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Surgical Treatment of Dissecting Aneurysm of the Interventricular Septum
Ann Thorac Surg 1997;63:545–7
CASE REPORT WU SURGICAL TREATMENT OF DISSECTING ANEURYSM
545
Surgical Treatment of Dissecting Aneurysm of the Interventricular Septum Qing-yu Wu, MD Department of Cardiac Surgery, Cardiovascular Institute and Fu Wai Hospital, Chinese Academy of Medical Sciences, Beijing, People’s Republic of China
Two extremely rare cases of dissecting aneurysm of the interventricular septum associated with aortic incompetence are reported. One was complicated with an aneurysm of the left coronary sinus of Valsalva, and the other may have been the result of trauma. Surgical operation involved resection or repair of the aneurysm and replacement of the aortic valve. Both patients recovered uneventfully. Early diagnosis and surgical intervention are emphasized. (Ann Thorac Surg 1997;63:545–7) © 1997 by The Society of Thoracic Surgeons
D
issecting aneurysms of the interventricular septum are quite rare. Two patients with dissecting aneurysm of the interventricular septum associated with aneurysm of the left coronary sinus of Valsava were operated on at Fu Wai Hospital and are reported here.
Case Reports Patient 1 A 39-year-old man was admitted to our hospital on May 3, 1992, because of very poor exercise tolerance and dyspnea for 6 months. Physical examination on admission showed a heart rate of 110 beats/min and blood pressures of 150/15 mm Hg on the upper extremity and 195/30 mm Hg on the lower extremity. A systolic thrill was palpable, and 4/6 systolic and diastolic murmurs were heard in the second and third intercostal spaces along the left sternal border. Hepatomegaly was noted 5 cm below the right costal margin. Electrocardiogram showed sinus tachycardia, atrial enlargement, left anterior bundle hemiblock, and left ventricular hypertrophy. Chest radiography revealed a cardiac/thoracic ratio of 0.65 and pulmonary interstitial edema and bilateral pleural effusions. Echocardiography showed a dilated left atrium of 45 mm in diameter and left ventricle of 65 mm in end-diastolic diameter. The myocardium of the upper interventricular septum was split and formed an aneurysm cavity, which communicated with the right coronary sinus of Valsalva (Fig 1). The aneurysm with a very thin wall bulged into the outflow tracts of both ventricles and led to stenosis of both outlet tracts. A perforation of the false cavity of the aneurysm attached by a vegetation about Accepted for publication Aug 22, 1996. Address reprint requests to Dr Wu, Department of Cardiac Surgery, Cardiovascular Institute and Fu Wai Hospital, Chinese Academy of Medical Sciences, Beijing 100037, People’s Republic of China.
© 1997 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
Fig 1. (Patient 1.) Echocardiogram of the dissecting aneurysm of the interventricular septum (arrow).
10 mm in diameter communicated with the right ventricle. The left coronary sinus of Valsalva was dilated severely. The operation was performed under hypothermia and cardiopulmonary bypass with general anesthesia on May 7, 1992. The heart was markedly enlarged and the tissue was edematous. The aortic valve was tricuspid and the right coronary cusp was undeveloped, shortened, and deformed. An unruptured aneurysm, approximately 3 3 5 3 3 cm in size, originated from the abnormal enlarged left coronary sinus of Valsalva and protruded into the aneurysm of the interventricular septum (Fig 2). Severe regurgitation of the aortic valve led to a markedly enlarged left ventricle. The wall of the huge interventricular septal dissecting aneurysm, 5 3 8 3 6 cm in size, was about 1 mm in thickness. The dissecting aneurysm involved the upper half part of the interventricular septum and extended to both ventricles, resulting in obstruction of both ventricular outflow tracts. A perforation about 1 cm in diameter communicated with the right ventricle. The other defect of the dissecting aneurysm, about 4 3 2 cm in size, communicated with the aorta in the left ventricular outlet tract below the left and right coronary sinuses of Valsalva. The lower part of the dissecting aneurysmal wall was intact, and the aneurysm could be partially seen in the right ventricular surface. After cross-clamping of the ascending aorta, transverse aortotomy and right ventriculotomy provided satisfactory exposure. Routine methods were used for myocardial protection. Aortic leaflets, the aneurysm of the left coronary sinus of Valsalva, and part of the wall of the dissecting aneurysm of the interventricular septum were resected. A 23 mm St. Jude Medical (St. Paul, MN) prosthetic valve was inserted with interrupted and pledgeted horizontal mattress sutures, which at the aortic annular level were put through from both layers of the wall of the dissecting aneurysm to the aortic wall and the sewing ring of the prosthetic valve. Then the cavity of the aneurysm was obliterated. Simultaneously, the perforation of the dissecting aneurysm on the right ventricular side was repaired. Incisions of the aorta and right ventricle were sutured continuously. 0003-4975/97/$17.00 PII S0003-4975(96)01247-7
