1. Cardiosurgery - Skopje Surgery for acute aortic dissection using moderate hypothermia and antegrade cerebral perfusion via the right subclavian artery Special Hospital for Surgery “ Filip Vtori”, Skopje, Macedonia A. Temelkovska, I. Kajevski, N. Hristov,Z. Mitrev May, 2010

2. Cardiosurgery - Skopje Acute aortic dissection (AAD) has one of the highest mortality rate in modern medicine, with a 68% mortality at 48 hours The aim of surgery is to prevent aortic rupture, pericardial tamponade and to relieve aortic regurgitation, neurologic injury. Various techniques have been proposed as means to protect the central nervous system. They all have both advantages and disadvantages

3. Cardiosurgery - Skopje Demographic data 103 patients 79 males. Mean age 54.3  10.3 Emergency surgery 29% 10 patients previous cardiovascular surgery.

4. Cardiosurgery - Skopje 45 patients(44%) hemodynamic instable, shock, pericardial tamponade, myocardial ischemia or superior vena cava compression. 5 were (2,3%) comatose, 8 (4%) had newly developed transient ischemic attack, 1 patient had stroke 10 had(4,5%) visceral ischemia, limb ischemia in 15 (6,8%) and 6 (2,7%) presented with acute renal failure.

5. Cardiosurgery - Skopje Diagnosis was made using: 1 patient MRI, 78 patients (80%) with CT, 103 (100%) patients TEE 50 (49%) DeBakey type II, 53 patients (51%) DeBakey type I Mild/moderate aortic regurgitation was present 78 patients (80%),severe aortic regurgitation in 25 patients (20%). Preoperative ejection fraction was 50.7  6.8.

6. Cardiosurgery - Skopje Right subclavian artery antegrade body/ antegrade cerebral perfusion Snarred innominate artery Occlusion left carotid and subclavian artery Upper pressure limit 60-70 mmHg Flow rates 10ml/kg body weight Temperature 30  C Retrograde blood cardioplegia CEREBRAL PERFUSION VIA DIRECT CANNULATION OF THE RIGHT SUBCLAVIAN ARTERY IN AORTIC DISSECTION

7. Cardiosurgery - Skopje

8. Early on, we performed 13 revisions due to bleeding. We developed suction assisted bio glue application on the anastomosis lines, forcing the bio glue to impregnate the anastomotic site and needle holes. As result, there was no re-exploration or early deaths as result of bleeding in the last 40 cases. Mitrev Z, Interact Cardiovasc Thorac Surg. 2007

9. Cardiosurgery - Skopje Table. 1 Operative techniques Tube graft replacement AA1 Tube graft replacement AA + hemiarch 83 Total84 Tube graft replacement AA + total arch 8 Bentall AA + total arch3 Bentall AA + hemiarch3 Tirone David AA + hemiarch 10 Aortic root reconstr.+AV suspension+ AA + hemiarch 3 Total27 Complex procedures AV suspension18 AV replacement1 ACBP3 Simple procedures Additional procedures

10. Cardiosurgery - Skopje Table.2 Extracorporal circulation data ECC – extracorporal circulation, ACP- antegrade cerebral perfusion,SD – standard deviation Tube graft replacement + AV resuspension Complex procedures ECC time, minutes, mean  SD105.6  16223.6  53.2 ACP time, minutes, mean  SD24.7  6.535.6  22.3 ACP flow, ml, mean  SD862  113 ACP pressure, mmHg, mean  SD71  6 Nasopharyngeal temperature,  C, mean  SD 30.8  2.4

11. Cardiosurgery - Skopje All patients but 10(10%) showed normal awakening within 8 hours postoperatively. 8 patients of the complex group had a fatal neurologic complication, the cause of coma and death was multiorgan failure and low cardiac output in 4pts, and bleeding in 2 patients. 5 patients had non-fatal neurologic complications. Transient neurologic dysfunction, defined as postoperative confusion, agitation and delirium.

12. Cardiosurgery - Skopje Average extubation time was 11.8  5.8 hours, except in 18 patients (19%) that required prolonged ventilation. Average in hospital stay was 9.0  3.5, except in 17 patients (complex group) who required prolonged in-hospital stay.

13. Cardiosurgery - Skopje Mortality rate of the complex group with cardiogenic shock was 27% Mortality rate of the simple group was 4%

14. Cardiosurgery - Skopje ACP via right subclavian artery enables safe period for circulatory arrest with effective cerebral perfusion, at the same time avoiding complications of the selective arch vessels cannulation. Moderate hypothermia 30  C shortens the cooling and rewarming time, thus reducing the complications related to long pump times. Dissection of the right subclavian artery was present in one patient, with succesfull cannulation and selective brain perfusion, and reconstruction of the artery following decannulation. There were no malperfusion cases.

15. Cardiosurgery - Skopje Conclusion Direct subclavian artery cannulation for extracorporal circulation and antegrade perfusion using moderate hypothermia (30  ), along with suction assisted bio glue application,is simple, fast and safe method for treatment of acute aortic dissection with excellent operative and early postoperative results