Experience on aortic arch surgery at King Fahd Armed Forced Hospital (KFAFH), Jeddah

Abstract

Introduction: To our knowledge KFAFH Department of cardiac surgery is one of the few centers performing aortic arch surgery in Saudi Arabia.The optimal strategy for management of the circulation during aortic arch surgery remains controversial and neurologic dysfunction due to cerebral ischemia remains a significant concern. We report our experience on aortic arch surgery performed with Deep or Moderate Hypothermic Circulatory Arrest (DHCA or MHCA) and Antegrade Selective brain Perfusion. Methodology: 21 consecutive patients (pts) underwent aortic arch repair between 2009 and 2017. 9 pts (42.8%) were operated on emergency basis because of type A aortic dissection or impending rupture, 12 pts (57.2%) on elective basis. 7 pts (33.3%) had complete arch replacement and 14 pts (66.6%) had emiarch repair. Axillary cannulation was performed in 15 pts (71.4%), femoral cannulation in 6 pts (28.6%). Our brain protection strategy consisted in DHCA (18–20 C) in 11 pts (52.4%), MHCA (23–25 C) in 10 pts (47.6%). Selective monolateral antegrade perfusion (uSAP) trough axillary artery was performed in 12 pts (57.1%), selective bilateral antegrade perfusion (bSAP) in 9 pts (42.9%). Mean circulatory arrest was 32 ± 15 min, Cerebral oximetry has been employed to monitoring brain perfusion. Results: In-hospital mortality rate was 1 (5%) (type A aortic dissection), no pt had permanent neurological deficit. 3 pts (14.2%) had a temporary neurological deficit, 4 pts renal impairment (19.4%), 1 pt vocal cord paralysis (4.8%), 3 pts bleeding (14.3%). uSAP but not temperature was identified as independent predictor of transient neurological deficit (p 0.05). DHCA was significantly associated to higher blood loss after surgery (p < 0.01). Mean follow-up (3.5 years): no pt died, 1 pt presented aortic pseudoaneurysm 6 months after surgery (Marfan syndrome with aortic dissection). 2 patients post type A dissection developed dilatation of the descending aorta and underwent TEVAR. Conclusion: KFAFH experience on aortic arch surgery has been performed with good outcomes. DHCA is a safe procedure but related to longer CPB and perioperative coagulation disorders. Antegrade systemic perfusion trough axillary artery and MHCA with b-SAP was the most effective approach to protect the brain and visceral organs.