Routine Hypothermia with Circulatory
Arrest and Retrograde Cerebral Perfusion
for Ascending Aortic Reconstruction
Division of Cardiac Surgery
Brigham and Women’s Hospital
Andrew W. ElBardissi, MD, MPH
Sary F. Aranki, MD
Lawrence H. Cohn, MD
Stanton K. Shernan, MD
Daniel J. FitzGerald, CCP, LP
R. Morton Bolman III, MD
Aortic Symposium 2010
1
Natural History of Aneurysmal Disease
2
Background
•Aneurysmal ascending aortic
degeneration includes aortic
tissue proximal to the
innominate artery
•Aortic cross-clamping leaves a
segment of aneurysmal distal
ascending aorta
3
Surgical Result following Reconstruction
Closed Distal Anastomosis
Open Distal Anastomosis
5
Objective
•Evaluate outcomes of elective
ascending aortic reconstruction
with open distal anastomosis
(with RCP) versus closed distal
anastomosis with aortic crossclamping.
6
Methods
687 patients with Ascending Aortic Reconstruction
(2005-Present)
Aortic Dissections
Complex aortic arch reconstructions
305 patients
195 closed distal (CD)
anastomosis
110 open distal (OD)
anastomosis with RCP
1:1 Propensity Matching
99 CD
99 OD
7
Methods
• Primary endpoint
– CVA
– Temporary Neurologic Deficit
– Ventilator Hours
– ICU Hours
– Length of Stay
• Secondary endpoint
– 30-day mortality
– Intermediate-term Survival
8
Preoperative Characteristics
Age
Male Gender n(%)
Caucasion n(%)
Diabetes n(%)
COPD n(%)
Hyperlipidemia n(%)
Hypertension n (%)
Serum Creatnine
History of CVA n(%)
Previous MI n(%)
CHF n(%)
Angina n(%)
NYHA Classification
I
II
III
IV
OD (n=99)
60±12
76 (77%)
93 (94%)
5 (5%)
88 (89%)
49 (50%)
57 (57%)
0.98±.23
4 (4%)
4 (4%)
23 (23%)
16 (16%)
42 (42%)
40 (40%)
20 (20%)
0 (0%)
Hemodynamic Data
Normal sinus rhythm n(%)
87 (86%)
Ejection Fraction
59 ±8
Mean PAP
23±7
Aortic Stenosis n(%)
29 (29%)
Aortic Stenosis Gradient (mmHg)
35±17
CD (n=99)
61±12
72 (73%)
97 (98%)
6 (6%)
87 (88%)
55 (56%)
61 (62%)
1.1±0.4
6 (6%)
9 (9%)
24 (24%)
20 (20%)
37
41
20
1
p-value
0.6
0.52
0.39
0.76
0.83
0.39
0.56
0.17
0.52
0.15
0.86
0.46
0.43
(37%)
(41%)
(20%)
(1%)
89 (89%)
57±13
22±8
37 (37%)
38±20
0.66
0.23
0.24
0.27
0.25
9
Operative Characteristics
Reoperation n (%)
CPB time (minutes)
Cross-clamp time (minutes)
DHCA Temperature (Celsius)
DHCA Time
RCP Time
Concomitant Procedures
Aortic valve replacement
CABG
OD (n=99)
CD (n=99)
23 (23%)
18 (18%)
206±95
160±79
156±73
120±73
21
.
21±8 (11, 50)
.
17±8 (3, 50)
.
22 (22%)
24 (24%)
30 (30%)
19 (19%)
p-value
0.38
0.0005
0.0006
.
.
.
0.55
0.39
10
Results
P=0.44
80
2%
P=0.42
70
P=0.57
60
RCP
1%
CPB
n=1 n=2
n=2 n=1
50
40
30
P=0.20
P=0.52
20
10
0
0%
CVA (%)
Ventilator Hours
TND (%)
ICU Stay
(hours)
Length of Stay
(days)
1.00
0.95
P=0.30
0.90
No difference in 30 day
(OD, 0% vs. CD, 1%, p=0.59) or
Intermediate-term Mortality
0.85
0.80
0.75
0.70
0.65
0.60
0.55
0.50
0.00
300
900
Follow-up (days)
1200
Conclusions
• Open distal reconstruction of ascending
aorta in AAA repair
– No difference in operative mortality,
stroke, temporary neurologic deficit,
ventilator hours, ICU hours, or LOS
compared to closed distal with aortic xclamping
– Should be considered as a routine
treatment strategy, as it allows removal
of AA in its entirety
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