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Risk of replacement of descending aorta with a standardized left heart bypass technique
H G Borst1, M Jurmann, B Bühner
1Division of Thoracic and Cardiovascular Surgery, Hannover Medical School, Germany.
Insights
Left heart bypass effectively supports circulation during descending aorta replacement, minimizing early mortality and renal failure. However, spinal cord injury remains a risk, particularly in extensive aortic repairs.
Area of Science:
- Cardiovascular Surgery
- Thoracic Surgery
- Vascular Surgery
Background:
- Aneurysms and dissections of the descending aorta require complex surgical repair.
- Minimizing spinal cord injury during these extensive procedures is a significant challenge.
- Standard surgical techniques often involve aortic clamping, potentially compromising distal perfusion.
Purpose of the Study:
- To evaluate the efficacy and safety of a standardized left heart vortex-pump bypass technique for descending aorta replacement.
- To assess the incidence of mortality and vital organ complications, particularly spinal cord injury.
- To identify factors influencing spinal cord injury and propose strategies for its reduction.
Main Methods:
- A highly standardized left heart vortex-pump bypass was employed in 132 patients undergoing descending aorta replacement.
- Procedures involved staged aortic clamping and intercostal artery reconnection.
- No additional adjuncts were used to mitigate spinal cord injury.
Main Results:
- The study included 132 patients with descending aorta aneurysms (51%) and dissections (49%).
- Early mortality was 3% (4 patients), and late mortality was 7% (9 patients).
- Permanent spinal cord injury occurred in 2.3% (3 patients), exclusively in cases involving replacement beyond thoracic segment 8.
Conclusions:
- Left heart bypass effectively unloads the proximal circulation and maintains distal organ perfusion during aortic occlusion.
- Low rates of early mortality and renal failure demonstrate the technique's safety.
- Reducing spinal cord injury risk may involve more aggressive intercostal artery reconnection and hypothermia to extend ischemic tolerance.
Abstract:
Replacement of the descending aorta for aneurysms (51%) and dissection (49%) was performed in 132 patients with a highly standardized left heart vortex-pump bypass. No adjuncts other than staged aortic clamping and intercostal artery reconnection were used to reduce spinal cord injury in extensive involvement. Four patients (3%) died early, two of cardiac cause, and nine (7%) died late. Complications of vital organ function occurred in eight patients, two having reversible renal failure and six spinal cord injury that was permanent in three (2.3%). Cord injury occurred only in replacement beyond thoracic segment 8 and could not be completely avoided despite distal intercostal artery reconnection in two cases; in the other four cases such vessels either did not appear worth reconnecting or were sacrificed in emergency operations. We conclude that left heart bypass effectively unloads the proximal circulation during aortic occlusion while maintaining adequate perfusion of distal vital organs as evidenced by low rates of early mortality and renal failure. The remaining risk of spinal cord damage may be lowered by more aggressive reconnection of all distal intercostal arteries and by extending the permissible cord ischemic period by means of hypothermia.