Diagnostic and surgical management of patients with aneurysms of the thoracic aorta with various causes. Echocardiography and contrast enhanced computed tomography in prophylactic replacement of the ascending aorta

One-stage intrathoracic repair of extended aortic aneurysms

Aneurysms of the entire thoracic aorta are usually approached in two to three stages. From 1990 to 1994, we performed one-stage aortic replacement from the root to the diaphragm in 16 patients (8 men and 8 women with a mean age of 55.7 years, range 49 to 73). There were 11 type A dissections, 7 of which were acute. Six patients underwent aortic valve reconstruction; seven had aortic root replacement by Bentall or Cabrol techniques. In two cases, the innominate artery had to be replaced by a vascular graft separately in addition to reimplantation of the supraaortic branches as an island flap into the arch prosthesis. In eight cases, a median sternotomy was used; eight had a bilateral transverse thoracotomy. The procedure was performed under deep hypothermic circulatory arrest in all cases (mean duration 50.5 min, range 38 to 62 min). Two patients, both operated upon for an acute dissection, expired perioperatively: one due to a bronchopneumonia, and one because of a thrombosed Cabrol graft to the right coronary artery. No patient developed bleeding or neurological complications. At a mean follow-up of 26.9 months (1 to 50 months), all patients discharged from the hospital were still alive. Four patients underwent subsequent thoracoabdominal aortic replacement. This experience suggests that complete thoracic aortic replacement can be performed in a single session with an operative risk comparable to that of the conventional two-stage approach. The bilateral transverse thoracotomy affords excellent exposure. The lack of spinal cord ischemia may be the result of spinal cord protection with hypothermic circulatory arrest and use of the open-clamp technique.

Replacement of the entire thoracic aorta in a single stage

Aneurysms of the entire thoracic aorta are usually approached in two to three stages. From 1990 to 1992, we performed one-stage aortic replacement from the root to the diaphragm in 12 patients (7 men, 5 women; median age, 51 years; range, 49 to 73 years). There were 9 type A dissections, 5 of which were acute. Five patients underwent aortic valve reconstruction, and 5 had aortic root replacement by Bentall or Cabrol techniques. In 2 patients the innominate artery had to be replaced by a vascular graft separately, in addition to reimplantation of the supraaortic branches as an island flap into the arch prosthesis. In 5 patients a mid-sternotomy was used; in 7 a bilateral transverse thoracotomy. The procedure was performed under deep hypothermic circulatory arrest in all cases (median, 45 minutes). Two patients, both operated on for an acute dissection, died perioperatively: 1 due to a bronchopneumonia, 1 because of a thrombosed Cabrol graft to the right coronary artery. No bleeding or neurologic complications developed. At a median follow-up of 14 months (range, 1 to 33 months), all patients discharged from the hospital were still alive. Four patients underwent subsequent thoracoabdominal aortic replacement. This experience suggests that complete thoracic aortic replacement can be performed in a single session, with an operative risk comparable with that of the conventional two-stage approach. The bilateral transverse thoracotomy affords an excellent exposure. The lack of spinal cord ischemia may be the result of spinal cord protection with hypothermic circulatory arrest and the open clamp technique.

Transesophageal echocardiography

Two-dimensional transesophageal echocardiography generally has superior sensitivity and image quality compared with precordial echocardiography. Its unique anatomic perspective posterior to the heart often provides important clinical information not obtainable by other imaging approaches and technologies. It is particularly useful in the diagnosis of mitral valve disease, left atrial masses, endocarditis and its sequelae, and aortic dissections. It is also useful for examination of the left main coronary artery, left ventricular outflow tract, atrial and ventricular septa, and congenital defects. In addition to its application as a diagnostic tool in conscious patients, it can be employed intraoperatively to evaluate and guide surgical intervention. Detection of ventricular wall motion abnormalities by transesophageal echocardiography has been shown to be the most sensitive indicator of myocardial ischemia available in the clinical setting. It has potential for wide application for safely monitoring left ventricular function in patients in intensive care or under anesthesia.