Aortic Valve Resuspension and Graft Replacement of the Ascending Aorta and Proximal Hemiarch During Moderate Hypothermic Systemic Circulatory Arrest and Antegrade Cerebral Perfusion for Repair of Acute Aortic Dissection

Abstract

Acute dissection involving the entire thoracic aorta (i e., DeBakey type I) is a highly lethal condition. Although it is universally accepted that proper management of type I dissection entails emergent surgical repair of the ascending aorta, there is remarkable variation in the technical and strategic aspects of this operation, and very little evidence to support the use of any one technique over the others. The purpose of this chapter is to present our preferred approach to managing acute type I aortic dissection. Our preferred approach revolves around the overarching philosophy that the primary goal is to save the patient’s life by preventing or treating aortic rupture, cardiac tamponade, severe valvular regurgitation, and malperfusion of the heart, brain, and other vital organs. The secondary goal of preventing late dissection-related complications in residual aorta is considered, but any such efforts should not substantially diminish the patient’s chance of early survival. Thus, when treating typical cases, we favor performing aortic valve resuspension and graft replacement of the ascending aorta and proximal hemiarch during moderate hypothermic systemic circulatory arrest and antegrade cerebral perfusion. Although it is currently unclear which patients will benefit from concomitant placement of a stent-graft in the proximal descending thoracic aorta, the potential to slow the rate of aneurysmal expansion over time or, perhaps, halt the distal propagation of the dissection is attractive and justifies its application in selected patients.