Normothermic myocardial perfusion reduces cross-clamp time and provides equivalent myocardial protection compared to cardioplegic cardiac arrest in a consecutive series of hybrid stent-graft implants
Presented During:
Thursday, April 25, 2024: 5:38PM - 7:00PM
Sheraton Times Square
Posted Room Name:
Central Park
Abstract No:
P0228
Submission Type:
Abstract Submission
Authors:
Shruthi Nammalwar (1), Pedro Catarino (2), Dominick Megna (1), Michael Bowdish (3), Joanna Chikwe (4), Aziz Ghaly (5), Derrick Tam (6)
Institutions:
(1) N/A, Los Angeles, CA, (2) Cedars-Sinai, Los Angeles, CA, (3) Cedars-Sinai Medical Center, La Canada, CA, (4) Cedars-Sinai Medical Center, Beverly Hills, CA, (5) N/A, New York, NY, (6) Cedars-Sinai Medical Center, Los Angeles, CA
Submitting Author:
Shruthi Nammalwar
-
Contact Me
N/A
N/A
Co-Author(s):
*Pedro Catarino
-
Contact Me
Cedars-Sinai
Cedars-Sinai
Dominick Megna
-
Contact Me
N/A
N/A
*Michael Bowdish
-
Contact Me
Cedars-Sinai Medical Center
Cedars-Sinai Medical Center
*Joanna Chikwe
-
Contact Me
Cedars-Sinai Medical Center
Cedars-Sinai Medical Center
Aziz Ghaly
-
Contact Me
N/A
N/A
Derrick Tam
-
Contact Me
Cedars-Sinai Medical Center
Cedars-Sinai Medical Center
Presenting Author:
Shruthi Nammalwar
-
Contact Me
N/A
N/A
Abstract:
Objective: Aortic arch operations involve long cardiopulmonary bypass runs with at least moderate hypothermia contributing to time-dependent myocardial ischemia if the heart is arrested. Normothermic myocardial perfusion reduces this myocardial ischemic period. The aim of this study was to compare the short-term outcomes of normothermic myocardial perfusion versus cardioplegia cardiac arrest in aortic arch reconstruction employing a hybrid frozen elephant trunk stent-graft.
Methods: Between July 2022 and October 2023, 28 consecutive patients (mean age: 61.5 +/- 9.8, 62% men) underwent hybrid frozen elephant trunk stent-graft implantation for arch surgery at a single center. In 15 patients, Del Nido cardioplegia was used to arrest the heart while in 13 patients the heart was continuously perfused with normothermic blood. In the latter patients, the cardioplegia circuit was used to deliver 36°C blood, without additives, at 250-450 ml/min into the ascending aorta which was clamped distally without aortic root pressure monitoring. The flow rate was adjusted to maintain a stable electrocardiogram with a narrow QRS. Antegrade cerebral perfusion and moderate hypothermia (23°C) were employed in all cases. The primary outcome was stroke, spinal cord ischemia, and changes in left ventricular ejection fraction. The secondary outcomes were cardiopulmonary bypass (CPB) and cross clamp time, total operative time, length of stay (LOS), and new dialysis requirements. Median follow-up was 140.5 days.
Results: The cardioplegia cardiac arrest cohort (n=15) were slightly older than the normothermic myocardial perfusion cohort (n=13) (63 +/- 11 vs 59 +/- 7.4) with no difference in sex (67% vs. 69%) and 47% of patients with previous sternotomy. Surgical indications included chronic dissection (13, 46.4%), acute dissection (8, 28.6%), aneurysm (4, 14.3%), and rupture (3, 10.7%). There were three (20%) strokes in the cardioplegia cardiac arrest cohort. There was one (7%) stroke (acute on chronic) and one (7%) spinal cord ischemic injury (temporary) in the normothermic myocardial perfusion cohort. There were no in-hospital or 30-day deaths in either group. Cross clamp times were shorter with normothermic myocardial perfusion (median minutes [IQR]: 150 [98-190] vs 48 [48-72.5]; p-value < 0.05). There was no significant different between pre-CPB and post-CPB left ventricular function in the cardioplegia cardiac arrest cohort (p=0.42) and the normothermic myocardial perfusion cohort (p=0.82) (Figure 1). There was no statistically significant difference in CPB time (median minutes [IQR]: 229 [211-272] vs 217 [201.5-240.5]; p=0.23) or total operative time (median minutes [IQR]: 495 [456-531] vs 463 [413.5-504]; p=0.17). There were no significant differences in hospital length of stay (median days [IQR]: 10 [8-14] vs 11 [8-23.5]; p=0.37) or ICU length of stay (median days [IQR]: 6 [5-7.5] vs 6 [4-10]; p-value 0.65). There were 3 (20%) new dialysis patients in the cardioplegia cardiac arrest cohort and no new dialysis requirements in the normothermic myocardial perfusion cohort (20% vs 7%).
