Repair of type A dissection with mitral regurgitation using total arch replacement with mitral valve surgery

Total aortic arch replacement surgery with a Core temperature of 34 °C

BACKGROUND

Traditional aortic arch replacement surgery must be performed under moderate or deep hypothermia (22-28 °C) and circulatory arrest. Hypothermia and hypoperfusion can cause damage to the nervous system; therefore, postoperative brain and spinal cord complications are common. Improvements in surgical techniques are necessary to solve this problem. Herein, we report a method of total aortic arch replacement that can be performed at a core temperature of 34 °C, similar to other simple cardiac operations.

CASE PRESENTATION

Four patients underwent surgery with this technique (3 males and 1 female, aged 48 to 67 years). Computed tomography angiography performed at admission showed a total aortic dissection, resulting in a diagnosis of Stanford type A aortic dissection. The patients underwent emergency aortic sinus remodelling, ascending aortic replacement, modified aortic arch replacement, and elephant trunk stenting. No patients had neurological complications. During a follow-up of more than 1-month, no patients had aortic valve regurgitation or anastomotic leak.

CONCLUSIONS

This technique can increase the operating temperature by approximately 6 to 12 °C and reduce the circulatory arrest time by approximately 18 to 28 min. All of the patients recovered well without any neurological complications, demonstrating the feasibility and safety of this technique. We believe that this technique can serve as a good alternative strategy for managing aortic dissection and aneurysm, especially for young surgeons who are acquiring experience in arch replacement surgery.

Surgery for mitral regurgitation in patients with aortic root aneurysm: Transaortic or transseptal approach?

OBJECTIVE

Mitral regurgitation is common in patients with aortic root aneurysm. Mitral valve repair (MVP) or replacement (MVR) can be performed for these patients through either a transverse aortotomy (TA) or transseptal approach (TS). This study sought to compare the early outcomes of mitral valve surgery through the TA and TS approaches and decide which is optimal for this subset of patients.

METHODS

Between March 2013 and April 2015, we operated on 99 patients (81 males, 81.8%) with aortic root aneurysm who developed mitral regurgitation. Mean age was 47.8±16.5years. MVR was performed in 66 patients (TAR=27; TSR=39) and MVP in 33 (TAP=8; TSP=25). The baseline and operative outcomes data were compared between patients with MVR and MVP through the TA vs TS approaches.

RESULTS

Preoperatively, the mitral regurgitation area was significantly larger in the MVR than MVP groups (8.9±2.0 vs 7.8±3.8 cm², p=0.0009), and in the TSP vs TAP groups (8.5±4.1 vs 5.6±1.3cm², p=0.0049), but no significant difference was found between the TAR and TSR groups (8.7±2.2 vs 9.0±1.8cm², p=0.4681); the aortic sinus size was significantly larger in the TAR than TSR group (66.7±15.8 vs 52.1±8.8mm, p=0.0061). Subvalvular structure was preserved in 12 MVR patients (18.2%). In MVP patients, Kay annuloplasty was used in 11 (33.3%) and annuloplastic ring in 22 (66.7%). The times of cardiopulmonary bypass (CPB) and cross-clamp in patients with TA approach were significantly shorter compared to those with the TS approach (139±34 vs 176±38min, p=0.0001; 101±26 vs 129±31min, p=0.0002). No cases of mortality, stroke and renal failure occurred in the whole series. The amount of transfusion, lengths of ICU and hospital stay did not differ between patients with MVR and MVP, and between the TA and TS approaches.

CONCLUSIONS

Both the TA and TS approaches achieved good early outcomes in MV surgery for patients with root aneurysm. The transverse aortotomy was associated with shorter CPB and cross-clamp times. Surgical approaches should be selected according to the underlying mitral valve etiology and the size of the aortic root.