Operative technique
The standard surgical strategy used at our institution has been described previously and included techniques of cerebral and visceral protection [8,9]. Briefly, cardiopulmonary bypass (CPB) was established via the axillary artery in most cases (n = 247, 79%), with femoral cannulation being performed in the vast majority of remaining patients. The level of hypothermia was defined by the extent of distal aortic repair, patient’s status, and surgeon’s preferences. In general, moderate hypothermia (24 – 28° C) was employed for uncomplicated aortic pathologies, while deep hypothermia (20° C) was reserved for those cases where total arch replacement was required. For blood drainage, a 2-stage venous cannula was introduced into the right atrium directly or in wire-guided fashion via the femoral vein. Cardioplegia was established using antegrade (n = 241), retrograde (n = 40) or combined (n = 33) techniques. Cerebral protection was performed in the earlier years of the study by means of retrograde perfusion, which was replaced over time by antegrade cerebral perfusion. In cases of isolated ascending aortic repair with open distal anastomosis or hemiarch procedure, unilateral cerebral perfusion was frequently used. For a larger extent of repair, bilateral antegrade perfusion with or without perfusion of the left subclavian artery was performed.
Mechanical composite conduits were used in 142 patients, and biological Bentall procedures using either a biological valve implanted into an aortic graft (homemade or prefabricated, n = 102) or xeno-/ homograft root conduits (n = 70) were performed in the remaining patients. Mechanical root replacement was usually performed in the younger group of patients without contraindication to anticoagulation. Patients older than 65 years or those with contraindications for anticoagulation (including women wishing to become pregnant) were recommended to consider implantation of a biological valve. The conduit was placed by means of pledget-supported mattress sutures, reimplantation of coronary arteries was performed using the button technique in the vast majority of patients.