Continuous Antegrade Heart Perfusion during Ascending Aorta and Aortic Arch Replacement in Patients with Aortic Aneurysm or Acute Aortic Dissections

Objectives: Interventions on the ascending aorta and arch often require an individual approach as well as a long duration of cardiopulmonary bypass with prolonged cardioplegic myocardial ischemia. We present our experience with the continuous antegrade heart perfusion during aortic arch repair or complex aortic surgery to reduce myocardial ischemia time.

Methods: Between 2015 and 2019, a total of 79 patients (mean age: 67.6 ± 11.6 years [34–89 years]) with an aortic aneurysm 30 (37.9%) or acute dissection 49 (62.1%) underwent ascending aorta, hemiarch, or full-arch replacement without concomitant procedures. In 17 (21.5%) patients, a continuous heart perfusion (CHP) was applied as follows: after revision and/or reconstruction of the aortic root (if needed), the implanted aortic tube graft prosthesis with either a prefabricated side branch, or an introduced vent needle was clamped ~3 cm above the proximal anastomosis. Thereafter, antegrade perfusion with cold blood (10°C) over the side branch/vent needle of the prosthesis was applied continuously with pressure control. Additional surgical intervention on the ascending aorta and/or aortic arch was then performed without any further cardioplegia administration. 62 (78.5%) patients received an intermittent infusion of either cold blood or crystalloid cardioplegia.

Result: Early mortality was exceptionally in patients with aortic dissection and nonsignificant greater after continuous heart perfusion (CHP) with 17.6% compared with 9.7% after intermittent cardioplegia (IC), p = 0.36. No differences in ICU or total hospital stay length were noted. Total operation, aortic clamp and cardiopulmonary bypass times were significantly greater during CHP, p < 0.01. In the group of CHP, 58.8% received an aortic arch replacement (AAR) compared with only 12.9% with IC, p < 0.0001. AAR with CHP resulted in significantly reduced cardiac ischemia times (77 ± 35 min vs. 129 ± 45 min, p < 0.0001) and no significant differences in cardiac enzymes levels (CK-MB, Troponin I) and incidence of postoperative low cardiac output syndrome (p = n.s.).

Conclusion: In this single-center cohort, the continuous antegrade heart perfusion presents a safe alternative to routine cardioplegia during complex aortic surgery reducing myocardial ischemia time. Continuous antegrade heart blood perfusion is an alternative cardiac protection treatment strategy in complex aortic pathologies with longer operation times, also in patients with a preexisting reduced left ventricular ejection fraction. However, further investigations based on large randomized studies are warranted for final judgment.

No conflict of interest has been declared by the author(s).

Publication History

Article published online:
19 February 2021