Consistency is Key: A Reproducible Approach to Managing Acute Type A Aortic Dissection
Following cardiac arrest, the aorta was transected and the root was
intensely evaluated. Unless there was a strong indication for root
replacement (baseline valvulopathy, sinus segment entry tear, or root
aneurysm), the authors routinely perform proximal repair with felt
neo-media reconstruction of the sinus segment (5-7). Semicircular
segments of felt were sized appropriately and secured within the layers
of the aorta with a running 4-0 prolene suture. Care was taken not to
impinge or distort both the left and right coronary arteries. The valve
was then resuspended with a 4-0 prolene pledgeted stitch placed as a
horizontal mattress 2 mm above each commissure. To maintain normal root
dynamics, it is important that this suture does not ‘pin’ the
commissure. The valve was then crudely tested for competence with saline
while the left ventricular vent was turned to approximately 400
The authors target moderate hypothermia
and utilize antegrade cerebral perfusion via a 9 Fr cardioplegia
cannula placed directly into the innominate artery (if not dissected).
If the arch vessels are dissected, then direct ostial cannulation during
circulatory arrest is preferred. Circulatory arrest was initiated and
the arch was inspected for a primary tear. If there was no tear
identified, the authors reconstruct the proximal arch with felt
neo-media in a similar fashion as described for the root. An
appropriately sized Dacron graft was then selected and sewn to the arch,
proximal to the innominate artery. The graft was re-cannulated, the
brain was de-aired, and cardiopulmonary bypass was reinstituted (8). The
proximal anastomosis was then performed to the aorta at the approximate
level of the sinotubular junction.
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