Doctor Piter: Half an hour on the verge of death: to repair an aneurysm, the human body is cooled to 24 degrees

More often than not, doctors have only a few tens of minutes to remove an overly dilated or dissected section of the aorta and restart circulation and blood flow. Each year, the Clinic of High Medical Technologies performs about 20 surgeries to repair an aortic aneurysm. The team of specialists includes up to ten people. Aortic surgery is among the most difficult areas of cardiac surgery as is heart transplantation. The clinics and surgeons who can use these techniques are of the highest-calibre.

Up to 65 years old and over

Do aortic aneurysms often occur?

Every year, according to the statistics, aneurysms occur in 5 to 20 people per 100,000, but they occur in 5% in people over 65 years old, that is in one in 20 people.

What are the causes of an aortic aneurysm?

It is primarily connective tissue dysplasia, Marfan syndrome, or Ehlers-Danlos syndrome. In other words, it can be a sporadic case (single, occasional) and occur arbitrarily, or it can fit into syndromic types (associated with an existing syndrome), when people have some genetic abnormalities or an ability to transmit pathological changes by inheritance or family forms.

There are atherosclerotic lesions, but more often they are associated with people over 65. There are a whole range of aggravating factors that trigger the formation of an aortic aneurysm:

• uncontrolled arterial hypertension (high blood pressure)
• sedentary lifestyle
• obesity
• smoking
• injury

Aneurysms can also occur due to infectious myocarditis, syphilis.

Are there any specific symptoms that indicate that this is an aortic aneurysm?

Centre for Cardiac Surgery and Interventional Cardiology at the Pirogov Clinic of High Medical Technologies at St Petersburg University

There are two large groups of aneurysms: an abdominal aortic aneurysm and a thoracic aortic aneurysm. If the aneurysm is found in the thoracic region, it is mostly associated with a pain syndrome, a feeling of heaviness behind the sternum, a pulsation of the brachiocephalic vessels (arteries responsible for the blood supply to the brain, tissues of the head and shoulder girdle). If the aneurysm presses on the bronchi and spine, it is mostly associated with numbness in the shoulder girdle and in the hands. If the aneurysm touches the abdominal aorta, it compresses the internal organs and tissues of the abdominal cavity and retroperitoneal space. Their functioning is disturbed. Most often it affects the kidneys, liver, or intestines. Yet there are no special prognostic signs that indicate that this is an aneurysm.

So, judging only by symptoms, doctors cannot tell that this is an aneurysm, and it can result in wrong diagnosis or misdiagnosis?

There is a differential diagnosis. It is the process of differentiating between probability of one disease versus that of other diseases with similar symptoms that could possibly account for illness in a patient. A patient has an examination, echocardiography, if it is necessary and there is a visible expansion of the thoracic region, CT angiography of the aorta, transesophageal echocardiography. Only after, we will be 100% sure whether we have an aortic aneurysm.

Can aneurysms be found during routine medical tests?

Sometimes people have ordinary lives and are not even aware of an aneurysm. That is why routine medical examination is so important. A person may not have any symptoms or discomforts, yet it is already possible to find some kind of deviation and take it under control.

An aneurysm does not always require surgery

Does an aneurysm always require surgery?

An aneurysm does not always require surgery. If expansion of the aorta is detected, it is taken under control. About once every six months or a year, a CT scan of the aorta with contrast is performed and the expansion is assessed in dynamics. If the aneurysm grows constantly or rapidly, then it requires surgery.

What might happen if we do not perform a surgery?

The most severe complication is aortic dissection that leads to rupture. When an aneurysm does a rupture, the likelihood of death is increasing. If this is a rupture of the abdominal aorta, it leaks blood into the abdominal cavity. If this is a rupture of the thoracic aorta, it leaks blood into the chest. Our task is to prevent this. If there is any suspicion of dissection, an aneurysm requires emergency surgery. The risk of death is increasing by 1% every hour.

In 48 hours it will be 48%, that is one in two will die. Further, this ratio of time and mortality decreases, yet 75% of people die if there is a one-week delay.

Is it always emergency surgery to repair an aneurysm?

