George Matalanis, Rhiannon Koirala Austin Medical Centre Melbourne, Australia Branch First Aortic...
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Transcript of George Matalanis, Rhiannon Koirala Austin Medical Centre Melbourne, Australia Branch First Aortic...
George Matalanis, Rhiannon Koirala
Austin Medical Centre
Melbourne, Australia
Branch First Aortic Arch Repair
Aortic Symposium 2010AATS
Without Deep HypothermiaOr Circulatory Arrest
Problems with Current Techniques
Circulatory arrest (CA) Maximum “safe” period Opportunity for air/debris
embolism
Deep hypothermia (DH) Prolonged bypass Coagulopathy
Retrograde Cerebral perfusion Negligible nutritive flow
Unilateral Antegrade Perfusion
Contralateral hypoperfusion
Ipsilateral hyperperfusion
Bilateral Antegrade Perfusion
Direct cannulation risks
View obstruction
Collateral Anatomy NOT like Carotid Endarterectomy
Without shunt complete reliance on CIRCLE OF WILLIS 15% inadequate ICA stump pressure Even then Stroke risk < 3%
if clamp time < 10-15 min
Collaterals Available in Individual Proximal Arch Branch Clamping
Rightcarotid
Subclavian
Upper body
ÉLeftcarotid
Externalcarotid É
Internalcarotid
Carotid
É
É
Lower body
Cannulation and bypass
Dual upper and lower body inflow pressure gradients Maintenance of body
perfusion after innominate clamping
Direct Ascending Aorta -alternative in PVD/thoraco-abdominal atheroma
Reconstruction Sequence
Patients 30 cases: Jul 2005- Oct
2009
Male : Female = 19:11
Age: 62 (28-85)
Smoking: 57%
Hypertension: 63%
CVD: 23%
CAD: 30%
Elective
18 (60%)
Urgent/Emergent
12 (40%)
Type A dissection
16 (53%)
Re-operation
4 (13%)
Concomitant Procedures
Aortic Root:19 (63%) Valve sparing: 14 (74%)
David: 3 Other valve sparing: 11
Bentall’s: 5 (26%) Mechanical: 3 Tissue: 2
Separate AVR: 2 (7%)
Elephant Trunk: 4 (13%) Regular: 2 Frozen: 2
CABG: 6 (20%)
Early outcomes Mortality: 1 (3.3%)
85 y.o, late presenting Ac Type A
Neurological Dysfunction: 4 (13%) All focal/embolic:
Amourosis Fugax Hemianopia, Hemiparesis, Dysphasia.
Complete recovery: 3 Residual deficit: 1 (hemianopia)
Other Morbidity Re-exploration: 3 (10%)
Mechanical Cardiac support: 1*(3.3%)
Renal support: 1* (3.3%)
Tracheostomy: 1 (3.3%)
Sternal infection: nil
* mortality
Benefits
Ventilation < 24 hrs: 12 (40%)
ICU stay < 2 days: 14 (47%)
Hospital stay ≤ 7 days: 10 (33%)
NO TRANSFUSION: 8 (26.7%) 2 of these were re-operative cases
Conclusions Branch First aortic arch repair is a safe procedure :
3.3% Mortality 3.3% permanent Stroke
Applicable to urgent and complex cases
Haemostatic 27% no blood/product transfusion
Better visceral organ protection 1.3% CVVH
Allows complete and unhurried repair Avoid late deaths from undertreated aortic segments Avoid difficult redo for persistent/recurrent aortic pathology