546
CASE REPORT WU SURGICAL TREATMENT OF DISSECTING ANEURYSM
Ann Thorac Surg 1997;63:545–7
chest trauma and sudden onset of palpitation. Electrocardiography showed a grade 3 atrioventricular block and left ventricular hypertrophy. Chest radiography revealed a cardiac/thoracic ratio of 0.62. Echocardiography showed that a cyst formed in the upper part of the interventricular septum communicated with the right coronary sinus of Valsalva. Magnetic resonance imaging angiography revealed aortic insufficiency, the dissecting aneurysm of the interventricular septum, and decreased left ventricular function (Fig 3). The patient underwent operation on May 12, 1993, with cardiopulmonary bypass and hypothermia. A temporary pulse generator was implanted intravenously 1 day before operation. The left ventricle was markedly enlarged. The aortic valve had extreme insufficiency with a dilated annulus. The right coronary cusp was small and shortened. Beneath that, the interventricular septum was split and formed an aneurysm sac, 5 3 4 3 6 cm in size, with a fibrotic lining and thrombi located in the subaortic region of the interventricular septum. The left and noncoronary cusps were thickened. A transverse aortomy and right ventriculotomy provided satisfactory exposure. After resection of the aortic leaflets, five interrupted and pledgeted mattress stitches were applied to close the dissecting aneurysmal cavity through the aortic side to sew the interventricular septum to the right ventricular side. A 25-mm Sorin (Irvine, CA) aortic prosthesis then was placed with interrupted and pledgeted mattress sutures. The overlapping tissue of the aneursym in the subaortic region and the aortic wall were sutured to the prosthetic valvular sewing ring. A permanent pacemaker was placed on June 16, and he was discharged on July 2. Two months after the operation, the symptoms of congestive heart failure disappeared. Roentgenography and echocardiography revealed an intact interventricular septum and a prosthetic aortic valve with normal function. He is doing well now. Fig 2. (Patient 1.) Operative photograph (A) and diagram (B) showing the wall of the aneurysm of the interventricular septum (a) and the pulmonary valve (b).
Comment Dissecting aneurysms of the interventricular septum are very rare [1, 2]. An unruptured aneurysm of the left
The patient recovered smoothly. Two weeks after being discharged, he was admitted again because of arrhythmia. Chest roentgenography and echography showed aortic insufficiency and communication between both ventricles. On July 10, 1992, reoperation was performed with the same approach. Two locations of perivalvular leakage, approximately 1 3 0.8 in size, were found. The dissecting aneurysmal wall was disrupted from the artificial valvular ring to form a defect with a size of 2 3 1.5 cm between the left and right ventricles. After the dissecting aneurysmal wall was resected, a large Dacron patch with a size of 4.5 3 7 cm was used to repair the defect. The other perivalvular leakage was closed inside the aorta. Incisions of the aorta and right ventricle were closed. The patient recovered and was discharged uneventfully. The chest x-ray plain film and echocardiography proved a satisfactory result. He had been doing well on follow-up.
Patient 2 A 50-year-old man presented to our hospital on January 8, 1993, with a 2-month history of dyspnea and exercise intolerance culminating in heart failure. He had a history of
Fig 3. (Patient 2.) Magnetic resonance image of the dissecting aneurysm of the interventricular septum (arrow).
Ann Thorac Surg 1997;63:547– 8
coronary sinus of Valsalva led to a dissecting aneurysm in patient 1, and probably traumatic dissecting aneurysm of the interventricular septum occurred in patient 2. The etiology of the disease remains obscure [3–5]. Clinical manifestations of the disease include arrhythmias, obstruction of one or both ventricular outflow tracts, and congestive heart failure. The diagnosis of the disease can be confirmed by means of echocardiography, magnetic resonance imaging, and left ventricular angiography. The main purpose of the operation was to restore the integrity of the interventricular septum and competency of the aortic value. In patient 1, the aneurysmal wall should be resected completely. The ventricular septum defect was repaired using a patch with a suitable size. In patient 2, the aneurysmal tissue was strong enough for repairing, so the integrity of the interventricular septum could be kept. Dissecting aneurysms of the interventricular septum have a progressive course and poor prognosis. Early diagnosis and surgical intervention are mandatory.
