Total Aortic Arch Replacement: Superior Ventriculo-Arterial Coupling with Decellularized Allografts Compared with Conventional Prostheses

Background: To date, no experimental or clinical study provides detailed analysis of vascular impedance changes after total aortic arch replacement. This study investigated ventriculoarterial coupling and vascular impedance after replacement of the aortic arch with conventional prostheses vs. decellularized allografts. Methods: After preparing decellularized aortic arch allografts, their mechanical, histological and biochemical properties were evaluated and compared to native aortic arches and conventional prostheses in vitro. In open-chest dogs, total aortic arch replacement was performed with conventional prostheses and compared to decellularized allografts (n = 5/group). Aortic flow and pressure were recorded continuously, left ventricular pressure-volume relations were measured by using a pressure-conductance catheter. From the hemodynamic variables end-systolic elastance (Ees), arterial elastance (Ea) and ventriculoarterial coupling were calculated. Characteristic impedance (Z) was assessed by Fourier analysis. Results: While Ees did not differ between the groups and over time (4.1 +/- 1.19 vs. 4.58 +/- 1.39 mmHg/mL and 3.21 +/- 0.97 vs. 3.96 +/- 1.16 mmHg/mL), Ea showed a higher increase in the prosthesis group (4.01 +/- 0.67 vs. 6.18 +/- 0.20 mmHg/mL, P<0.05) in comparison to decellularized allografts (5.03 +/- 0.35 vs. 5.99 +/- 1.09 mmHg/mL). This led to impaired ventriculoarterial coupling in the prosthesis group, while it remained unchanged in the allograft group (62.5 +/- 50.9 vs. 3.9 +/- 23.4%). Z showed a strong increasing tendency in the prosthesis group and it was markedly higher after replacement when compared to decellularized allografts (44.6 +/- 8.3dyn.sec.cm(-5) vs. 32.4 +/- 2.0dyn.sec.cm(-5), P<0.05). Conclusions: Total aortic arch replacement leads to contractility-afterload mismatch by means of increased impedance and invert ventriculoarterial coupling ratio after implantation of conventional prostheses. Implantation of decellularized allografts preserves vascular impedance thereby improving ventriculoarterial mechanoenergetics after aortic arch replacement.