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J Thorac Cardiovasc Surg 2007;133:1393
© 2007 The American Association for Thoracic Surgery

Letter to the Editor

Limitations with transapical aortic cannulation in type A aortic dissection: What about aortic regurgitation and cardiopulmonary bypass time?

Department of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, Pa

To the Editor:

I read with great interest the recent article by Dr Wada and colleagues¹ detailing their experience with transapical cannulation in type A dissection (n = 138; 22.5% with significant aortic regurgitation). In their Methods section, they list the following contraindications to this technique: severe aortic stenosis, prior aortic valve replacement, and certain reoperation cases, presumably with dense adhesions.

What about the impact of significant aortic regurgitation that occurred commonly in this study?^2,3 Baseline significant aortic regurgitation in the setting of transapical cannulation would be expected to cause significant retrograde flow into the left ventricle. The consequences could be inadequate forward flow with vital organ ischemia, left ventricular distention with inadequate myocardial protection, and/or excessive left ventricular vent return.

The authors conducted this cannulation technique with echocardiographic guidance. Clearly, the degree of aortic regurgitation and ventricular distention could be precisely monitored with transesophageal echocardiography. Careful review of their article does not reveal their management strategy for these important considerations.

Last, a possible disadvantage of this technique is the inability to clamp the ascending aorta during cooling, which represents lost operative time and, as a consequence, extended cardiopulmonary bypass time with added risk for morbidity. The authors do not present their cardiopulmonary bypass times in their article.

I would greatly appreciate feedback from the authors about these intraoperative considerations.

References

1. Wada S, Yamomoto S, Honda J, Hiramoto A, Wada H, Hosoda Y. Transapical aortic cannulation for cardiopulmonary bypass in type A aortic dissection operations. J Thorac Cardiovasc Surg 2006;132:369-372.[Abstract/Free Full Text]
   
2. Fukuda I, Aikawa S, Imazuru T, Osaka M. Transapical aortic cannulation for acute aortic dissection with diffuse atherosclerosis. J Thorac Cardiovasc Surg 2002;123:369-370.[Free Full Text]
   
3. Fusco DS, Shaw RK, Tranquilli M, Kopf GS, Elefteriades JA. Femoral cannulation is safe for type A dissection repair. Ann Thorac Surg 2004;78:1285-1289.[Abstract/Free Full Text]
   

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted 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): John G.T. Augoustides Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Augoustides, J. G.T. Search for Related Content PubMed PubMed Citation Articles by Augoustides, J. G.T. Related Collections Extracorporeal circulation Myocardial protection Related Article