P017: EFFECTIVE COMMUNICATION FOR A SUCCESSFUL INTERVENTION IN PATIENT UNDERGOING COMPLEX AORTIC PATHOLOGY PROCEDURE
Arthur C De Souza, BS1; Gabriel Flambert, BS1; Yong G Peng, MD, PhD, FASE, FASA2
1University of Florida College of Medicine; 2University of Florida Department of Anesthesiology
Introduction: Aortic root and ascending aortic pathologies are life threatening conditions that commonly require a surgical intervention. The Bentall procedure is a surgical technique involving replacement of the ascending aorta, reconstructed aortic root and aortic valve with valve conduit, along with coronary artery reimplantation. If there is aortic insufficiency due to ascending aortic aneurysms without morphological aortic valve defect¹, the valve sparing procedure like the David or Florida sleeve approach demonstrate favorable outcomes in an elective setting for the treatment of ascending aortic pathology2.
Methods: We present a 68 year old male with a previous aortic dissection and a bioprosthetic aortic valve replacement, presenting 7 years later with a 5.6-6 cm aortic pseudoaneurysm and a chronic DeBakey type 1 dissection. He underwent a redo sternotomy with cardiopulmonary bypass using bicaval and central aortic cannulation. Deep hypothermia, 18–20°C, was used for cerebral protection. The native arch tissue was unsuitable for a single distal anastomosis, and the distance between the supra-aortic arteries posed tension risk to the anastomoses if reimplanted in situ. Therefore, the surgical team decided to use a 14x10x10mm trifurcate Gelweave graft for end-to-end bypasses to the innominate and left common carotid artery. A 32 mm side-arm graft was shortened and sown onto the distal aorta, followed by reconstruction of the aortic root with a 27 mm Edwards Konect bovine pericardial valve conduit and coronary reimplantation with 8mm grafts.
Results: Cerebral perfusion was restored sequentially as each vessel was debranched, with 22 minutes of cerebral ischemia time and 66 minutes of lower body ischemia time. The cross-clamp was removed after 299 minutes, then the patient was rewarmed and weaned after 386 minutes of cardiopulmonary bypass time without difficulty. The post-bypass intraoperative transesophageal echocardiography confirmed preserved ventricular function, no paravalvular leak, and mean transvalvular gradient of 4.1mmHg. He was transferred to the intensive care unit, weaned and subsequently extubated without difficulty.
Discussion: Surgical aortic root and arch reconstruction present technical challenges due to the variability of the native tissue quality and altered anatomy. The surgical team used a trifurcate graft for debranching instead of the in situ technique, which allowed sequential restoration of cerebral perfusion and minimized cerebral ischemia time. The graft configuration also enabled customization of branch length to achieve tension-free anastomoses and preserved the option for future endovascular stent intervention should the patient develop additional aortic pathology. Controlling the hypothermic circulatory arrest is essential for neurologic protection, in addition transesophageal echocardiography provided real-time assessment of ventricular and valvular function, offering valuable information for both anesthetic management and timely surgical decision-making. This case highlights the importance of individualized surgical planning and effective communication between the surgical and anesthesia teams to optimize neuroprotection and overall patient outcomes.
References
1. Joo, H. C., et al.. (2012). Clinical experience with the Bentall procedure: 28 years. Yonsei medical journal, 53(5), 915.
2. Yang, B., et. al. (2018). Sixteen-year experience of David and Bentall procedures in acute type A aortic dissection. The Annals of Thoracic Surgery, 105(3), 779-784.