RP10. Direct Cerebral Perfusion as a Novel Approach to Dangerous Sternal Reentry

Background: Re-operative cardiac surgery with aortic proximity to the sternum is a high-risk situation for aortic hemorrhage and death from air embolism during sternal reentry. A common strategy to manage this problem is hypothermic circulatory arrest prior to sternotomy, however this necessitates prolonged operative time with rewarming. Here we describe the novel technique of direct cerebral perfusion (DCP) for dangerous sternal reentry, and present the case of a retrosternal aortic pseudoaneurysm repaired using this approach (Video 1).

Case details: Our patient is a 37 year old man with a bicuspid aortic valve (BAV), for which he underwent aortic valve and ascending aortic replacement 6 weeks prior. Postoperatively, the patient developed persistent chest discomfort, and a CT scan revealed a 3 x 2 x 1.8 cm retrosternal aortic pseudoaneurysm (Figure 1A). The patient was brought to the operating room for surgical repair. Following heparinization and peripheral cannulation via the right femoral artery and vein, an incision was made on the right neck to expose the right common carotid artery, and a 12-French perfusion cannula was placed. The carotid artery was clamped, and DCP was commenced and maintained at 1 liter per minute of flow throughout the surgery (Figure 1B). During sternal reentry, all peripheral blood in the body is drained into the bypass reservoir, flow to the body is stopped, and DCP is continued with the heart beating. As anticipated was likely, the aortic false aneurysm was entered during sternal reopening, however minimal blood loss occurred under DCP as the only blood in the aorta was excess flowing down from the brain via the left carotid artery. The defect in the aortic graft was identified, and a Dacron patch was used to repair the false aneurysm (Figure 1C). With aortic bleeding controlled, cardiopulmonary bypass to the body was recommenced. The pseudoaneurysm repair was completed by reinforcing the Dacron patch with a circumferential suture line. The right carotid artery was unclamped and the patient was weaned off bypass. The total DCP time was 52 minutes with 29 minutes of body ischemia and 23 minutes of body perfusion time. The patient tolerated the procedure well without complication, and he was discharged home on postoperative day 5.

Conclusion: In cases of dangerous sternal reentry, the novel technique of direct cerebral perfusion presents a safe, effective, and efficient strategy to approach cardiac reoperation.

Elbert E. Heng (1), Aravind Krishnan (2), Stefan Elde (3), Vincent Gaudiani (4), John MacArthur (5), (1) Stanford University Medical Center, Palo Alto, CA, (2) Stanford Hospital, Palo Alto, CA, (3) Stanford University, Palo Alto, CA, (4) El Camino Hospital, Mountain View, CA, (5) Stanford Hospital and Clinics, Menlo Park, CA

Elbert E. Heng

Poster Presenter

Elbert Heng is a 6th year integrated cardiothoracic surgery resident at Stanford University. He attended medical school at Brown University, during which he conducted research on the comparative histology of bicuspid aortic valve associated aortopathy under the mentorship of Dr. Thoralf Sundt III at the Massachusetts General Hospital. He is currently a postdoctoral research fellow in the laboratory of Dr. John W. Macarthur, where he is investigating novel bioprinting technologies to promote microvascular organization in therapeutic angiogenesis. Dr. Heng's clinical interests include aortic reconstruction, coronary revascularization, and valve technologies.