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Perfusion strategies in acute type A aortic dissection: single center experience
- 1. Perfusion strategies in acute type A aortic dissection: single center experience Azienda Ospedaliera SS Antonio e Biagio Alessandria, ITALY C.Cavozza, A. Audo, A.Campanella , P. Scoti, M.Serra, G. Camporini , D. Mercogliano SOC Cardiac Surgery Mortality and morbidity in the setting of acute type A aortic dissection were most correlated with surgical techniques and strategies of tissues and organs protection MORTALITY 18% CAUSES OF DEATH •Low cai-organrdiac output •Stroke •Mult-failure •intraoperativeDescending aortic rupture Site of arterial cannulation: After Sternotomy: if no dissected innominate artery (direct) or subclavian artery below sterno-clavicular junction (dacron graft) or axillary artery (dacron graft ) Method 91 patients with a mean age of 62.6 ± 14.8 years underwent surgery for Stanford type A dissection. After sternotomy, arterial cannulation is direct into innominate artery, while is made through a dacron graft into the right subclavian or axillary artery. Antegrade selective cerebral perfusion has been used as during hypothermic circulatory arrest. To assess unilateral or bilateral brain perfusion we used near-infrared spectroscopy. In last ten patients a cuffed cannula , connected to separate roller pump, was inserted into the descending thoracic aorta. Perfusion in the distal body, as well selective antegrade brain perfusion, were started simultaneously Results Mean duration of CPB and aortic cross-clamping was 183±82 and 104±27min, respectively. The mean duration of circulatory arrest and brain perfusion was 38,6±15 min. Ascending aorta with aortic valve resunspension and hemi-arch replacement was the most frequent surgical procedure. Twelve patients underwent bilateral perfusion because of unilateral drop less than 20% of the baseline value of NIRS. Overall mortality was 18,6%. Selective Antegrade Cerebral Perfusion (SACP) has probably become the gold standard for cerebral protection during aortic surgery. Some technical aspects related to the management of SACP remain controversial : Site of arterial cannulation, degree of hypothermia, exstension (bilateral, unilateral) Brain perfusion during HCA • To asses brain perfusion we used infrared spectroscopy scalp capillary saturation by a dual sensor for NIRS • NIRS: rSO 2 regional SO2 left reduction of 20% from baseline values or an absolute decrease of 50% Bilateral Cerebral Perfusion is mandatory Data Preoperative state Low Body Perfusion: ten patients. Pruitt catheter (PRUITT® - LeMaitre Vascular) connected to cardioplegia line 0,6-0,8 l/m Monitoring NIRS : lower back and brain Preliminary results Pre and postoperative measuraments of renal and hepatic function STERNOTOMY CENTRAL CANNULATION CPB ON HYPOTHERMIA 26°C Operative Techniques Replacement of ascending aorta 100% Replacement of Transverse Arch 21% Replacement of Aortic Valve -Isolated -Composite Graft 18% 20% Rewarming time more fast In this group no patient had permanent neurologic deficit Conclusions The central cannulation offers the advantage of antegrade perfusion of the aorta. In addition, performing low body perfusion at the same time will enable safe increase in the systemic temperature during CPB and reduce morbidity and mortality