There are two types of surgery: planned surgery, when specialists are monitoring the changes and an increase in the dynamics of the aorta is visible, and then surgery is recommended; and emergency surgery, when there is an aortic dissection. Emergency surgery is performed in clinics that receive patients for emergency care. If it is a planned surgery, it can be performed in cardio centres, including our centre. Almost 100% of surgeries are performed within the high-tech medical care (HMP) quotas. It is free for all Russian citizens. The exception is foreigners; they have to pay for surgery.

Is it always open repair surgery for aortic aneurysm?

Not always, yet in most cases. There is also endovascular surgery, when a delivery system is inserted through the peripheral vessels, and a stentgraph, a special intravascular prosthesis of the aorta, is expanded in the right place. It repairs an aneurysm and lessen the risk of dissection. We prevent a tear to avoid a catastrophe.

The stopped heart

Could you tell us more about a surgery that requires to stop the heart and to cool the body?

It is about the aortic arch, where brachiocephalic vessels depart. Through these vessels blood enters the brain. If an aneurysm or dissection has occurred in this area, it is necessary to temporarily provide artificial blood circulation (perfusion) into the brain and during this time to reconstruct the altered aortic area.

If the blood does not flow to these vessels, the brain will die within a maximum of five minutes. The heart can be "started", but the person will be like a "plant".

Once the perfusion of the brain through one brachiocephalic vessel is ensured, we cool a patient to 24-26 degrees and, by lowering the temperature, we protect the internal organs. Blood does not circulate anywhere except in the brain. After that, we have 20-30 minutes to repair this most critical area. We remove the damaged tissues and sew in the prosthesis, start the blood flow in the whole body except for the heart and start warming the patient, and then calmly perform the correction of other structures, for example, the aortic valve, and gradually complete the surgery.

In other words, a patient’s heart does not work for 20-30 minutes?

The heart is usually stopped in cardiac surgery; it is used in 90-95% of all cardiac surgeries. We protect the heart with a special cardioplegic solution, which preserves the heart for some time and protects it throughout the main stage. The surgeon has about two hours to perform a surgery.

In the case of an aortic aneurysm, surgery is more about the speed because we cannot protect the kidneys, liver, or pancreas. All tissues and organs will suffer, there will be multiple organ failure, the heart will work, but the rest will ’break’, and it will lead to death.

How can you do so much in half an hour?

The biggest problem with aortic surgery is a high risk of bleeding. The wall of the aorta in the case of an aneurysm is very weak, you start stitching it, it bleeds or spreads apart. We therefore have to stitch several times and glue with a special bio-adhesive to ensure tightness of the aorta.

What prostheses are implanted if the aortic valve is damaged?

There are mechanical and biological prostheses. Biological prostheses are mostly from the pericardium of bulls or pigs, when animal proteins are removed and fixed on the frame. Yet human proteins, from a donor, are also used. For an adult, it does not matter whether the valve is of animal or human origin. Yet there is a difference for children. In this case, the human valve works longer.

When it comes to reliability, it is mostly about mechanics. If the surgery is successful, the patient takes all the recommended drugs and anticoagulants that thin blood. Blood is prone to thrombosis, and it is natural that implantation of a foreign body will trigger thrombus formation. In this case, the valve will work smoothly for 30-40 years or even more. Yet there are disadvantages, too. Any bleeding, for example, when a tooth is removed, will be difficult to stop. As a result, many people, especially over 60 years old, tend to choose biological prosthetics. The service life of a biological prosthesis is 10-12 years. After this time, a second surgery will be required due to the degradation of the biological tissues from which the prosthesis is made.

Open surgery or minimally invasive surgery

Is there any age limit when it comes to surgery?

There is no age limit. The exception is the cases where there are absolute contraindications to surgery for health reasons: oncology with severe concomitant diseases, cirrhosis of the liver, kidney failure, or infections. There is the question whether a patient is fit for surgery. It is not about aortic aneurysms, but any cardiac surgery, when it comes to open surgery.

Previously, when we had patients with oncology, unfortunately, we had to refuse. Now there is a solution to the problem, i.e. X-ray endovascular surgery for aortic valve replacement and aortic replacement. The narrowed prosthesis is inserted and opened at the site of the aneurysm or dissection. There are few surgeries, as it is costly.

