`Monograph
`
`Number 89
`
`I
`
`,
`
`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 1111
`
`4,
`
`Published by the
`
`@PAmerican HeartAssociation
`
`73-075A
`
`MEDTRONIC 1111
`
`

`

`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
`
`American Heart Association
`
`CHAIRMAN: Mortimer J. BuckLey, M.D.
`
`VICE-CHAIRMAN: James A. DEWEEsE, M.D.
`
`PROGRAM COMMITTEE
`
`CHAIRMAN: FLoyp D. Loop, M.D.
`
`MEMBERS: FrepericK O. Bowman, Jr., M.D.
`
`Donacp B. Dory, M.D.
`
`Grapy L. HALLMAN, M.D.
`
`NicuoLas T. Koucuouxkos, M.D.
`
`Noet Mitis, M.D.
`
`QUENTIN STILES, M.D.
`
`Copyright © 1982
`
`THe AMERICAN HEART ASSOCIATION
`
`7320 Greenville Avenue
`
`Dallas, TX 75231
`
`All Rights Reserved
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`Library of Congress Catalog Card Number 66-9486
`
`Published and copyrighted as Part II of
`
`CircULATION Vol. 66, August 1982, Pages I-I to I-226
`
`An Official Journal of the
`
`American Heart Association, Inc.
`
`Printed and Bound in U.S.A.
`
`

`

`CIRCULATION
`
`An Official Journal of the American Heart Association, Inc.
`7320 Greenville Ave., Dallas, Texas 75231
`
`EDITOR-IN-CHIEF
`Elliot 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
`Margaret A. Inman
`Assistant Editor
`Stephen Ordway
`
`GUEST EDITOR
`Floyp D. Loop, M.D.
`
`
`Supplements to CIRCULATIONare published occasionally and may
`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 separate supplement index whenever supple-
`ments have been published.
`
`
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`PUBLICATIONS COMMITTEE, AMERICAN HEART ASSOCIATION
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`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
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`Louis MANSFIELD
`Seattle, WA
`FRANK I. MARCUS
`Tucson, AZ
`ALBERT J. MILLER
`Chicago, IL
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`SHAHBUDIN H. RAHIMTOOLA
`Los Angeles, CA
`ELLior RAPAPORT
`San Francisco, CA
`Epwin W. SALZMAN
`Boston, MA
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`Epwin L. BIERMAN
`Seattle, WA
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`Tuomas P. GrauaM, JR.
`Nashville, TN
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`Rosert A. O’RouRKE
`San Antonio, TX
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`FRANK M. Yatsu
`Portland, OR
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`
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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.,
`
`Davip A. Orr, M.D., Wittiam E. Wacker, M.D., Pu.D., AND GEorGE J. REuL, M.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)
`and brief circulatory arrest. Simplified surgical techniques were developed to allow rapid repair. The
`‘“‘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
`minutes). Dacron grafts preclotted by a new method greatly reduced postoperative blood loss. Since these
`simplified techniques were adopted, 14 patients (93%) have survived aortic arch replacement, with mini-
`mal postoperative morbidity. One patient with severe preoperative left ventricular dysfunction died of
`cardiac failure after operation. These results suggest that aortic arch replacement can be performedsafely
`and with low operative risk.
`
`SINCEsurgical treatment wasfirst proposed for tho-
`racic aortic aneurysms,' various operative techniques
`have been recommended for resection of aneurysms
`involving the aortic arch. However, resection of aortic
`arch aneurysms remains a complex procedure that is
`often associated with high mortality and morbidity
`rates. The optimal operative technique for manage-
`mentof this difficult group of aneurysmshas not been
`established.
`Early attempts at lateral aortorrhaphy were limited
`to the treatment of localized saccular aneurysms, and
`carried the risk of emboli from application of partial
`occlusion clamps during the procedure.':? Temporary
`bypass grafts allowed circulatory diversion while the
`aneurysm wasresected, but these long, tedious proce-
`dures required multiple arterial anastomoses and were
`accompanied by technical difficulties from bleeding
`and emboli.*° With the advent of cardiopulmonary
`bypass, the aneurysm could be approached more di-
`rectly.° Multiple arterial perfusion lines were used in
`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.’
`Deep hypothermia with circulatory arrest simplified
`the approach to aneurysmsof the aortic arch and pro-
`vided a dry, unobstructed operative field in which the
`surgeon could work.*'° Deep hypothermia to 12—16°C
`has been usedto preserve cerebral and cardiac integrity
`during periods of necessary circulatory arrest. Al-
`though the effectiveness of this technique has been
`demonstrated,'' ’ further experience during the last 5
`years has revealed several problems.'* Prolongedper-
`iods of cardiopulmonary bypass are needed for the
`cooling and rewarming phases of the procedure. The
`interference of normal coagulation mechanisms by
`
`
`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.
`
`prolonged bypass and hypothermia has produced
`troublesomebleeding in somepatients. Multiple organ
`system dysfunction has been observed postoperatively
`after a technically satisfactory operation and hasraised
`doubts regarding the level of protection with this
`technique.
`Weevaluated the technique andresults used recent-
`ly in 15 consecutive patients who underwent resection
`of the transverse aortic arch.
`
`Methods
`The essential features of the operative techniqueare
`illustrated in figure 1. Aneurysms of the ascending
`aorta and the transverse aortic arch are approached
`through a median sternotomy. Techniques of cannula-
`tion and methods of hypothermic perfusion have been
`described.'* '* All patients are cannulated using a sin-
`gle,
`large,
`right atrial cannula with arterial
`return
`through the femoral artery. Care is taken to ensure
`arterial cannulation and perfusion of the femoral artery
`in continuity with the true lumen.
`induced with
`Moderate systemic hypothermia is
`core cooling to 24°C. Additional myocardial cooling
`can be accomplished by infusing cold cardioplegic so-
`lution into the coronary ostia after opening the aneu-
`rysm. Total circulatory arrest is accomplishedbyfirst
`clamping the arch vessels and then ceasing extracol-
`poreal bypass. Clampsare applied to both the arterial
`and venous perfusion lines to prevent introduction ©
`air into the bypasscircuit. After opening the aneurysm,
`blood is aspirated only as necessary to visualize the
`transverse arch and proximal descending thoracic aol
`ta. This provides a dry, unobstructed operative field
`and facilitates a rapid repair.
`Attention to the origin of the arch vessels, relief of
`arch obstruction by endarterectomy or bypass, and re
`pair ofaortic dissection are possible during brief circU”
`latory arrest. The distal aortic anastomosis is then com
`pleted to the ‘‘open’’ aorta, using an elliptical suture
`line, and a long tongue of the Dacron graft is sewn !”
`beneath the aortic arch tributaries." In cases of aorll¢
`dissection, the two layers of the aortic wall are incol™
`porated in a single suture line, obliterating the fals¢
`
`1-122
`
`

