Ali El-Sayed Ahmad

Selective antegrade cerebral perfusion and mild (28°C-30°C) systemic hypothermic circulatory arrest for aortic arch replacement: results from 1002 patients.

OBJECTIVES The use of selective antegrade cerebral perfusion (ACP) makes deep hypothermia nonessential for aortic arch replacement. Consequently, a growing tendency to increase the body temperature during circulatory arrest with ACP has recently been reported from various institutions. However, very little is known about the clinical effect of different modes of ACP (unilateral vs bilateral) on neurologic morbidity. Also, the safe limits of this approach for spinal chord and visceral organ protection are yet to be defined. METHODS Between January 2000 and January 2011, 1002 consecutive patients underwent aortic arch repair during ACP (unilateral, 673; bilateral, 329) with mild systemic hypothermia (30°C ± 2°C; range, 26°-34°C) at 2 centers in Germany. The mean patient age was 62 ± 14 years, 663 patients (66%) were men, and 347 patients (35%) had acute type A dissection. Hemiarch replacement was performed in 684 patients (68%), and 318 (32%) underwent total arch replacement. RESULTS The cardiopulmonary bypass time accounted for 158 ± 56 minutes and the myocardial ischemic time, 101 ± 41 minutes. Isolated ACP was performed for 36 ± 19 minutes (range, 9-135). We observed new postoperative permanent neurologic deficits in 28 patients (3%; stroke in 25 and paraplegia in 3) and transient neurologic deficits in 42 patients (4%). All 3 cases of paraplegia occurred in patients with acute type A dissection and a broad range of ACP times (24, 41, and 127 minutes). A trend was seen toward a reduced permanent neurologic deficit rate after unilateral ACP (P = .06), but no difference was seen in the occurrence of transient neurologic deficits (P = .6). Overall, the early mortality rate was 5% (n = 52). Temporary dialysis was necessary primarily after surgery in 38 patients (4%). When corrected for the unequal distribution of type A dissection, neurologic morbidity, early mortality, and the need for temporary dialysis were independent of the duration of ACP and were not affected by unilateral versus bilateral ACP. CONCLUSIONS Current data suggest that ACP and mild systemic hypothermic circulatory arrest can be safely applied to complex aortic arch surgery even in a subgroup of patients with up to 90 minutes of ACP. Unilateral ACP offers at least equal brain and visceral organ protection as bilateral ACP and might be advantageous in that it reduces the incidence of embolism arising from surgical manipulation on the arch vessels.

Surgical repair for acute type A aortic dissection in octogenarians.

BACKGROUND Despite limited data, the necessity for immediate surgical intervention in octogenarians with acute type A aortic dissection (AAD) has recently been questioned because the surgical risk may outweigh its potential benefits. At the same time, evolving stent graft technologies are pushing in the market for pathology within the ascending aorta, even for treatment of AAD. Against this background, we analyzed our institutional experience in this patient cohort during the last 8 years. METHODS Between October 2005 and October 2013, 39 patients aged older than 80 years (82 ± 2 years) underwent surgical repair for AAD, of which 29 patients (74%) were men. Owing to patient age and comorbidities, we aimed to limit the operation to supracoronary hemiarch replacement whenever possible. Clinical data were prospectively entered into our institutional database. Late follow-up was 3.6 ± 2.8 years and was 100% complete. RESULTS Hemiarch replacement was performed in 32 patients (82%), and full arch replacement was necessary in the remaining 7. In 31 patients (79%), the aortic root could be glued and reconstructed or remained untouched. The remaining 8 patients (21%) underwent the bio-Bentall procedure. Mean ventilation time was 46 ± 23 hours, and the intensive care unit stay was 5 ± 9 days. We observed new postoperative permanent neurologic deficits in 2 patients (5%) and transient neurologic deficits in 3 (8%). The 30-day mortality was 26% (n = 10). Kaplan-Meier estimates for late survival were 46% ± 16% at 5 years. CONCLUSIONS Given the guidelines regarding the predicted risk of death in patients with untreated AAD, current data suggest a survival benefit with immediate open surgical intervention even in octogenarians. Similarly to the early days of transcatheter-based aortic valve implantation, open surgical reference data are warranted to set the bar for upcoming endovascular treatment of AAD in octogenarians.

