It was hard to believe that my husband had such a major surgery. Of course that wound down his chest, along the same scar line as his first surgery, proved that his chest indeed had been opened again.
The procedure was Wednesday morning, by Friday he was asking to go home, and Saturday morning he was discharged! Amazing - the third morning post op! He healed and recovered well.
But what had actually been done inside his chest? Would it stand the test of time? Later I would learn that there are things about aortic surgery that are debated too. I mentioned previously that there are two controversies that my husband escaped. One was the size of the aneurysm when surgery should be done. Here I write about the second one: whether or not to remove the entire ascending aorta using total circulatory arrest. Today I am so thankful that, in the right hands, my husband's entire ascending aorta was removed!
23 Minutes of Circulatory Arrest
The surgeon spoke to us after my husband's surgery, before I went in to ICU to see him. I wrote down something about 23 minutes, but at the time I did not really understand what it meant.
Later I would learn more about this. I would realize that my beloved's head was packed in ice during this time. Extra protection during a time when his brain waves went to zero! Nothing, no brain activity at all! I would eventually learn something about the history of this. And one day, I would go into surgery and watch it done to someone else's husband.
How Much Aorta Was Left Behind?
Perhaps there are many debates about the exact "how" of aortic surgery. This one is particularly meaningful and important to me.
The largest "bulge" of the aneurysm for those with BAV is usually in the middle of the ascending aorta. Of course, there are exceptions to this, as there are exceptions in all things BAV!
The simplest, easiest surgery is just to cut out that piece of the aorta that is obviously bulging, leaving behind the part of the ascending aorta closest to the arch (the curve of the "candy cane") or so-called top part of the ascending aorta.
Why is this simpler, easier? Because the surgeon simply puts a clamp on the top of the ascending aorta, allowing the heart lung machine to keep circulating blood while cutting away the aortic tissue lower down.
Very Cold, No Blood Flow ( Deep Hypothermic Total Circulatory Arrest)
But what if the surgeon removes all of the ascending aorta, right up to the arch? There is no place to put a clamp. How can this be done, if the aorta is wide open, without blood pouring out of that opening?
Well, the flow of blood has to temporarily be stopped (circulatory arrest). That can be done by stopping the heart lung machine, but how can a patient survive that? Every cell in their body needs proper blood flow.
People can survive temporary blood flow interruption if they are kept very cold. The term used is deep hypothermic total circulatory arrest. As you can imagine, this is not easy to do without injuring the person whose life you are trying to save from the aneurysm.
My husband had this procedure. This was the 23 minutes, when his brain waves went to zero, he was very cold, and no blood circulated in his body. Yes, his head was packed in ice for extra brain protection. Unaware of all this, I sat in the waiting area. I was waiting to hear those wonderful words "the aneurysm is removed." At last, I heard them, some of the most special words ever spoken to me! A tremendous feeling of relief flowed through me at that moment. I remember that feeling, that moment to this day. Those words, that feeling, are tucked away among the special "sounds" in my heart.
When someone was talking to me about this part of surgery, they called this the part of the operation "where they deaded me"! We might think this sounds like death, and it would be at room temperature perhaps. But when very cold, the brain is protected, and comes back beautifully when slowly re-warmed. This is what prevents brain and other organ damage to those who fall through the ice in frigid northern climates. They come out just fine, if they are rescued from the icy waters in a reasonable time.
Every time I think of my husband's aorta, I am very thankful that his entire ascending aorta is all gone! There is actually a "tongue" of Dacron underneath his arch, as his tissue there was not "good". So, it is a very good thing for him that the hands he trusted had the skill to do what was needed and nothing was left behind.
Not All Surgeons Do Circulatory Arrest and Take the Entire Ascending Aorta
There is a man, still young today, who lives in a rural setting. I picture him and his family enjoying those wonderful, wide open spaces. He does not live near any major medical center. As a young husband and father, he had his BAV and ascending aneurysm replaced. He and his wife traveled to a major medical center, far from home, for this surgery.
I well remember asking them how many minutes he had been under circulatory arrest. I wondered how long it had taken. My understanding was that up to 30 minutes was generally safe. Much to my surprise, they were told that it had not been necessary to do it, that the upper part of his ascending aorta was "fine". The years have passed. What about the aorta that was left behind? What does it mean for him? It is something to be watched. I think of him and his family often.
Since then, I have heard of many surgeries where some part of the upper ascending aorta was left behind. In that moment, done by those hands, perhaps it was the safest that could be done. But what about these people in the long term?
Thankfulness but Not Forgetfulness
Today my husband and I are grateful for life-extending surgery. Without it, his own and so many precious lives would end much too soon. But none of us can forget about aortic disease, once it enters our lives. There are things we can understand to help us live more confidently, although we may have aortic disease.
Before Aneurysm Surgery
I was given some good advice about surgery once. I was told never to urge a surgeon to do a specific technique on me, in order to have me as a patient. Surgeons will offer their patients what they do best. Just listen and try to understand. I was told not to push them for something else. If I did, I might be the first patient they try it on! Especially with something as complicated as what is described here, if the surgeon did not offer it to me, I would never ask for it. I would continue my search for help.
If a surgeon did offer it to me, I would ask how many of this exact procedure his hands do on a yearly basis. I would also ask how many complications (bleeding, stroke) there were. I would ask how many deaths. It is important to ask these questions. It is my life, my future at stake.
I would also try to find someone who works at the hospital, who knows this surgeon's work. I am thinking of a woman who did this. She found out that the number of procedures that the surgeon quoted her was not for the heart procedure she needed at all. She had been given confusing, if not outright misleading, information. Being both brave and intelligent, she continued her research and ultimately traveled out of state, where expert hands performed this technique during her surgery.
After Aneurysm Surgery
If I already had my aneurysm removed, I would try to learn how much of the ascending aorta was left behind. One way to do this is to get my surgery report from the hospital medical records, and read it. Usually the surgeon's report describes in detail what was done.
And then, every few years, I would have my aorta scanned. It is better that I leave nothing to chance. It is best to know if my aorta has changed or not, since my surgery and since the last scan I had.
Time Tests the Surgeon's Work
Yes, surgeons may continue to debate the best techniques in aortic surgery for years to come. While they are debating, men, women, even children live with their work inside their chests. Time tests each surgeon's work.
I am very grateful that this is one debate that does not touch us. His entire ascending aorta is all gone. It cannot hurt him now. Something else did hurt him. It hurt him very badly. I will share that next.
May all with aneurysms be kept safe,
both before and after their surgery,
- Arlys Velebir
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