Makoto Takinami

Total arch replacement using aortic arch branched grafts with the aid of antegrade selective cerebral perfusion

BACKGROUND We report our clinical experience with total arch replacement using aortic arch branched graft in an attempt to determine the independent predictors of both in-hospital mortality and neurologic outcome. METHODS We studied 220 consecutive patients who underwent total arch replacement using aortic arch branched graft between May 1990 and June 1999. All operations were performed with the aid of hypothermic extracorporeal circulation, antegrade selective cerebral perfusion, and open distal anastomosis. RESULTS The overall in-hospital mortality rate was 12.7%. Multivariable analysis showed independent determinants of in-hospital mortality to be chronic renal failure, long pump time, participation in early series, and shock. Postoperative permanent neurologic dysfunction was 3.3%. On multivariable analysis, old cerebral infarct and pump time were independent determinants of permanent neurologic dysfunction. The selective cerebral perfusion time had no significant influence on in-hospital mortality or neurologic outcome. The 5-year survival rate including in-hospital deaths was 79% +/- 6%. CONCLUSIONS Selective cerebral perfusion allows increased ease of performance of total arch replacement, a complex and time-consuming procedure, and helps reduce periprocedural mortality and morbidity in patients with aortic arch aneurysm and those with acute aortic dissection.

Role of biologic glue repair of proximal aortic dissection in the development of early and midterm redissection of the aortic root

BACKGROUND Redissection of the aortic root after supracommissural aortic graft replacement with reapproximation of the layers of the dissected aortic root is relatively rare. Causes and surgical treatment of this lesion remain controversial. METHODS From January 1983 to September 2000, 130 patients had emergency operation for acute type A aortic dissection. Of them, 57 patients underwent root reconstruction using biologic glues and 4 patients (7.0%) developed redissection of the aortic root associated with moderate to severe aortic regurgitation 5 to 27 months after the initial operation. In all patients, the proximal false lumen was obliterated with infusion of gelatin-resorcinol-formaldehyde (GRF) glue or BioGlue and the aorta was reinforced with Teflon felt strip or Surgicel placed on its outside wall. RESULTS During reoperation, the noncoronary aortic sinus was found to be redissected in all patients with the dissection extending retrogradely to the aortic annulus. This resulted in aortic regurgitation with prolapse of the noncoronary cusp because the proximal suture line dehisced. Histopathology showed disappearance of the nuclei of the medial smooth muscle cells, suggesting tissue necrosis at the site of GRF glue application. The lesions were treated successfully with full root replacement using a freestyle heterograft bioprosthesis or a composite graft prosthesis. CONCLUSIONS The use of biologic glues for reapproximating the layers of the dissected aortic root is associated with a certain amount of risk of aortic wall necrosis. Therefore, care should be taken to ensure proper use of these glues. Full root replacement could be a preferable technique for treating redissection of the aortic root.

Extended total arch replacement for acute type a aortic dissection: Experience with seventy patients

OBJECTIVE We sought to report the clinical experience with extended total arch replacement for acute type A aortic dissection and to determine the factors that influence early mortality, late survival, and late reoperation. METHODS Between December 1988 and August 1998, 70 patients underwent emergency graft replacement of both the ascending aorta and the total aortic arch for acute type A aortic dissection. All operations were performed with hypothermic extracorporeal circulation, selective cerebral perfusion for cerebral protection during aortic arch repair, and open distal anastomosis. Concomitant procedures included aortic valve resuspension in 18 patients, composite graft replacement in 10 patients, and coronary artery bypass grafting in 5 patients. RESULTS The early mortality rate was 16% (11 of 70 patients). Multivariable analysis showed that renal-mesenteric ischemia and coronary artery bypass grafting were independent determinants for early death. Survival rates at 3 and 5 years postoperatively, including the early deaths, were 75% +/- 5% and 73% +/- 6%, respectively. Multivariable analysis showed that renal-mesenteric ischemia and en bloc repair were independent determinants for late death. Freedom from reoperation was 91% +/- 4% and 77% +/- 8% at 3 and 5 years, respectively. Multivariable analysis showed that anastomotic leakage was the only significant determinant for late reoperation. CONCLUSIONS Extended total arch replacement for acute type A aortic dissection could be justified in properly selected patients.

Aortic regurgitation with dilation of ascending aorta and right coronary artery occlusion by a rudimentary aortic cusp

Occlusion of a coronary artery ostium, especially that of the right by an aortic cusp, is a rare congenital anomaly. We had the experience of dealing with an adult patient with aortic regurgitation due to a rudimentary aortic cusp that also occluded the right coronary ostium. We performed composite graft replacement because the patient also had coexistent dilation of the ascending aorta. Postoperative course was uneventful.

Aortic arch resection under temporary bypass grafting for advanced thymic cancer

Extensive surgery for malignant disease requiring cardiopulmonary bypass may cause postoperative immunosuppression. We conducted resection of the aortic arch and total arch replacement under temporary bypass grafting in a patient with advanced thymic cancer invading the aortic arch. No major postoperative complications such as brain damage or paraplegia occurred. Temporary bypass grafting is thus applicable in extensive surgery for malignant disease invading the aortic arch.

Surgical treatment of annuloaortic ectasia with coronary aneurysm and fistula

Annuloaortic ectasia associated with a giant aneurysm of the left coronary artery and a coronary artery fistula is extremely rare, and it is difficult to decide how to repair this complex lesion. The cause of the huge aneurysm of the left coronary artery in our patient was thought to be cystic medial necrosis, the coronary artery fistula, or both. The surgical management of this extremely rare pathological combination is described.

A newly developed cerebral perfusion catheter for aortic arch operation

The object of this study was to develop a better catheter for selective cerebral perfusion during aortic arch operation. Flow through the catheter was evaluated in an in vitro study under 40 mmHg pressure at 25°C using 40% glycerin when the catheter was straight or right-angled with either a gentle or a sharp curve. Two catheters of 14, 16, or 18 French were connected with a Y-shaped tube, and the flow through each catheter was tested in the same way when the catheters were straight or right-angled. Moreover, we evaluated the operative outcome using this new catheter in 38 patients who underwent total arch replacement. The correlation between right radial artery pressure and catheter tip pressure was examined in 17 of these 38 patients. The difference in oxygenation between the right and left hemispheres was also exmained by two-channel nearinfrared spectroscopy. The results showed that flow through the catheter was almost identical, regardless of the type of its configuration. When two catheters of different sizes were connected with a Y-shaped tube, the total flow and flow ratio between the two catheters were also similar in both the straight and the right-angled configuration. As regards the clinical outcome, there were no in-hospital deaths, no permanent neurological dysfunction, and one temporary neurological dysfunction. Dissociations between right radial artery pressure and catheter tip pressure were seen in 3 of the 17 patients. No difference in oxygenation between the two hemispheres was found. We conclude that the new catheter provided an uncluttered operative field and may contribute to improved surgical results.

Unexpected extraction of a ventricular septal defect patch without an interventricular shunt

We report the case of a mediastinocutaneous fistula, 13 years after the total correction of tetralogy of Fallot. During a fistula curettage operation, we unexpectedly extracted a ventricular septal defect patch. An interventricular shunt was not detected after the operation. The patient is well 3 years after the last operation.