Fifteen years of surgery for acute type A aortic dissection in moderate-to-mild systemic hypothermia†

OBJECTIVE: Surgery for acute type A aortic dissection remains a surgical challenge because of prolonged operative times, bleeding complications, and a considerable risk of neurological morbidity and mortality. The following study investigates the clinical results after surgical treatment for acute type A aortic dissection using selective antegrade cerebral perfusion and moderate-to-mild systemic hypothermia (≥28 °C). METHODS: Between January 2000 and January 2015, 453 consecutive patients underwent surgical treatment for acute type A aortic dissection at two aortic referral centres in Germany. Patient mean age was 67 ± 13 years, 298 patients (66%) were male. Selective unilateral or bilateral cerebral perfusion under moderate-to-mild systemic hypothermia was used in all patients. Ascending aortic replacement, hemiarch replacement and total arch replacement was performed in 9 patients (2%), 342 patients (75%) and 102 patients (23%), respectively. Clinical data were prospectively entered into the institutional databases. Mean late follow-up was 6 ± 3 years and was 98% complete. RESULTS: Cardiopulmonary bypass time totalled 181 ± 68 min and the myocardial ischaemic time 107 ± 43 min. Mean duration of selective antegrade cerebral was 46 ± 23 min. Mean lowest core temperature amounted to 28.8 ± 0.6 °C. Unilateral cerebral perfusion was performed in 298 patients (66%) and bilateral in 155 patients (34%). Mean intensive care unit stay was 5 ± 7 days. We observed new postoperative permanent neurological deficits in 27 patients (6%) and transient neurological deficits in 31 patients (7%). Thirty-day mortality was 7% (n = 32). Overall survival rate at 5 years was 77 ± 6%. CONCLUSIONS: Our data suggest that selective antegrade cerebral perfusion in combination with moderate-to-mild systemic hypothermia (≥28 °C) can be safely and reproducibly applied to surgery for acute type A aortic dissection and offers sufficient neurological and visceral organ protection.

Staged treatment of mega aortic syndrome using the frozen elephant trunk and hybrid thoracoabdominal repair

Objective: We report our experience with a staged hybrid approach for the treatment of extended aortic disease, also known as “mega aortic syndrome.” Methods: A total of 15 patients (10 male, 5 female) underwent staged repair of the thoracoabdominal aorta, consisting of 3 separate stages (repair of ascending aorta and aortic arch using the frozen elephant trunk technique and hybrid thoracoabdominal repair with debranching of the renovisceral branches and stent graft implantation). Results: The procedure was completed in 14 patients. After the first stage (repair of ascending aorta and aortic arch), no mortality or spinal cord ischemia occurred. One patient required temporary dialysis. After the thoracoabdominal repair, permanent paraplegia developed in 1 patient. One patient died intraoperatively after aneurysm rupture. The in‐hospital mortality for the complete repair reached 6.7%. None of the surviving patients required permanent dialysis. Interval aortic events consisted of 1 contained rupture. Conclusions: The concept of a staged hybrid repair of the mega aortic syndrome is technically feasible. The frozen elephant trunk technique represents an attractive treatment option, offering an adequate landing zone for later thoracoabdominal repair in patients with extended aortic disease. For completion of the repair, a staged hybrid approach with renovisceral debranching and aneurysm exclusion using off‐the‐shelf stent grafts shows promising results with low surgical morbidity and mortality.

Simple and controlled method to avoid hyperperfusion of the right arm following axillary artery cannulation for extracorporeal membrane oxygenator support.