References 1. Engel PJ, Held JS, van der Bel-Kahn J, Spitz H. Echocardiographic diagnosis of congenital sinus of Valsalva aneurysm with dissection of the interventricular septum. Circulation 1981;63:705–11. 2. Raffa H, Mosieri J, Sorefan AA, Kayali MT. Sinus of Valsalva aneurysm eroding into the interventricular septum. Ann Thorac Surg 1991;51:996– 8. 3. Callet B, Combe E, Saudemont JP, et al. Aneursym of the left aortic sinus causing coronary compression and unstable angina. Successful repair by isolated closure of the aneurysm. Am Heart J 1988;115:1308–10. 4. Sawyer AJ, Mauss IH, Rosenblaff P. Congenital diverticulosis of left ventricle. Am J Dis Child 1950;79:117–9. 5. Fasoli G, Della Valentina P, Scognamiglio R. Echocardiographic findings in left ventricular septal aneurysm. Int J Cardiol 1988;18:441–3.
CASE REPORT IMAMAKI ET AL SEPARATE-HYPOTHERMIA RCP
547
R
etrograde cerebral perfusion (RCP) is a useful method of protecting the brain during operations involving the aortic arch [1], but it seems to be effective for a limited time in comparison with selective cerebral perfusion. Prolonged RCP may induce neurologic complications. If the blood temperature in RCP is kept at a deep hypothermic level, the brain may be protected more adequately without neurologic complications. However, systemic deep hypothermia and prolonged cardiopulmonary bypass may induce coagulation disorder, respiratory failure, or infection. Thus, we developed an RCP method we refer to as separate-hypothermia RCP (SHRCP). The cardiopulmonary bypass circuit used in this method is shown in Figure 1. The usual cardiopulmonary bypass circuit is modified for the SHRCP circuit. The RCP circuit is derived from the arterial reservoir, and a roller pump and heat exchanger exclusive to this circuit are incorporated into it. Extracorporeal circulation is begun with femoral arterial perfusion and bicaval drainage, and SHRCP is started after the core temperature has cooled down to 25°C. The RCP is regulated with blood temperature at about 10°C and an internal jugular vein pressure of 25 cm H2O. An occlusion balloon catheter is inserted into the descending aorta. Simultaneously, femoral arterial perfusion is continued while the rectal temperature is maintained at moderate hypothermia with a low flow rate, and inferior vena caval drainage is performed. The head is not packed in ice. After distal anastomosis and reconstruction of the arch vessels, RCP is terminated and the proximal anastomosis is made during the rewarming with perfusion in the usual manner.
Case Reports Patient 1
Separate-Hypothermia Retrograde Cerebral Perfusion
The patient was a 68-year-old man who had undergone graft replacement of the descending thoracic aorta for a dissecting aneurysm (Stanford type B) 4 years previously.
Mizuho Imamaki, MD, Touitsu Hirayama, MD, and Masamichi Nakajima, MD Department of Cardiovascular Surgery, Saiseikai Kumamoto Hospital, Kumamoto, Japan
We have developed a technique of cerebral protection in which the blood for the retrograde cerebral perfusion from the superior vena cava cannula is cooled down to 10°C, while the core temperature is maintained at moderate hypothermia. We performed graft replacement of the ascending and aortic arch in 2 patients with dissecting aneurysm using this method. This technique may provide excellent cerebral protection without coagulation disorder. (Ann Thorac Surg 1997;63:547– 8) © 1997 by The Society of Thoracic Surgeons Accepted for publication Aug 28, 1996. Address reprint requests to Dr Imamaki, Division of Cardiovascular Surgery, Kimitsu Chuo Hospital, 1010, Sakurai, Kisarazu-city, Chiba Prefecture, 292 Japan.
