Retrograde cerebral perfusion for surgery of type A aortic dissection.

BACKGROUND: For type A aortic dissection (TAAD), antegrade cerebral perfusion (ACP) was proposed as a more physiological method than retrograde cerebral perfusion (RCP) for intra-operative brain protection, but it is still debatable whether antegrade cerebral perfusion (ACP) or retrograde cerebral perfusion (RCP) is related to the better clinical outcome. The present study was undertaken to compare the results in our patients receiving surgery for TAAD with ACP or RCP. The primary aim of this study was focused on the incidence of and the factors associated with surgical mortality, post-operative neurological outcomes and long-term survival. METHODS: From February 2001 to March 2019, there were 223 consecutive patients with TAAD treated surgically at our hospital. The median age at presentation was 56 years (range 29-88 years) and 70 patients (31.4%) over 65 years of age. There were 168 patients treated with RCP and 55 patients treated with ACP. The primary endpoints were surgical mortality and neurological outcome. Propensity score matching was used to compare the treatment results of surgeries with RCP or ACP. The long-term survival was also analyzed. RESULTS: The overall in-hospital mortality rate and the overall 30-day mortality rate were 15.6% and 14.3% respectively. For the patients without pre-operative shock (n = 184), the in-hospital mortality rate was 10.3% and the 30-day mortality rate was 8.7% and higher long-term survival rates (88.3% for 5 years, 86.5% for 10 years, 86.5% for 15 years) were documented for this patient group. There was no significant difference on the surgical mortality between the ACP group and the RCP group. In the entire cohort, there were 23 patients (10.3%) who suffered from post-operative neurological deficits (PND) and there were less PND for the patients with RCP than the patients with ACP (7.7% vs 18.1%, p = 0.027). After propensity score matching, there was still higher incidence of PND in the ACP group than in the RCP group but without statistical significance (18.5% vs 11.1%, p = 0.279). CONCLUSIONS: Aortic surgery carries high risk for the patients with TAAD and PND is not an unusual post-operative morbidity. In our series, pre-operative shock, pre-operative CPR, CRI, past history with CAD are related to higher surgical mortality. The younger patients (<65 years old) without pre-operative shock got better surgical outcome and long-term survival. RCP could provide acceptable cerebral protection during aortic surgery for the TAAD patients. Old age, pre-operative shock, CRI and past history of CAD are independent risk factors for long-term survival.

Staged surgical repair for infants with interrupted aortic arch.

BACKGROUND: Interrupted aortic arch (IAA) is a rare congenital cardiac anomaly, which necessitates surgical treatment. There are several surgical strategies for corrective repair of IAA, such as one-stage repair, rapid two-stage repair and two-stage repair. Here, we reported our surgical result of staged-repair policy for the patients with IAA. METHOD: From November 2003 to July 2015, there were 14 patients (8 boys, 6 girls) with IAA treated by us. Except one teenager patient, we routinely used intravenous infusion of prostaglandin E1 for all the infant patients (n = 13) to keep adequate end organ perfusion before the first surgical intervention. Surgical repair was performed after the perfusion of end organs recovered. RESULT: Two patients (1 teenager and 1 infant with one-stage surgery) were excluded from this study. At the time of the first surgery, we did the first-stage surgery with anastomosis in between aortic arch and descending aorta, division of patent ductus arteriosus and banding of pulmonary trunk through left thoracotomy. The overall surgical survival rate of the first surgery was 100% (12/12). At the time of the second surgery, corrective repair was done under cardiopulmonary bypass through median sternotomy. The surgical survival rate of the corrective surgery was also 100%. There is no late death during follow-up for 9 years (range 4.2-15.0 years). CONCLUSION: Out of several surgical strategies for the infants with IAA, staged repair still could be a treatment option to achieve satisfied surgical result.