MANAGEMENT OF THE SEVERELY ATHEROSCLEROTIC AORTA DURING CARDIAC OPERATIONS

Embolization of atheroma from the ascending aorta is a major cause of stroke following cardiac surgery. We evaluated a protocol for intraope rative detection and treatment of the severely atherosclerotic ascendi ng aorta which included epiaortic ultrasonographic scanning and resect ion and graft replacement of the involved segment using hypothermic is chemic arrest. During an 81-month interval, 47 patients 50 years of ag e and older (mean age 71 years) who underwent coronary artery bypass g rafting had resection and graft replacement of the ascending aorta. Th is represented approximately 2% of the patients in this age group who had cardiac operations during this interval. Nineteen patients (40%) r equired additional procedures. The 30-day mortality rate was 4.3% (2 p atients). Both patients died of myocardial failure. None of the 45 sur viving patients sustained a perioperative stroke. There have been no s trokes or transient ischemic events in the follow-up period, which ext ends to 72 months (mean 21 months). While this technique for managemen t of the severely atherosclerotic aorta could be considered radical, i t was associated with lower mortality and stroke rates than those that were observed in patients with moderate or severe atherosclerosis in whom only minor modifications in technique were made to avoid emboliza tion of atheroma. Resection and graft replacement during a period of h ypothermic circulatory arrest is currently our preferred method of tre atment for the severely atherosclerotic aorta during cardiac surgery.