Open aortic valve replacement under the quota costs 480,000 roubles for the country. When it comes to prosthetics using the X-ray surgical method, this is already 2 million roubles.

As few as 1,000 such surgeries are performed annually across our country. Mostly in Moscow, St Petersburg, Novosibirsk, Krasnodar, Penza, Perm — large federal centres. X-ray surgery has one significant advantage: the next day after the intervention, the patient is transferred to a hospital room, and on the 3rd or 4th day they are discharged for rehabilitation.

How often do you perform surgery with stopped heart and body cooling?

Every year, we perform 800 open cardiac surgeries, with 20 of them on the thoracic aorta. For seven years, we have performed more than 100 surgeries on the thoracic aorta with zero mortality. Achieving such results is ensured that you can use all surgical methods. It is necessary to have a team, and these are not only surgeons, but also assistants, anaesthesiologists, and high-calibre resuscitators.

We need a perfusionist, i.e. a doctor who works with a heart-lung machine to ensure artificial blood circulation. Super-resuscitation is needed, which takes care of severe patients after a surgery, and a full range of laboratory and instrumental diagnostics. About 10 people are present in the operating room: nurses, assistants, and doctors. This is only intraoperatively, while there are several divisions involved. The whole system must work on the top five to ensure a good result.

Do patients want to know how the surgery goes?

Most often I talk with patients and their relatives. This is not an ordinary surgery. It is very difficult for everyone: for doctors, for the patient, and for relatives. According to the degree of complexity, it can end in different ways. Negative results are also possible. We describe everything in detail to prepare everyone for any outcome. We warn about the risks of bleeding, kidney problems, stroke, heart attack. No one can give you a 100% guarantee. Yet we do everything to save lives, prevent complications, and death.

Are they still for surgery after having known all the details?

With an aortic aneurysm, there have been no such cases. If we talk about all types of cardiac surgery, it may happen. If there is a severe lesion of the coronary arteries, multi-vessel, with the involvement of the valves, a person can die at any moment. The patient has a quota, they have already been examined, the surgery is scheduled for tomorrow, and they suddenly refuse, and says I will live what I shall live. When they are at home and if there is a sudden deterioration, then they will live only a few minutes, even an ambulance may not have time to drive up in time.

It is always better to be proactive and this is the main task of doctors. In emergency surgery, the results are always worse. In planned surgery, there is time to play it safe, to develop an operation plan, plan B, plan C, we have all necessary equipment and consumables. In the event of an emergency, you just save a life and the risks are much higher.

If there is no doctor nearby

How long is the rehabilitation period?

It depends on what state the patient is for surgery. It depends on how surgery went, whether it was planned or there were some difficulties, how the early postoperative period went. In general, we evaluate the results of the surgery not earlier than in a year. You discharged the patient and much depends on whether they follow drug therapy, actively rehabilitate, take care of themselves. It is not uncommon that some patients begin to lift weights, do not come to the examinations of surgeons and do not treat wounds.

The more you live after the surgery, the less the risks are. According to the hospital period, according to our statistics, a person stays in the hospital for 10 to 12 days. Then rehabilitation is better in a cardiological health resort, where there are cardiologists who advise the relevant daily routine and drug therapy.

Do they have to visit you for follow-up care?

Patients should visit hospitals at their place of residence. However, we recommend that they visit us for a scheduled postoperative examination so that we can assess the clinical condition and further prognosis.

This is medicine: you did a surgery, you can perform it brilliantly, but a patient may die within a year, because there is simply no cardiologist in the clinic nearby.

There is simply no one to turn to in some villages in the Vologda Region or the Pskov Region.

We therefore strongly recommend that they visit us on the 3rd, 6th, 9th, 12th month for an examination by a cardiologist, to do an ultrasound of the heart. The surgery is a very important part, but not the last part of their treatment. If during this year we avoided complications, the prognosis is favourable and life expectancy is good.

What will be after the surgery? Will their life change dramatically?

Life with an operated heart and aorta is different. You should bear in mind that this is no longer a healthy heart. If a person was engaged in intellectual work, they will be able to return to their work. If it was heavy physical work, they will not be able to return. They will not be able to actively engage in sports; the sport of high achievements ends. Yet not fitness.