Total Arch Replacement with Hypothermic Circulatory Arrest, Antegrade Cerebral Perfusion and the Y-graft

This study examines postoperative morbidity and mortality and long-term survival after total arch replacement (TAR) using deep to moderate hypothermic circulatory arrest (HCA), antegrade cerebral perfusion (ACP), and the Y-graft. Seventy-five patients underwent TAR with the Y graft. Deep to moderate HCA was initiated at 18–22°C. ACP was either initiated immediately (early ACP) or after the distal anastomosis was performed (late ACP). The arch vessels were then serially anastomosed to the individual limbs of the Y-graft. The median age was 66 years (range = 32–82). Etiology of aneurysmal dilatation included 20 (27%) patients with medial degenerations, 25 (33%) with chronic dissections, 14 (19%) with acute dissections, 9 (12%) with atherosclerosis and 2 (3%) with Marfan syndrome. In-hospital mortality was 5%. Neurologic complications occurred in 8 (11%) patients; 2 (3%) had strokes and 6 (8%) had transient neurologic deficits. Patients undergoing TAR with moderate hypothermia had a significantly higher incidence of new-onset renal insufficiency (3 [23%] vs [0%], P < 0.001) and TND (3 (23%) vs 3 (5%), P = 0.028) than the profound and deep hypothermia cohort. Excluding the 1 patient who died intraoperatively, 89% (95%CI: 79–94%) were alive at 1 year, 78% at 5 years (95%CI: 66–86%), and 73% at 10 years (95%CI: 59–82%). The combination of deep to moderate HCA, ACP, and the Y-graft is a safe and reproducible technique. Further inquiry is needed to assess if early ACP provides superior clinical outcomes. This study examines postoperative morbidity and mortality and long-term survival after total arch replacement (TAR) using deep to moderate hypothermic circulatory arrest (HCA), antegrade cerebral perfusion (ACP), and the Y-graft. Seventy-five patients underwent TAR with the Y graft. Deep to moderate HCA was initiated at 18–22°C. ACP was either initiated immediately (early ACP) or after the distal anastomosis was performed (late ACP). The arch vessels were then serially anastomosed to the individual limbs of the Y-graft. The median age was 66 years (range = 32–82). Etiology of aneurysmal dilatation included 20 (27%) patients with medial degenerations, 25 (33%) with chronic dissections, 14 (19%) with acute dissections, 9 (12%) with atherosclerosis and 2 (3%) with Marfan syndrome. In-hospital mortality was 5%. Neurologic complications occurred in 8 (11%) patients; 2 (3%) had strokes and 6 (8%) had transient neurologic deficits. Patients undergoing TAR with moderate hypothermia had a significantly higher incidence of new-onset renal insufficiency (3 [23%] vs [0%], P < 0.001) and TND (3 (23%) vs 3 (5%), P = 0.028) than the profound and deep hypothermia cohort. Excluding the 1 patient who died intraoperatively, 89% (95%CI: 79–94%) were alive at 1 year, 78% at 5 years (95%CI: 66–86%), and 73% at 10 years (95%CI: 59–82%). The combination of deep to moderate HCA, ACP, and the Y-graft is a safe and reproducible technique. Further inquiry is needed to assess if early ACP provides superior clinical outcomes. Total Aortic Arch Replacement: An Evolving ProcessSeminars in Thoracic and Cardiovascular SurgeryVol. 32Issue 4PreviewThe authors thank Seminars for the opportunity to present our patient outcomes after total aortic arch replacement and Dr Girardi for his commentary.1,2 Dr Girardi is an authority in aortic arch surgery, and his comments are both insightful and compelling. The authors would like to reply to the editor with some clarifications. Full-Text PDF Commentary: Total Arch Replacement: So Many Options for SuccessSeminars in Thoracic and Cardiovascular SurgeryVol. 32Issue 4PreviewIn this issue of Seminars in Thoracic and Cardiovascular Surgery, Orlov et al, report their experience performing total arch replacement (TAR) using a Y-graft for great vessel reconstruction and hypothermic circulatory arrest with antegrade cerebral perfusion (ACP) for cerebral protection.1 Over a 12-year period, the authors performed TAR on 75 patients for a variety of etiologies including chronic type A dissection, acute type A dissection, degenerative aneurysms, and connective tissue disorders. Full-Text PDF Commentary: More Than a Cold ComfortSeminars in Thoracic and Cardiovascular SurgeryVol. 32Issue 4PreviewWe would like to congratulate Dr Orlov and her group for excellent short- and long-term outcomes after total arch replacement using arch vessel reconstruction with Y-graft (Spielvogel's trifurcated graft1 or so-called Christmas tree-type graft) under deep to moderate hypothermic circulatory arrest (HCA) with bilateral antegrade cerebral perfusion (ACP). In their study, 75 patients were treated with the technique over a 13-year period. They reported in-hospital mortality of 5% and postoperative stroke of 3%, and 73% of patients were alive after 10 years. Full-Text PDF