© 1997 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
Fig 1. Schema of the circuit of separate-hypothermia retrograde cerebral perfusion (SHRCP). The circuit is interrupted by clamp B during conventional heart-lung bypass. On initiation of SHRCP, the clamp on A is applied and the clamp on B is released. (IVC 5 inferior vena cava; SVC 5 superior vena cava.) 0003-4975/97/$17.00 PII S0003-4975(96)00933-2
CASE REPORT WU SURGICAL TREATMENT OF DISSECTING ANEURYSM
545
Surgical Treatment of Dissecting Aneurysm of the Interventricular Septum Qing-yu Wu, MD Department of Cardiac Surgery, Cardiovascular Institute and Fu Wai Hospital, Chinese Academy of Medical Sciences, Beijing, People’s Republic of China
Two extremely rare cases of dissecting aneurysm of the interventricular septum associated with aortic incompetence are reported. One was complicated with an aneurysm of the left coronary sinus of Valsalva, and the other may have been the result of trauma. Surgical operation involved resection or repair of the aneurysm and replacement of the aortic valve. Both patients recovered uneventfully. Early diagnosis and surgical intervention are emphasized. (Ann Thorac Surg 1997;63:545–7) © 1997 by The Society of Thoracic Surgeons
D
issecting aneurysms of the interventricular septum are quite rare. Two patients with dissecting aneurysm of the interventricular septum associated with aneurysm of the left coronary sinus of Valsava were operated on at Fu Wai Hospital and are reported here.
Case Reports Patient 1 A 39-year-old man was admitted to our hospital on May 3, 1992, because of very poor exercise tolerance and dyspnea for 6 months. Physical examination on admission showed a heart rate of 110 beats/min and blood pressures of 150/15 mm Hg on the upper extremity and 195/30 mm Hg on the lower extremity. A systolic thrill was palpable, and 4/6 systolic and diastolic murmurs were heard in the second and third intercostal spaces along the left sternal border. Hepatomegaly was noted 5 cm below the right costal margin. Electrocardiogram showed sinus tachycardia, atrial enlargement, left anterior bundle hemiblock, and left ventricular hypertrophy. Chest radiography revealed a cardiac/thoracic ratio of 0.65 and pulmonary interstitial edema and bilateral pleural effusions. Echocardiography showed a dilated left atrium of 45 mm in diameter and left ventricle of 65 mm in end-diastolic diameter. The myocardium of the upper interventricular septum was split and formed an aneurysm cavity, which communicated with the right coronary sinus of Valsalva (Fig 1). The aneurysm with a very thin wall bulged into the outflow tracts of both ventricles and led to stenosis of both outlet tracts. A perforation of the false cavity of the aneurysm attached by a vegetation about Accepted for publication Aug 22, 1996. Address reprint requests to Dr Wu, Department of Cardiac Surgery, Cardiovascular Institute and Fu Wai Hospital, Chinese Academy of Medical Sciences, Beijing 100037, People’s Republic of China.
© 1997 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
Fig 1. (Patient 1.) Echocardiogram of the dissecting aneurysm of the interventricular septum (arrow).
10 mm in diameter communicated with the right ventricle. The left coronary sinus of Valsalva was dilated severely. The operation was performed under hypothermia and cardiopulmonary bypass with general anesthesia on May 7, 1992. The heart was markedly enlarged and the tissue was edematous. The aortic valve was tricuspid and the right coronary cusp was undeveloped, shortened, and deformed. An unruptured aneurysm, approximately 3 3 5 3 3 cm in size, originated from the abnormal enlarged left coronary sinus of Valsalva and protruded into the aneurysm of the interventricular septum (Fig 2). Severe regurgitation of the aortic valve led to a markedly enlarged left ventricle. The wall of the huge interventricular septal dissecting aneurysm, 5 3 8 3 6 cm in size, was about 1 mm in thickness. The dissecting aneurysm involved the upper half part of the interventricular septum and extended to both ventricles, resulting in obstruction of both ventricular outflow tracts. A perforation about 1 cm in diameter communicated with the right ventricle. The other defect of the dissecting aneurysm, about 4 3 2 cm in size, communicated with the aorta in the left ventricular outlet tract below the left and right coronary sinuses of Valsalva. The lower part of the dissecting aneurysmal wall was intact, and the aneurysm could be partially seen in the right ventricular surface. After cross-clamping of the ascending aorta, transverse aortotomy and right ventriculotomy provided satisfactory exposure. Routine methods were used for myocardial protection. Aortic leaflets, the aneurysm of the left coronary sinus of Valsalva, and part of the wall of the dissecting aneurysm of the interventricular septum were resected. A 23 mm St. Jude Medical (St. Paul, MN) prosthetic valve was inserted with interrupted and pledgeted horizontal mattress sutures, which at the aortic annular level were put through from both layers of the wall of the dissecting aneurysm to the aortic wall and the sewing ring of the prosthetic valve. Then the cavity of the aneurysm was obliterated. Simultaneously, the perforation of the dissecting aneurysm on the right ventricular side was repaired. Incisions of the aorta and right ventricle were sutured continuously. 0003-4975/97/$17.00 PII S0003-4975(96)01247-7