The right axillary artery has become the cannulation site of choice for establishment of extracorporeal membrane oxygenator support in many centers. Dissection and cannulation of this vessel are simple and safe in the majority of patients. Typically, a side graft is used to avoid malperfusion of the right arm. Although this protocol offers many advantages, a common complication is the critical hyperperfusion of the right arm. Subsequent compartment syndrome and decline of antegrade inflow of oxygenated blood, especially into the brain and coronary arteries, can be life threatening in such critical patients. We describe herein a simple yet effective and controlled technique to avoid this particular problem.

Is More than One Hour of Selective Antegrade Cerebral Perfusion in Moderate-to-Mild Systemic Hypothermic Circulatory Arrest for Surgery of Acute Type A Aortic Dissection Safe?

Abstract Objectives Surgery for acute type A aortic dissection (AAD) remains a surgical challenge with considerable risk of morbidity and mortality. Antegrade cerebral perfusion (ACP) has been popularized, offering a more physiologic method of brain perfusion during complex aortic arch repair, often necessary in setting of AAD. The safe limits of this approach under moderate‐to‐mild systemic hypothermic circulatory arrest (≥ 28°C) are yet to be defined. Thus, the current study investigates our clinical results after surgical treatment for AAD in patients with a selective ACP and systemic circulatory arrest time of ≥ 60 minutes in moderate‐to‐mild hypothermia (≥ 28°C). Methods Between January 2000 and April 2016, 63 consecutive patients underwent surgical treatment for AAD employing selective ACP during moderate‐to‐mild systemic hypothermia (≥ 28°C) with prolonged ACP and circulatory arrest times. Patients’ mean age was 59 ± 15 years, and 39 patients (62%) were men. Hemiarch replacement and total arch replacement were performed in 13 (21%) and 50 (79%) patients, respectively. Frozen elephant trunk, arch light, and elephant trunk technique were performed in nine (14%), six (10%), and three patients (5%), respectively. Clinical data were prospectively entered into our institutional database. Mean late follow‐up was 6 ± 4 years and was 98% complete. Results Cardiopulmonary bypass time accounted for 245 ± 81 minutes and the myocardial ischemic time accounted for 140 ± 43 minutes. Mean duration of ACP was 74 ± 12 minutes. The mean lowest core temperature accounted for 28.9 ± 0.8°C. Unilateral ACP was performed in 44 patients (70%); bilateral ACP was used in the remaining 19 patients (30%). Intensive care unit stay reached 6 ± 5 days. New onset of acute renal failure requiring hemofiltration was observed in 8% of patients (n = 5). New postoperative permanent neurologic deficits were found in five patients (8%) and transient neurologic deficits in six patients (10%). There was one case of paraplegia. Thirty‐day mortality and in‐hospital mortality were 8 (n = 5) and 11% (n = 7), respectively. Overall survival at 5 years was 76 ± 9%. Conclusion Our preliminary data suggest that selective ACP during moderate‐to‐mild systemic hypothermic circulatory arrest (≥ 28°C) can safely be applied for more than 1 hour even in the setting of AAD.

Treatment of a giant ascending aortic pseudoaneurysm presenting as a presternal pulsatile protrusion almost perforating through the skin.

Aortic pseudoaneurysms have the potential for eroding bony structures in the chest, including the sternum, over time. Here, we report the case of a 54-year old woman with a giant pseudoaneurysm of the ascending aorta, 19 years after aortic root (mechanical conduit) and hemiarch replacement. The patient presented to her primary-care physician with a pulsatile presternal subcutaneous protrusion in the midline of her median sternotomy scar. We performed a challenging midline resternotomy after the establishment of a surgical safety net for cerebral and visceral organ protection followed by a supracoronary ascending and hemiarch replacement including a reinsertion of the coronary ostia employing selective antegrade cerebral perfusion and mild systemic hypothermic circulatory arrest. We discuss here the specific surgical considerations of this case.

