Outcomes of Aortic Arch Replacement Performed Without Circulatory Arrest or Deep Hypothermia.

BACKGROUND: Aortic arch replacement using standard techniques, including deep hypothermic circulatory arrest and selective antegrade cerebral perfusion, is still associated with significant mortality and cerebral morbidity. We have previously described the "branch-first" technique that avoids circulatory arrest or profound hypothermia with excellent outcomes. We now describe our clinical experience with a larger cohort of patients as well as follow-up of our earlier results. We also describe a further technical simplification to this technique. METHODS: From 2005 to 2010, 43 patients underwent a "branch-first continuous perfusion" technique for aortic arch replacement. In this technique, arterial perfusion is peripheral, usually by femoral inflow. Disconnection of each arch branch and anastomosis to a perfused trifurcation graft proceeds sequentially from the innominate to the left subclavian artery, with uninterrupted perfusion of the heart and viscera by the peripheral cannula. In the first cohort perfusion to the trifurcation graft was by right axillary cannulation. Since 2009, a modification was introduced such that perfusion is supplied directly by a sidearm on the trifurcation graft. This was used in the last 18 patients of this series. After reconstruction of the debranched arch and ascending aorta, the common stem of the trifurcation graft is anastomosed to the arch graft. In this series, there were 27 males, and mean age was 63 ± 13 years. Fifteen cases (35%) were performed with urgent/emergent priority. Nineteen patients (44%) were operated for aortic dissection, and the remainder for aneurysms. Seven patients (16%) had previously undergone a cardiac surgical procedure. RESULTS: There were two (4.7%) early mortalities while one patient (2.3%) experienced a permanent stroke. One patient (2%) required mechanical support while three (7%) required hemofiltration for renal support. Extubation was achieved within 24 hours in 21 patients (49%) while 19 (42%) were discharged from the Intensive Care Unit (ICU) within two days. Eight patients (19%) did not require any transfusion of red cells or platelets. Mean follow-up duration was 21 ± 19 months and was 100% complete. At three years, survival was 95 ± 3.2%. No patients required subsequent aortic reoperation during this early follow-up period. CONCLUSIONS: This modified branch-first continuous perfusion technique brings us closer to the goal of arch surgery without cerebral or visceral circulatory arrest and the morbidity of deep hypothermia. Our early experience is encouraging although greater numbers and longer follow-up will reveal the full potential of this approach.

Patients' perception of surgical training in private hospitals.

INTRODUCTION: Surgical training is traditionally a public hospital-based practice. At Epworth Private Hospital, Richmond, Victoria, there are three accredited surgical training positions and one fellowship position. We conducted a patient survey to review the patients' perspective of surgical trainees in private hospitals. METHODS: Over 6 weeks, 100 patients admitted under the surgical units with full-time surgical registrars were given a survey to complete in two parts on the training of surgeons in private hospitals. RESULTS: Seventy per cent of surveys were returned completed. Ninety per cent of respondents agreed that private hospitals should be involved in surgical training and 85.7% of patients were agreeable to having trainees involved in their operation. Only 1.4% of patients were not in agreement with surgical training in private and 8.6% of patients were neutral in their opinion. CONCLUSION: Our results clearly show that private hospital patients are generally favourably disposed to the presence and participation of surgical trainees in the private hospital setting.

Branch-first aortic arch replacement with no circulatory arrest or deep hypothermia.

BACKGROUND: For aortic arch surgery, the potential risks of deep hypothermic circulatory arrest with or without antegrade cerebral perfusion have been widely documented. We hereby describe our early experience with a "branch-first continuous perfusion" technique that, by avoiding deep hypothermia and circulatory arrest, has the potential to reduce morbidity and mortality. METHODS: Arterial perfusion is peripheral using femoral and axillary inflows. Disconnection of each arch branch, and anastomosis to the trifurcation graft, proceeds sequentially from the innominate to the left subclavian artery, with continuous perfusion of the heart and viscera by lower body and brain by upper body arterial return. After the descending aorta is clamped, the debranched arch may then be replaced and connected to the ascending aorta before the common stem of the trifurcation graft is joined to the arch graft. Thirty patients underwent this technique. Twelve patients were operated on for aortic dissection and the remainder for aneurysms. RESULTS: With experience, minimum pump temperature rose from 16°C to 34°C. There was 1 (3.3%) death, and 2 (6.7%) patients had neurological dysfunction. Extubation was achieved within 24 hours in 12 (40%) patients, whereas 14 (47%) left the intensive care unit within 2 days. Ten (33%) patients were discharged from the hospital within 7 days. Eight (27%) patients required no transfusion of blood or blood products. CONCLUSIONS: This technique brings us closer to the goal of arch surgery without cerebral or visceral circulatory arrest and the morbidity of deep hypothermia. Early results are encouraging.