546
CASE REPORT WU SURGICAL TREATMENT OF DISSECTING ANEURYSM
Ann Thorac Surg 1997;63:545–7
chest trauma and sudden onset of palpitation. Electrocardiography showed a grade 3 atrioventricular block and left ventricular hypertrophy. Chest radiography revealed a cardiac/thoracic ratio of 0.62. Echocardiography showed that a cyst formed in the upper part of the interventricular septum communicated with the right coronary sinus of Valsalva. Magnetic resonance imaging angiography revealed aortic insufficiency, the dissecting aneurysm of the interventricular septum, and decreased left ventricular function (Fig 3). The patient underwent operation on May 12, 1993, with cardiopulmonary bypass and hypothermia. A temporary pulse generator was implanted intravenously 1 day before operation. The left ventricle was markedly enlarged. The aortic valve had extreme insufficiency with a dilated annulus. The right coronary cusp was small and shortened. Beneath that, the interventricular septum was split and formed an aneurysm sac, 5 3 4 3 6 cm in size, with a fibrotic lining and thrombi located in the subaortic region of the interventricular septum. The left and noncoronary cusps were thickened. A transverse aortomy and right ventriculotomy provided satisfactory exposure. After resection of the aortic leaflets, five interrupted and pledgeted mattress stitches were applied to close the dissecting aneurysmal cavity through the aortic side to sew the interventricular septum to the right ventricular side. A 25-mm Sorin (Irvine, CA) aortic prosthesis then was placed with interrupted and pledgeted mattress sutures. The overlapping tissue of the aneursym in the subaortic region and the aortic wall were sutured to the prosthetic valvular sewing ring. A permanent pacemaker was placed on June 16, and he was discharged on July 2. Two months after the operation, the symptoms of congestive heart failure disappeared. Roentgenography and echocardiography revealed an intact interventricular septum and a prosthetic aortic valve with normal function. He is doing well now. Fig 2. (Patient 1.) Operative photograph (A) and diagram (B) showing the wall of the aneurysm of the interventricular septum (a) and the pulmonary valve (b).
Comment Dissecting aneurysms of the interventricular septum are very rare [1, 2]. An unruptured aneurysm of the left
The patient recovered smoothly. Two weeks after being discharged, he was admitted again because of arrhythmia. Chest roentgenography and echography showed aortic insufficiency and communication between both ventricles. On July 10, 1992, reoperation was performed with the same approach. Two locations of perivalvular leakage, approximately 1 3 0.8 in size, were found. The dissecting aneurysmal wall was disrupted from the artificial valvular ring to form a defect with a size of 2 3 1.5 cm between the left and right ventricles. After the dissecting aneurysmal wall was resected, a large Dacron patch with a size of 4.5 3 7 cm was used to repair the defect. The other perivalvular leakage was closed inside the aorta. Incisions of the aorta and right ventricle were closed. The patient recovered and was discharged uneventfully. The chest x-ray plain film and echocardiography proved a satisfactory result. He had been doing well on follow-up.
Patient 2 A 50-year-old man presented to our hospital on January 8, 1993, with a 2-month history of dyspnea and exercise intolerance culminating in heart failure. He had a history of
Fig 3. (Patient 2.) Magnetic resonance image of the dissecting aneurysm of the interventricular septum (arrow).
Ann Thorac Surg 1997;63:547– 8
coronary sinus of Valsalva led to a dissecting aneurysm in patient 1, and probably traumatic dissecting aneurysm of the interventricular septum occurred in patient 2. The etiology of the disease remains obscure [3–5]. Clinical manifestations of the disease include arrhythmias, obstruction of one or both ventricular outflow tracts, and congestive heart failure. The diagnosis of the disease can be confirmed by means of echocardiography, magnetic resonance imaging, and left ventricular angiography. The main purpose of the operation was to restore the integrity of the interventricular septum and competency of the aortic value. In patient 1, the aneurysmal wall should be resected completely. The ventricular septum defect was repaired using a patch with a suitable size. In patient 2, the aneurysmal tissue was strong enough for repairing, so the integrity of the interventricular septum could be kept. Dissecting aneurysms of the interventricular septum have a progressive course and poor prognosis. Early diagnosis and surgical intervention are mandatory.
