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J Thorac Cardiovasc Surg 2003;126:1192-1194
© 2003 The American Association for Thoracic Surgery

Brief communication

Combination of the HEARTSTRING proximal seal system with a blower mister: a possible source of gas emboli

^a Department of Cardiac Surgery, University of Munich, Munich, Germany

Received for publication March 11, 2003; accepted for publication April 8, 2003.

^* Address for reprints: Dr Georg Nollert, Department of Cardiac Surgery, Klinikum Grosshadern, Marchioninistr 15, 81366, Munich, Germany
gnollert{at}hch.med.uni-muenchen.de

Dr Nollert

Using a side clamp for the performance of proximal anastomoses in coronary artery bypass surgery may injure the ascending aorta and cause intimal tears, with subsequent dissection or debridement of atherosclerotic material and stroke. Several devices were developed to perform proximal bypass anastomoses without the necessity of side clamping, the latest being the HEARTSTRING proximal seal system (Guidant Corp, Santa Clara, Calif). The system comprises the proximal seal, a delivery device, and an aortic punch. The proximal seal is delivered into the aorta via a punch hole site and provides a sealed region to facilitate the proximal anastomosis.¹ The proximal seal covers the punch hole from inside the aorta, because the blood pressure pushes and a tension spring mechanism pulls the seal against the aortic wall.

Patient

The first use of the HEARTSTRING device in our clinic was scheduled in an 83-year-old woman who presented with unstable angina. Three bypasses were implanted including the left internal thoracic artery connected to the left anterior descending and 2 saphenous vein grafts for the first diagonal branch and the distal right coronary artery. The proximal anastomoses were performed with the aid of the HEARTSTRING device after removal of the crossclamp without using a side clamp. Because of bleeding during the performance of the proximal anastomoses, the operative field was cleared with a blower mister (Medtronic Inc, Minneapolis, Minn) as recommended by the manufacturer.¹ Mean arterial pressure was above 70 mm Hg. Postoperatively the patient was hemodynamically stable without inotropic support. As the patient did not wake up a cerebral computed tomography (CT) scan was performed immediately followed by a second CT of the brain, thorax, and abdomen 11 hours later. It revealed a new hypodense right frontal area (2 x 2 cm large) in the region of the anterior cerebral artery (see Figure 1) and multiple spleen infarctions.

View larger version (63K): [in this window] [in a new window]   Figure 1. CT scans 11 hours postoperatively demonstrating a large frontal ischemic stroke and multiple spleen infarcts. An 83-year-old woman did not wake up after bypass surgery using the HEARTSTRING device and a blower mister for facilitating the proximal anastomoses. Air emboli caused by the devices were suspected.

A German land race pig (35 kg) was anesthetized, intubated, and ventilated. For arterial blood pressure monitoring as well as blood gas sampling, the right carotid artery was cannulated. The chest was opened by median sternotomy. Air emboli to brain were monitored using a 7.5-MHz continuous wave Doppler ultrasound probe (Sonos5500, HP Inc, Andover, Mass) on the left carotid artery.² Performance of proximal anastomoses was simulated using the HEARTSTRING device and a blower mister as described by the company.¹ During this maneuver we recorded several high-intensity signals in the carotid artery fulfilling the criteria for air emboli.² Figure 2 demonstrates 4 emboli within 30 seconds at a mean arterial pressure of 75 mm Hg.

View larger version (110K): [in this window] [in a new window]   Figure 2. Detection of air emboli in the left carotid artery during an animal experiment. Several high-intensity signals were recorded with a continuous wave 7.5-MHz probe during simulation of a proximal anastomosis using the HEARTSTRING device and a blower mister. The figure shows 4 subsequent high-intensity signals detected within 30 seconds at a mean arterial pressure of 75 mm Hg.

We do not know whether the embolic complication in our patient is related to the use of the HEARTSTRING device in combination with a blower mister, because other mechanisms like crossclamping or cannulation of the ascending aorta bear a stroke risk of more than 8% in octogenarians³ and may have been the cause for emboli. However, we cannot rule out that air provided by the blower mister device entered the aorta through a leak between the proximal seal and the aortic wall and caused the emboli. The possibility of such a mechanism was proven in an animal experiment. This should be sufficient reason to strongly discourage the simultaneous use of the HEARTSTRING device in combination with a blower mister.

References

1. Guidant Corporation. HEARTSTRING Proximal Seal System. Instructions for use. Santa Clara, Calif. 2002
   
2. Nollert G, Nagashima M, Bucerius J, et al. Oxygenation strategy and neurological damage after deep hypothermic circulatory arrest. Part I. Gaseous emboli. J Thorac Cardiovasc Surg. 1999;117:1166–1171[Abstract/Free Full Text]
   
3. Roach GW, Kanchuger M, Mangano CM, et al. Adverse cerebral outcomes after coronary bypass surgery. N Engl J Med. 1996;335:1857–1863[Abstract/Free Full Text]
   

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This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Georg Nollert Bruno Reichart Calin Vicol Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Nollert, G. Articles by Vicol, C. Search for Related Content PubMed PubMed Citation Articles by Nollert, G. Articles by Vicol, C. Related Collections Minimally invasive surgery