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J Thorac Cardiovasc Surg 2007;134:547-548
© 2007 The American Association for Thoracic Surgery
Letter to the Editor |
Department of Cardiovascular Surgery, Université Claude Bernard, Louis Pradel Hospital, Bron, France
To the Editor:
In the article by Reece and colleagues,1
the authors performed 24 central cannulations in acute aortic dissection repair over a series of 70 patients operated on between 1996 and 2005. The cannulation is performed over a guide wire by a Seldinger technique, after identifying the proper aortic cannulation site by transesophageal echography (TEE) and computed tomographic scan. The cannula is held firmly by hand during cooling because of the low reliability of the dissected aortic wall to hold a purse string. The results of this approach are remarkable inasmuch as none of the patients had a postoperative malperfusion. More important, the authors did not report any aortic rupture because of the direct cannulation. In light of this interesting series, one question has to be raised: why is the evidence not so obvious for everybody?
Lijoi and colleagues2 were the first to report this technique in acute aortic dissection. Yet, they did not report whether they used a purse-string suture to attach the cannula. Furthermore, they did not take any precaution concerning the cannulation of the false lumen since they did not clamp the aorta before reaching deep hypothermia and subsequent circulatory arrest. In 2003, Minatoya and associates,3 from the Hanover group, reported a similar technique, but with moderate hypothermic (28°C) circulatory arrest and antegrade cerebral perfusion during arch replacement. For these authors, cannulation and perfusion of the false lumen was not a serious pitfall. At the 2006 meeting of the European Association for Cardio-thoracic Surgery, Karck and associates,4 from the same group, presented a series of 150 dissections over 5 years. Seventy percent were central cannulations, also without technique-related complications.
In our institution, we5 started routinely performing central cannulations in February 2005 in type A aortic dissection. We systematically exclude patients with a high suspicion of aortic rupture or important aortic wall hematoma. Like our colleagues in Hanover, we usually put one polypropylene 4-0 purse string in the concavity of the aorta, at the junction between the ascending segment and the arch. The perfusion of the correct lumen is assessed by TEE and by a double arterial pressure control (right radial and left femoral). A malperfusion of the true lumen is accompanied by a dramatic drop of the right radial pressure at crossclamping. In this particular case, we perform a surgical fenestration of the intimal wall at the level of the arch, during a brief circulatory arrest and after releasing the aortic clamp. Over a 2-year period, we have operated on 20 type A aortic dissections using central cannulations in 75%. All the treated patients had a reimplantation valve-sparing technique (David) and, in 80% of the cases, an arch replacement under mild (30°C) hypothermia and antegrade cerebral perfusion. None of the patients had aortic rupture during cannulation, despite the purse string attaching the aortic cannula.
In our opinion, central cannulation is safe in acute aortic dissection repair, regardless of the systematic need for an open distal anastomosis, and the race to find the best arterial perfusion site seems useless since the evidence is right before everybody’s eyes.
References
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