What If Valve Disease Plus Mobile Atheroma In The Aortic Arch: Modified Isolation Selective Cerebral Perfusion Technique
Ryushi Maruyama, Akira Yamada.
Teine Keijinkai Hospital, Sapporo, Japan.
Mobile atheroma in the proximal aorta is a risk factor for brain stroke after cardiopulmonary bypass (CPB). CPB perfusion through sick aorta or axillae artery may cause atheromatous emboli. Previously the Isolation Selective Cerebral Perfusion (ISCP) technique was described for replacing ascending aorta and aortic arch with mobile atheroma to prevent aotrogenic brain embolism. Here we report this case report using modified ISCP technique for the patient with infective endocarditis plus mobile atheroma in the aortic arch.
Method (Case Report)
A 77-year-old man was referred to our hospital due to persistent high fevers. A transthoracic echocardiogram revealed vegetations on the both aortic and mitral valve. An enhanced computed tomography (eCT) showed thick atheromatous plaque in the aortic arch, which might be mobile. To avoid the brain stroke during valve surgery on CPB, we decided to adopt the modified ISCP technique. Replacing the sick aortic arch was not our option to
minimize the usage of prosthesis in this infectious case. Through a median sternotomy arch vessels were dissected, and both axillae arteries were encircled simultaneously. Epiaortic echogram showed thick mobile atheroma in the aortic arch. After systemic heparinization, the FEM-FLEX II cannulas were induced to both axiilae arteries (20Fr to the right, 12Fr to the left, respectively), and the 3.4mm JMS cannula was inserted into the left carotid artery. Then we started CPB perfusion (the flow rate :1.5L/min from the right axillae cannula, 1.5L/min from the left axilla and left carotid cannula collectively), and core cooling to make the bladder temperature 28℃. The aortic cross clamp was placed on the non sick part of the ascending aorta, followed by both aortic and mitral valve replacement using the Edwards Bioprosthesis.
Post-operative CT showed no brain stroke, atheroembolism in abdominal organs and lower extremities. After 6 weeks of antibiotic treatment, he was discharged.
This modified ISCP technique is feasible for the patients with valve disease plus mobile atheroma in the ascending and transverse aorta.
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