Myers, Patrick O.

Panos, Aristotelis

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European Journal of Cardio-Thoracic Surgery 43 (2013) 205 LETTER TO THE EDITORdoi:10.1093/ejcts/ezs317 Advance Access publication 31 May 2012Extended mild hypothermic aortic surgery†Aristotelis Panosa and Patrick O. Myersb,c,*a Department of Cardiac Surgery, Hygeia Hospital, Athens, Greeceb Department of Cardiac Surgery, Children’s Hospital Boston & Harvard Medical School, Boston, USAc Department of Cardiovascular Surgery, Geneva University Hospitals & Medical Faculty, Geneva, Switzerland* Corresponding author. Department of Cardiac Surgery, Children’s Hospital Boston & Harvard Medical School, 300 Longwood Ave, Bader 273, Boston,MA 02445, USA. E-mail: patrick.myers@childrens.harvard.edu (P.O. Myers).Received 7 April 2012; accepted 19 April 2012Keywords: Aortic arch repair • Mild hypothermia • Cardiopulmonary bypassWe read with great interest the report by Urbanski et al. [1] ontheir approach to mild hypothermic aortic arch surgery and theassociated editorial [2]. We congratulate the authors for their im-pressive series, thoughtful approach and excellent results. Wewould like to discuss the previously published alternative strat-egies for mild and normothermic total arch replacement.They demonstrate that an approach to bypass tailoring thedegree of cooling to the anticipated extent of repair and dur-ation of corporeal circulatory arrest can be rewarded with excel-lent outcomes [2]. Nonetheless, the authors had a meancirculatory arrest time of the lower body of 34 ± 12 min, extend-ing to 70 min, at 30°C. These numbers are pushing the limits onwarm ischaemia, as ‘safe’ ischaemic times are in the range of 35min for the liver, 90 min for the kidneys and 20 min for thespinal cord [3] at mild hypo- or normothermia. Furthermore,their approach required an elaborate succession of cannulations(up to four) and retrograde descending aorta perfusion (as wellas a portion of the arch vessels at intermediate steps of complet-ing the arch replacement) through the femoral artery. In apatient population burdened with atheromatous large vesseldisease such as this one, this is not an innocuous choice devoidof risk compared with antegrade perfusion.Axillary artery cannulation has been shown to provide ad-equate antegrade cerebral perfusion, which we have been usingroutinely since 2001, including in patients with acute aortic dis-section [4]. We have continued to apply this approach routinelysince then, with comparable results.Total arch replacement is also possible under whole bodyantegrade perfusion [5], by placing a Medtronic DLP© venouscannula (Y-ed from the arterial line) through the tube graft intothe distal aorta for antegrade lower body perfusion (see ﬁgureavailable at: http://ats.ctsnetjournals.org/content/vol85/issue1/images/large/347.S0003497507013525.gr1.jpeg). The brain andlower body are continuously perfused with the exception of avery limited circulatory arrest time (6–8 min) of the lower body,which only represents the time necessary for resection of theaortic tissues, positioning of the cuffed DLP cannula in the des-cending aorta and the inﬂation of the occlusion balloon. In thisway, an arch repair is transformed into a standard cardiopul-monary bypass heart operation, with vascular exclusion of theaortic arch and total body antegrade perfusion. The 8 minlimited duration of the circulatory arrest in the lower body issafe for the spinal cord and splanchnic organs at this tempera-ture and even in normothermia, as can be necessary in patientswho cannot be cooled, such as with cold reactive agglutinins [6].Furthermore, cannulation of the newly implanted graft is not ne-cessary to achieve antegrade systemic perfusion after the com-pletion of the distal aortic anastomosis. We would also like tonote that we have applied this approach in emergent situations,such as acute aortic dissection, with good results, and notrestricted this technique to elective cases as reported byUrbanski et al. [1].REFERENCES[1] Urbanski PP, Lenos A, Bougioukakis P, Neophytou I, Zacher M, DiegelerA. Mild-to-moderate hypothermia in aortic arch surgery using circulatoryarrest: a change of paradigm? Eur J Cardiothorac Surg 2012;41:185–91.[2] Bonser RS. A paradigm shift in aortic arch surgery, certainly—but corrob-oration required. Eur J Cardiothorac Surg 2012;41:191–2.[3] Kirklin J, Barrat-Boyes B. Hypothermia and Total Circulatory Arrest.Cardiac Surgery, 2nd edn. New York, NY: Churchill Livingstone, 1993,1712–3.[4] Panos A, Murith N, Bednarkiewicz M, Khatchatourov G. Axillary cerebralperfusion for arch surgery in acute type A dissection under moderatehypothermia. Eur J Cardiothorac Surg 2006;29:1036–9.[5] Panos A, Myers PO, Kalangos A. Novel technique for aortic arch surgeryunder mild hypothermia. Ann Thorac Surg 2008;85:347–8.[6] Panos A, Murith N, Myers PO, Kalangos A. Aortic arch repair andcold-reactive agglutinins: what to do? Ann Thorac Surg 2007;84:1403–4.†The corresponding author of the original article [1] was invited to reply, butdid not respond.LETTERSTOTHEEDITORLetters to the Editor / European Journal of Cardio-Thoracic Surgery 205

Extended mild hypothermic aortic surgery†

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