Adoption of Left Heart Bypass During Thoracoabdominal Aortic Aneurysm Repair: An Initial Institutional Experience and Case Series

P0031 

Abstract Submission 

Jake Awtry (1), Thais Faggion Vinholo (2), Ajami Gikandi (3), Michael Gilfeather (2), Trevor Smith (2), Douglas Shook (4), Mohamad Hussain (2), Kim de la Cruz (5)

(1) Brigham and Women's Hospital, United States, (2) Brigham and Women's Hospital, Boston, MA, (3) Harvard Medical School, Boston, MA, (4) Brigham and Women's Hospital, Newton, MA, (5) Division of Cardiac Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA

Jake Awtry    -  Contact Me
Brigham and Women's Hospital

Thais Faggion Vinholo    -  Contact Me
Brigham and Women's Hospital

Ajami Gikandi    -  Contact Me
Harvard Medical School

Michael Gilfeather    -  Contact Me
Brigham and Women's Hospital

Trevor Smith    -  Contact Me
Brigham and Women's Hospital

Douglas Shook    -  Contact Me
Brigham and Women's Hospital

Mohamad Hussain    -  Contact Me
Brigham and Women's Hospital

Kim de la Cruz    -  Contact Me
Division of Cardiac Surgery, Brigham and Women’s Hospital, Harvard Medical School

Jake Awtry    -  Contact Me
Brigham and Women's Hospital

Objective: Thoracoabdominal aortic aneurysm (TAAA) repair is a highly complex, morbid surgery with up to 10% reported operative mortality requiring integrated expertise from multiple disciplines for successful completion. The use of left heart bypass (LHB) may reduce complications including mortality and spinal cord injury compared to circulatory arrest or full cardiopulmonary bypass, but its use remains confined primarily to specific, experienced centers.z Here, we report the results of extensive TAAA repair after the implementation of routine LHB at a new institution by an experienced surgeon.

Methods: All patients undergoing extensive TAAA repair at our institution from November 2022 to May 2023 were included. Patient characteristics and their operative outcomes were collected via direct chart review and our institutional STS database data. All patients were managed via a standardized perioperative protocol, including routine use of left heart bypass and passive intraoperative hypothermia.

Results: A total of seven cases were performed over the course of six months. The median age was 38 years, 4/7 were female, 5/7 were White. All had prior Stanford Type A (4/7) or B (3/7) aortic dissections resulting in descending aortic aneurysm (6 Extent II, 1 Extent III) with a median diameter of 5.0 cm. All patients had a spinal drain placed preoperatively and were transfused to a goal hemoglobin of 10.0 g/dL intraoperatively. LHB was initiated after the placement of venous and arterial cannulas at the left pulmonary vein/left atrial junction and the descending aorta, respectively; the median LHB time was 65 minutes. The descending and abdominal aorta was replaced with a four-branch Coselli graft in all patients with bypass performed to the celiac, superior mesenteric, and bilateral renal arteries. The intercostal arteries were routinely revascularized, with re-implantation in six patients and graft-intercostal artery bypass with PTFE performed in the other. Significant postoperative complications included one return to the operating room for bleeding, 3 patients with prolonged ventilation with 1 requiring a tracheostomy (decannulated before discharge), 4 patients with renal failure (none dialysis-dependent at discharge), and one patient with persistent lower extremity weakness secondary to a retroperitoneal hematoma. The median length of stay was 18 days. At the time of reporting, all patients were alive and living independently.

Conclusions: Our experience demonstrates that the use of LHB during extensive TAAA repair can be effectively and safely implemented under the guidance of an experienced expert. Elements critical to implementation success include a standardized protocol for perioperative management as well as collaborative, interdisciplinary work between the surgeon, anesthesiologist, and perfusionist during each case.

Descending/Thoracoabdominal Aorta