References 1. Engel PJ, Held JS, van der Bel-Kahn J, Spitz H. Echocardiographic diagnosis of congenital sinus of Valsalva aneurysm with dissection of the interventricular septum. Circulation 1981;63:705–11. 2. Raffa H, Mosieri J, Sorefan AA, Kayali MT. Sinus of Valsalva aneurysm eroding into the interventricular septum. Ann Thorac Surg 1991;51:996– 8. 3. Callet B, Combe E, Saudemont JP, et al. Aneursym of the left aortic sinus causing coronary compression and unstable angina. Successful repair by isolated closure of the aneurysm. Am Heart J 1988;115:1308–10. 4. Sawyer AJ, Mauss IH, Rosenblaff P. Congenital diverticulosis of left ventricle. Am J Dis Child 1950;79:117–9. 5. Fasoli G, Della Valentina P, Scognamiglio R. Echocardiographic findings in left ventricular septal aneurysm. Int J Cardiol 1988;18:441–3.
CASE REPORT IMAMAKI ET AL SEPARATE-HYPOTHERMIA RCP
547
R
etrograde cerebral perfusion (RCP) is a useful method of protecting the brain during operations involving the aortic arch [1], but it seems to be effective for a limited time in comparison with selective cerebral perfusion. Prolonged RCP may induce neurologic complications. If the blood temperature in RCP is kept at a deep hypothermic level, the brain may be protected more adequately without neurologic complications. However, systemic deep hypothermia and prolonged cardiopulmonary bypass may induce coagulation disorder, respiratory failure, or infection. Thus, we developed an RCP method we refer to as separate-hypothermia RCP (SHRCP). The cardiopulmonary bypass circuit used in this method is shown in Figure 1. The usual cardiopulmonary bypass circuit is modified for the SHRCP circuit. The RCP circuit is derived from the arterial reservoir, and a roller pump and heat exchanger exclusive to this circuit are incorporated into it. Extracorporeal circulation is begun with femoral arterial perfusion and bicaval drainage, and SHRCP is started after the core temperature has cooled down to 25°C. The RCP is regulated with blood temperature at about 10°C and an internal jugular vein pressure of 25 cm H2O. An occlusion balloon catheter is inserted into the descending aorta. Simultaneously, femoral arterial perfusion is continued while the rectal temperature is maintained at moderate hypothermia with a low flow rate, and inferior vena caval drainage is performed. The head is not packed in ice. After distal anastomosis and reconstruction of the arch vessels, RCP is terminated and the proximal anastomosis is made during the rewarming with perfusion in the usual manner.
Case Reports Patient 1
Separate-Hypothermia Retrograde Cerebral Perfusion
The patient was a 68-year-old man who had undergone graft replacement of the descending thoracic aorta for a dissecting aneurysm (Stanford type B) 4 years previously.
Mizuho Imamaki, MD, Touitsu Hirayama, MD, and Masamichi Nakajima, MD Department of Cardiovascular Surgery, Saiseikai Kumamoto Hospital, Kumamoto, Japan
We have developed a technique of cerebral protection in which the blood for the retrograde cerebral perfusion from the superior vena cava cannula is cooled down to 10°C, while the core temperature is maintained at moderate hypothermia. We performed graft replacement of the ascending and aortic arch in 2 patients with dissecting aneurysm using this method. This technique may provide excellent cerebral protection without coagulation disorder. (Ann Thorac Surg 1997;63:547– 8) © 1997 by The Society of Thoracic Surgeons Accepted for publication Aug 28, 1996. Address reprint requests to Dr Imamaki, Division of Cardiovascular Surgery, Kimitsu Chuo Hospital, 1010, Sakurai, Kisarazu-city, Chiba Prefecture, 292 Japan.
© 1997 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
Fig 1. Schema of the circuit of separate-hypothermia retrograde cerebral perfusion (SHRCP). The circuit is interrupted by clamp B during conventional heart-lung bypass. On initiation of SHRCP, the clamp on A is applied and the clamp on B is released. (IVC 5 inferior vena cava; SVC 5 superior vena cava.) 0003-4975/97/$17.00 PII S0003-4975(96)00933-2