`

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

`

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

`

`OPEN AORTIC ANASTOMOSIS/Livesayet al.
`
`1)
`
`B 3/16/81
`
`C 3/16/81
`
` Figure 3. Treatment for recurrent aortic
`
`3/18/81
`
`dissection, right carotid occlusion, and aortic
`insufficiency. (A) Aortogram before first oper-
`ation showing aortic dissection involving the
`innominate artery.
`(B) Aortogram after first
`operation showing recurrent aortic dissection
`with right carotid obstruction.
`(C) Diagram
`before reoperation showing the extent ofaortic
`dissection.
`(D) Diagram after
`reoperation
`showing aortic arch reconstruction,
`innomi-
`nate artery endarterectomyandbypass, aortic
`valve replacement andobliteration of the false
`lumen.
`
`postoperative bleeding problems. The mean postoper-
`ative bloodlossfor the first 24 hours in 13 patients was
`low — 1152 + 245 ml(fig. 5). The average postoper-
`ative transfusion requirement was 2.6 units of blood.
`One patient of the Jehovah’s Witness faith underwent
`successful resection of the aortic arch without blood
`replacement. One patient required reexploration for
`excessive bleeding and was found to have an occult
`tear in the left subclavian artery from a cross-clamp
`injury.
`
`Discussion
`Aneurysms of the aortic arch have long posed a
`formidable surgical challenge, because resection in-
`Volves interruption ofcirculation through this channel
`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
`Tesults have been reported.*"'”: '?:'7-'8 In 1978, were-
`Ported our initial experience with this technique; five
`
`
`of six patients survived aortic arch replacement." In
`
`
`1980, Ergin and Griepp'’ reported that 10 of 14 pa-
`tients survived arch resection using deep hypothermic
`arrest,
`including nine of 10 patients operated upon
`electively.'? We reviewed our continued experience
`with this technique over a 4-year period in 20 pa-
`tients.'? An overall operative mortality of 50% (10 of
`20 patients) has led us to reassess our methods of
`hypothermic arrest. Three specific complications were
`identified: postoperative bleeding, dysfunction of vital
`organs and uncertain preservation of cerebral and myo-
`cardial integrity.
`Hypothermia depresses normal coagulation mecha-
`nisms, and prolonged cardiopulmonary bypass de-
`pletes factors necessary for coagulation.'? *° Continued
`exposure of the preclotted graft to heparinized blood
`during necessary periods of rewarming on bypass
`washesfibrin from the surface of the graft and pro-
`motes bleeding from its long suture lines. The tech-
`nique of Bethea and Reemtsma’! has been modified to
`prepare grafts for hypothermic conditions.'> These
`plasma-soaked grafts prepared by autoclave have
`greatly reduced the amount of postoperative bleeding
`after thoracic aortic replacement.
`Despite a technically satisfactory operation, some
`patients have major organ system dysfunction after
`deep hypothermic arrest. Hepatic dysfunction, renal
`
`Ficure 4. Treatment of patient with Mar-
`fan's syndrome, aortic aneurysm, dissection
`andvalvular insufficiency. (A) Aortogram and
`computerized tomographic scan before oper-
`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-
`proved greatly in this difficult group of patients. The
`length of operation and the duration of cardiopul-
`monary bypass have been shortened. Postoperative
`Results
`bleeding has been significantly reducedto the level of
`Survival
`other intracardiac procedures. The complications of
`.
`3
`.
`;
`.
`.
`30-day mortality
`major organ system dysfunction seen with deep hypo.
`-
`thermia have not been observed with moderatelevels
`Morbidity
`of hypothermia. Morbidity has been minimalafter op-
`13
`2
`Neurologic deficit
`eration. Most important, 14 of 15 patients (93%) sur-
`7
`1
`Myocardial infarction
`vived. These improved results demonstrate that aortic
`7
`\
`Pulmonary insufficiency
`arch replacement can be safely accomplished by
`7
`1
`Postoperative bleeding
`simplified techniques, with an acceptably low opera-
`:
`
`
`
`0 0Renal or hepatic dysfunction tive risk
`
`14
`|
`
`93
`iL
`
`failure and pulmonary complications have beenreport-
`ed. Similar complications with deep hypothermia in
`adults have also been reported.”4 Ergin and Griepp'”
`noted almost routine postoperative pulmonary edema
`in their patients.'’ In addition, the degree of cerebral
`and myocardial protection with deep hypothermia has
`been unpredictable. These complications may berelat-
`ed to methods of cooling and rewarming with
`hypothermic perfusion, the rapidity of which may pro-
`duce temperature gradients, tissue edema, cellular in-
`jury and formationoffree gaseous emboli in the blood.
`Wehave modified our technique to provide moder-
`ate levels of systemic hypothermia (23—24°C) and to
`expedite a rapid repair using brief circulatory arrest.
`Moderate levels of hypothermia afford adequate cere-
`bral and myocardial protection and reduce the duration
`of perfusion for the cooling and rewarming phases of
`bypass. Circulatory arrest provides an unobstructed,
`dry operative field. The ‘‘open’’ aortic technique fa-
`cilitates direct repair of obstructive lesions, dissec-
`tions, and aneurysmsofthe aortic arch. A single ellip-
`tical anastomosis can be performed to the ‘‘open’’
`distal aorta at the level of the arch tributaries, usually
`in less than 15 minutes.
`*
`
`5
`
`S
`
`wo
`
`Nh
`
`No.ofPatients
`
`_ 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
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`

