The human body can tolerate 30 minutes of total circulatory arrest (No blood flowing in the body) at a core temperature of 18 degrees Celsius without tissue damage.
Case Details:
A 45-yrs-old-gentleman from Nagpur who complained of atypical chest pain and breathlessness was referred to Dr. Sameet Pathak (Cardio-Thoracic and Vascular Surgeon) at Wockhardt hospital by a local physician. The patient was investigated thoroughly and diagnosed to have a large pseudoaneurysm (abnormal swelling) arising from ascending aorta (Large blood vessel). This pseudoaneurysm was of size7cm x 7cm x 5 cms in dimension and was eroding the sternum (breast bone) from below. It was partially filled with an organized blood clot and its wall was also calcified at places. Pulsations from the aorta could be felt over the breast bone.
This problem requires urgent surgical intervention as sudden rupture of this aneurysm is always fatal. Hence, the patient and relatives were counseled regarding the need for surgery and its possible complications.
Surgical Procedure Details:
Opening the breast bone is usually the first step in cardiac surgical procedures. But in this patient, it was not at all possible because the pseudoaneurysm was touching the breast bone from below and could have ruptured instantly. Hence, this surgery was done by a very special technique called the Deep Hypothermic Circulatory Arrest. In this technique, both femoral artery and vein (groin blood vessels) were cannulated and the patient was put on the cardiopulmonary bypass machine. Cooling of core temperature was initiated gradually
from 36 degrees to 18 degrees Celsius. At this temperature, the heart stops beating. Once an 18-degree core temperature was achieved, the circulation was completely stopped and whole blood from the patient’s body was drained in the venous reservoir of the heart-lung machine. So practically no blood was flowing in the patient’s body. But the vital organs are not damaged because the oxygen requirement of the body is extremely low due to
the lowering of its core temperature. But this Golden Period of total circulatory arrest is approximately 30 mins. Keeping that in mind, as soon as the circulation was stopped the breast bone was split open and all the organized blood clot was removed, the neck of the pseudoaneurysm was identified. Immediate repair of the ascending aorta was done using the Dacron patch and Prolene suture. Just before the last stitch was tightened the circulation was restarted from the femoral artery and the whole aorta was de-aired to avoid air embolism. Re-warming of the patient was started and the slowly optimal core temperature was achieved and the heart started beating happily again. The total circulatory arrest time was 44 mins.
Post-Surgery:
Hemodynamically he made an uneventful recovery with no bleeding issues. He developed transient neurological injury which gradually improved. It’s been a year now and he still comes for regular follow-up and is doing well.
Dr. Pathak said, this procedure is very rarely performed and very few cases like this have been reported to date in the literature. The usual causes of such swelling of the blood vessel are atherosclerosis, hypertension, connective tissue disorders, and trauma. The deep hypothermic circulatory arrest is the only technique by which this high risk
Surgery can be successfully managed.
Dr.Sameet Pathak
MBBS, MS (General Surgery), M.Ch (CVTS)Consultant – Cardio Thoracic & Vascular Surgery
