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George Matalanis, Rhiannon Koirala Austin Medical Centre Melbourne, Australia

Aortic Symposium 2010 AATS. Branch First Aortic Arch Repair. Without Deep Hypothermia Or Circulatory Arrest. George Matalanis, Rhiannon Koirala Austin Medical Centre Melbourne, Australia. Problems with Current Techniques. Circulatory arrest (CA) Maximum “safe” period

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George Matalanis, Rhiannon Koirala Austin Medical Centre Melbourne, Australia

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  1. Aortic Symposium 2010 AATS Branch First Aortic Arch Repair Without Deep Hypothermia Or Circulatory Arrest • George Matalanis, Rhiannon Koirala • Austin Medical Centre • Melbourne, Australia

  2. 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

  3. 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

  4. Collaterals Available in IndividualProximal Arch Branch Clamping Subclavian Right carotid Left carotid Carotid Upper body External carotid Internal carotid Lower body

  5. 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

  6. Reconstruction Sequence

  7. 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%)

  8. 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%)

  9. 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)

  10. 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

  11. 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

  12. 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

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