`

`CLOSURE OF AORTIC ANNULUS MYCOTIC ANEURYSMS/Bailey et al.
`
`1-127
`
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`
`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 aneurysmsweresuccessfully operated on over
`a 3-year period. Aortic valve replacement was facilitated in all six patients by closing theorifice of the
`abscess with a Dacron patch and then seating the prosthetic valve at the level of the aortic annulus. In each
`case, a portion of the prosthetic valve ring was sutureddirectly to the patch. Nopatient hasclinical evidence
`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
`endocarditis may require extraordinary techniques to
`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 University of Washington in Seattle from
`January 1, 1978, to December31, 1980, each of whom
`had a large mycotic aneurysm involvingthe aortic an-
`nulus. Aortic valve replacement wasfacilitated in all
`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
`whounderwentaortic valve replacementat the Univer-
`Sity Hospital between January 1, 1978, and December
`31, 1980, either as an isolated or combined procedure.
`All six patients (five men and one woman)operated
`Upon during that interval in whom an annular abscess
`Was closed with a patch are includedin this report. The
`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,
`Address for correspondence: Warren W. Bailey, M.D., Cardiotho-
`"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
`cardiopulmonary bypass techniques and cold potas-
`sium cardioplegia. The abscess cavity was debrided
`andits orifice closed with a woven Dacron patch sewn
`into place with a continuous monofilament suture
`(figs. 1-3). An aortic xenograft prosthesis was inserted
`and attached to the remaining noninfected aortic annu-
`lus and to the patch at the level of the annulus with
`interrupted mattress sutures. No attempt was madeto
`tilt or displace the prosthetic valve ring to avoid sewing
`across the Dacron patch.
`
`Results
`All patients survived the operation, and all except
`patient 6 had an uneventful convalescence. Patient 6
`developed a systolic murmurandincreasing heart fail-
`ure 3 weeksafterinitial operation. Cardiac catheteriza-
`tion demonstrated a subaortic ventricular septal defect,
`but no perivalvular aortic incompetence. At reopera-
`tion (table 1), the lower margin of the patch used to
`close a large abscess extending from the aortic annulus
`into the interventricular septum had dehisced from the
`crest of the septum; inflammatory tissue was not pre-
`sent. The defect was successfully repaired.
`All patients were active and free of cardiac symp-
`toms 18-48 months after operation. Persistent or re-
`current infection has not occurred, and none ofthe
`patients has a murmurofaortic valve incompetence.
`
`Discussion
`The surgical managementof patients with infective
`
`