Conclusion: Aortic arch repair with a hybrid frozen elephant trunk stent-graft using normothermic myocardial perfusion reduces cross-clamp times and provides equivalent myocardial protection while maintaining neurological outcomes compared to cardioplegic cardiac arrest.
Methods: Between July 2022 and October 2023, 28 consecutive patients (mean age: 61.5 +/- 9.8, 62% men) underwent hybrid frozen elephant trunk stent-graft implantation for arch surgery at a single center. In 15 patients, Del Nido cardioplegia was used to arrest the heart while in 13 patients the heart was continuously perfused with normothermic blood. In the latter patients, the cardioplegia circuit was used to deliver 36°C blood, without additives, at 250-450 ml/min into the ascending aorta which was clamped distally without aortic root pressure monitoring. The flow rate was adjusted to maintain a stable electrocardiogram with a narrow QRS. Antegrade cerebral perfusion and moderate hypothermia (23°C) were employed in all cases. The primary outcome was stroke, spinal cord ischemia, and changes in left ventricular ejection fraction. The secondary outcomes were cardiopulmonary bypass (CPB) and cross clamp time, total operative time, length of stay (LOS), and new dialysis requirements. Median follow-up was 140.5 days.
Results: The cardioplegia cardiac arrest cohort (n=15) were slightly older than the normothermic myocardial perfusion cohort (n=13) (63 +/- 11 vs 59 +/- 7.4) with no difference in sex (67% vs. 69%) and 47% of patients with previous sternotomy. Surgical indications included chronic dissection (13, 46.4%), acute dissection (8, 28.6%), aneurysm (4, 14.3%), and rupture (3, 10.7%). There were three (20%) strokes in the cardioplegia cardiac arrest cohort. There was one (7%) stroke (acute on chronic) and one (7%) spinal cord ischemic injury (temporary) in the normothermic myocardial perfusion cohort. There were no in-hospital or 30-day deaths in either group. Cross clamp times were shorter with normothermic myocardial perfusion (median minutes [IQR]: 150 [98-190] vs 48 [48-72.5]; p-value < 0.05). There was no significant different between pre-CPB and post-CPB left ventricular function in the cardioplegia cardiac arrest cohort (p=0.42) and the normothermic myocardial perfusion cohort (p=0.82) (Figure 1). There was no statistically significant difference in CPB time (median minutes [IQR]: 229 [211-272] vs 217 [201.5-240.5]; p=0.23) or total operative time (median minutes [IQR]: 495 [456-531] vs 463 [413.5-504]; p=0.17). There were no significant differences in hospital length of stay (median days [IQR]: 10 [8-14] vs 11 [8-23.5]; p=0.37) or ICU length of stay (median days [IQR]: 6 [5-7.5] vs 6 [4-10]; p-value 0.65). There were 3 (20%) new dialysis patients in the cardioplegia cardiac arrest cohort and no new dialysis requirements in the normothermic myocardial perfusion cohort (20% vs 7%).
Conclusion: Aortic arch repair with a hybrid frozen elephant trunk stent-graft using normothermic myocardial perfusion reduces cross-clamp times and provides equivalent myocardial protection while maintaining neurological outcomes compared to cardioplegic cardiac arrest.
Aortic Symposium:
Aortic Arch
Image or Table
Presentation
