Reoperative Arch and Root Surgery Using DHCA With Antegrade Cerebral and Intermittent Upper and Lower Body Retrograde Perfusion

Aortic root and arch replacement after a previous operation on the aortic valve (AV), root, or ascending aorta remains a major challenge. Indications for reoperation include true and false aneurysms, dissection or re-dissection, structural valve dysfunction, and prosthetic valve-graft infection (1). The authors present the case of a patient with aneurysmal root dilatation and persistent arch dissection following a prior type A dissection repair that necessitated total arch replacement and a bio-Bentall procedure.

A 56-year-old man with permanent atrial fibrillation underwent repair of an acute ascending aortic dissection a decade earlier that involved AV resuspension, complex root repair, and hemi-arch replacement. However, years later, he complained of persistent exertional dyspnea, and workup revealed aneurysmal growth of the aortic root from 6 to 7.3 cm over 12 months, along with severe aortic regurgitation (AR) and a persistent dissection flap in the arch that extended to the level of the left subclavian origin.

At operation, following redo median sternotomy and aortic/bi-caval cannulation, the old graft was clamped while cooling to 24°C. Exposure of the root pathology demonstrated that the previous reconstruction of the noncoronary sinus had pulled loose and the reinforcement felt inside was hanging free within the gigantic aneurysm. The decision was made to replace the AV, which was calcified and fenestrated. The coronary ostia were mobilized. The left atrial roof was opened and left-sided cryo-maze lesions were performed. The left atrial appendage was then closed, and deep hypothermic circulatory arrest (DHCA) was instituted. Following mobilization and separation of the proximal arch branches, a 14 X 10 X 10 mm trifurcated arch branch graft was then attached using continuous 5-0 Prolene. During this 54-minute period of DHCA, a pattern of two-minute cycles of retrograde perfusion was used: first to the lower body, then to the upper, and then brief drainage to restore volume to the pump (2). The inflow end of the trifurcation graft was then used for antegrade cerebral perfusion (ACP). During this time, a 30 mm Gelweave graft was attached as the primary graft to the proximal descending aorta. After a 42-minute period of ACP, the retrograde perfusion scheme was reinstituted while the arch graft was attached to the right side of the primary graft. After appropriate de-airing, flow to both the head and lower body was restored, and systemic warming was begun. A valve-conduit composed of a 29 mm bovine pericardial valve attached to a 32 mm Valsalva graft was then implanted as part of a bio-Bentall procedure. Finally, the right atriotomy was exposed for three right-sided cryo-maze lesions. The patient was rewarmed, separated from cardiopulmonary bypass uneventfully, and transferred to the ICU in stable condition. He was extubated on day eight, and postrepair echocardiography showed normal biventricular function with no AR.

This case of complex reoperative arch and root surgery demonstrates the feasibility of central cannulation in protecting the brain and reducing end-organ dysfunction during DHCA by adding intermittent upper and lower body retrograde perfusion to selective ACP.

References

1. Kirsch EW, Radu NC, Mekontso-Dessap A, Hillion ML, Loisance D. Aortic root replacement after previous surgical intervention on the aortic valve, aortic root, or ascending aorta. J Thorac Cardiovasc Surg. 2006;131:601-608.
2. Spindel SM, Yanagawa B, Mejia J, Levin MA, Varghese R, Stelzer PE. Intermittent upper and lower body perfusion during circulatory arrest is safe for aortic repair. Perfusion. 2019;34:195-202.

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