Moderate Hypothermic Circulatory Arrest (≥ 28°C) with Selective Antegrade Cerebral Perfusion for Total Arch Replacement with Frozen Elephant Trunk Technique

OBJECTIVES  The optimal hypothermic level during circulatory arrest in aortic arch surgery remains controversial, particularly in frozen elephant trunk (FET) procedures. We describe herein our experience for total arch replacement with FET technique under moderate systemic hypothermic circulatory arrest (≥ 28°C) during selective antegrade cerebral perfusion. METHODS  Between January 2009 and January 2016, 38 consecutive patients underwent elective total arch replacement for various aortic arch pathologies with FET technique using the E-vita Open hybrid prosthesis (Jotec GmbH, Hechingen, Germany). Selective unilateral or bilateral cerebral perfusion under moderate systemic hypothermic circulatory arrest (28.7°C ± 0.5°C) was used in all patients. Minimally invasive total arch replacement with FET via partial upper sternotomy was performed in 15 patients (39%) and in the remaining 23 patients (61%) via full sternotomy. Mean late follow-up was 3 ± 2 years and was 98% complete. Clinical data were prospectively entered into our institutional database. RESULTS  Cardiopulmonary bypass time accounted for 198 ± 58 minutes and the myocardial ischemic time 109 ± 29 minutes. Selective antegrade cerebral perfusion time was 55 ± 6 minutes. Lower body circulatory arrest time was 39 ± 11 minutes. Unilateral cerebral perfusion was performed in 31 patients (82%), and bilateral in 7 patients (18%). Intensive care unit stay was 4 ± 3 days. Thirty-day mortality was 5% (n = 2). Late survival at 3 years was 87 ± 3%. Two patients (5%) required reexploration for bleeding. Patients were discharged after a hospital length of stay of 7 ± 2 days. Postoperative permanent neurologic complication occurred in two patients (5%). Three patients (8%) experienced a transient neurologic disorder. New transient renal replacement therapy was necessary in three patients (8%). No spinal cord injury was noted. CONCLUSIONS  Our data suggest that moderate systemic hypothermic circulatory arrest (≥ 28°C) in combination with antegrade cerebral perfusion can safely be applied for total aortic arch replacement with FET and offers sufficient neurologic and visceral organ protection.

Late Clinical Presentation of Inferior Vena Cava Deviation into the Left Atrium Following Atrial Septal Defect Repair in the Childhood

A 19-year-old woman underwent ASD closure with patch in the childhood. Fifteen years later, she presented with severe cyanosis and dyspnea on exertion. Clinical diagnostics revealed a dislocation of the patch resulting in a right-to-left shunt (RLS) that was compensated in the past years by a recurrent ASD allowing a left-to-right shunt (LRS). The existing balance between interatrial shunts vanished by the growth of the patient leading to the clinical deterioration. After successful redo surgery, the patient was discharged home 8 days postoperatively.

Challenging rescue of a 4 years old boy with H1N1 infection by extracorporeal membrane oxygenator: A case report

INTRODUCTION World Health Organization announced on April 2009 a public health emergency of international concern caused by swine-origin influenza A (H1N1) virus. Acute respiratory distress syndrome (ARDS) has been reported to be the most devastating complications of this pathogen. Extracorporeal membrane oxygenator (ECMO) therapy for patients with H1N1 related ARDS has been described once all other therapeutic options have been exhausted. Here, we report the case of a child (German, male) with H1N1-associated fulminate respiratory and secondary hemodynamic deterioration who was rescued by initial emergent ECMO established through a dialysis catheter and subsequent switch to central cannulation following median sternotomy. This report highlights several important issues. First, it describes a successful use of a dialysis catheter for the establishment of a veno-venous ECMO in an emergency case by child. Second, it highlights the importance of a closely monitoring of clotting parameters during ECMO therapy and third, if severe respiratory failure is complicated by cardiogenic shock, veno-atrial ECMO support via median sternotomy should be considered as a viable treatment option without further delay.