Aortic arch reconstruction in surgical treatment of ascending aortic aneurysms and dissections

Aim. The study focused on the analysis of short-term results of aortic arch reconstruction in patients undergoing open heart surgery for ascending aortic aneurysms and dissections, comparison of intra-operative brain protection methods and verification of predictors of complications. Methods. 84 patients (mean age 55.5 ± 11.5 years, 72.6 % (61) males) with ascending aortic aneurysms and Stanford type A ascending aortic and arch dissections underwent surgery over a period from January, 2013, to March, 2015. Patients were divided into 3 groups. The 1st group included patients with ascending aortic aneurysm combined with aortic dilatation at the level of innominate artery >4.0 cm (n = 41). The 2nd group consisted of patients with Stanford type A acute ascending aortic and arch dissection (n = 25). In the 3rd group there were patients with type A chronic ascending aortic and arch dissection (n = 18). No significant differences between the groups were observed. Mean values of the maximum ascending aortic diameter did not differ significantly and were 59.6, 58.4 and 62.4 mm in the 1 st, 2nd and 3rd groups, respectively. 3 patients from the 2nd group presented with acute heart failure, 6 -acute myocardial infarction, and 3 - stroke. Higher values of pressure gradient on the aortic valve were registered in the 1st group, as compared to those in the 2nd and 3rd groups (mean value of the peak gradient was 4.5, 8.1 and 12.4 mm Hg, respectively). EuroSCORE II value in the 1st, 2nd and 3rd groups was 9.4 %, 17.7 % and 5.8 %, respectively. Results. Overall hospital mortality was 1.2 %: 1 patient with acute type A aortic dissection and later dissection of innominate artery developed stroke and died due to multiple organ failure. More prolonged cardiopulmonary bypass time and aortic cross-clamp time were required for patients with acute ascending aortic dissections, but the total surgery time and circulatory arrest time differed significantly only in the 2nd and 3rd groups. Lengthy inotropic support, ventilation time and total ICU stay, as well as a higher rate of neurologic disorders in patients with aortic dissections in comparison with patients with aneurysms were observed. We verified correlation of the urgent type of surgery, acute type A aortic dissection, including arch and descending thoracic aortic dissection, also with dissection of cervicocerebral arteries, with a more complicated hospital period, increased inotropic support and prolonged duration of stay in the intensive care unit. Conclusion. Hemiarch repair of aortic arch dilatation in case of ascending aortic replacement is an effective and safe method of treatment of extended ascending aortic aneurysms and dissections. Unilateral anterograde cerebral perfusion with simultaneous crossclamping of contralateral common carotid artery allows to maintain effective cerebral protection in conditions of moderate hypothermia and duration of circulatory arrest for at least 30-40 minutes. Adverse prognostic factors are urgent surgery, ascending aortic, arch and descending thoracic aortic dissection, prolonged extracorporeal circulation and myocardial ischemia, and disuse of the axillary artery for cannulation.