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.