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The Journal of Thoracic and Cardiovascular Surgery, Vol 103, 453-462, Copyright © 1992 by The American Association for Thoracic Surgery and The Western Thoracic Surgical Association
TH Wareing, VG Davila-Roman, B Barzilai, SF Murphy and NT Kouchoukos
Embolization of atheroma from the ascending aorta is a principal cause of
stroke after cardiac operations. We have previously shown that
intraoperative ultrasonographic scanning of the aorta rapidly, safely, and
accurately identifies atheromatous disease in the ascending aorta.
Intraoperative ultrasonography of the ascending aorta was performed in 500
of a consecutive series of 540 patients 50 years of age or older (mean 68
years) who underwent a variety of cardiac operations. Eighty- nine percent
required bypass grafting. Sixty-eight patients (13.6% of the total) with a
mean age of 72 years (range 55 to 85 years) had significant atheromatous
disease in the ascending aorta and were considered to be at increased risk
for embolization. Palpation identified the atheromatous disease in only 26
(38%) of these patients and underestimated its severity. A total of 168
modifications in the standard techniques for cannulation and clamping of
the aorta were implemented in the 68 patients (mean 2.5 per patient) and
included alterations in the sites of aortic cannulation (50 patients),
aortic clamping (54 patients), attachment of the vein grafts (35 patients),
and cannulation for infusion of cardioplegic solution (29 patients). Ten
patients with severe diffuse atheromatous disease underwent graft
replacement of the ascending aorta with hypothermic circulatory arrest
without aortic clamping. Fourteen patients with symptoms or with high-
grade carotid artery occlusive disease were treated by concomitant carotid
endarterectomy. Thirty-day mortality for the entire group was 3.4% (17
patients). Permanent neurologic deficits occurred in five (1.0%) of the
patients in the entire group but in none of the 68 patients with
significant atheromatous disease in whom modifications in technique were
used. One patient in the latter group had a reversible ischemic neurologic
deficit. Modification of standard cannulation and clamping techniques based
on ultrasonography may reduce the frequency of stroke related to
atheromatous embolization.
ARTICLES
Management of the severely atherosclerotic ascending aorta during cardiac operations. A strategy for detection and treatment
Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Mo.
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