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J Thorac Cardiovasc Surg 2002;123:586-587
© 2002 The American Association for Thoracic Surgery
Letters to the Editor |
Atatürk University
Medical Faculty
Department of Cardiovascular Surgery
Erzurum, Turkey
To the Editor:
We read with a great interest the article by Hirotani and colleagues.
1 We congratulate them for their good results. In their "Comment," they stated: "Because both skillful management and techniques will be needed to replace the transverse aorta, in less-experienced centers the more limited standard repair (ie, a solely ascending repair) remains the most appropriate approach." We think this is an important point. Working in a limited-experience clinic, we prefer to perform ascending aortic replacement in ascending aortic dissection if there is no intimal tear in the arcus aorta.
We wonder about the authors' initial experience from 1992 to 1995, during which they stated that their number of patients was very small.
Retrograde cerebral perfusion has been used in totally hypothermic circulatory arrest during surgery for aortic dissection in general. 2,3 The authors mention no use of retrograde cerebral perfusion. Although their results were good, we question their opinion about this technique, especially in periods of totally hypothermic circulatory arrest of up to 80 minutes. They state that femoral and right axillary arteries were cannulated for arterial reperfusion, and the ascending aorta was crossclamped just proximal to the origin of the innominate artery. However, they did not explain how flow rate was managed. Was there any difference in flow rate between the axillary and femoral arteries?
David and colleagues 4 explained that avoidance of aortic crossclamping, resection of the primary tear in the ascending aorta or transverse arch, and anterior perfusion after completion of the distal anastomosis improve the early and late outcomes of surgery for acute type A dissection. Postoperatively, a patent false lumen was found in 91% of group I (aorta clamped and retrograde femoral perfusion used) and in 59% of group II (no clamp used under circulatory arrest, the primary tear resected, and antegrade cardiopulmonary bypass started after completion of the distal anastomosis) (P = .01). We routinely perform this second technique in proximal aortic dissection. What is the authors' opinion about this technique and their false lumen patency rate?
Our last question concerns gelatin-resorcin-formol (GRF) glue. We use GRF glue most often for hemostasis and to obliterate any false channel, but there are questions about GRF glue. Bingley and colleagues 5 have discontinued using it because of unsatisfactory long-term complications. Do the authors have any experience in this matter?
Our last comment concerns aortic root replacement. For root replacement, we are using a composite valved conduit with a skirted technique. As Yakut 6 reported, the valve is sutured 5 to 7 mm above the end of the graft. With this technique, good hemostasis and physiologic effect can be achieved.
12/8/121675doi:10.1067/mtc.2002.121675
References
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