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J Thorac Cardiovasc Surg 2008;136:792-793
© 2008 The American Association for Thoracic Surgery
Brief Communication |
a Department of Cardiac Surgery, University Hospital Grosshadern, Ludwig-Maximilians-University, Munich, Germany
b Department of Anaesthesiology, University Hospital Grosshadern, Ludwig-Maximilians-University, Munich, Germany
Received for publication October 27, 2007; accepted for publication January 13, 2008. * Address for reprints: Eckehard Kilian, MD, Department of Cardiac Surgery, University Hospital Grosshadern, Ludwig-Maximilians-University, Marchioninistrasse 15, 81377 München, Germany. (Email: Eckehard.Kilian{at}med.uni-muenchen.de).
Early surgical intervention is vital for the treatment of acute aortic dissection and acute aortic valve endocarditis, because interventional delay is associated with increased mortality. Although heart operations should not be performed without knowledge of the current coronary status, preoperative coronary angiography may delay the procedure and entails additional risks for the patient.1
Furthermore, patients who have aortic valve endocarditis with floating bacterial structures on the valve cusps face an increased risk of coronary ostia embolism during coronary angiography.2 Preoperative catheterization in patients with acute aortic dissection may also affect the false lumen or aggravate the dissection, thus increasing perioperative risk.3
We report here the successful use of intraoperative coronary angiography to detect coronary disease in high-risk patients with acute aortic dissection or acute endocarditis.
Seven patients with acute aortic dissection of Stanford A type (n = 2) or acute aortic valve endocarditis with valvular vegetations (n = 5) were urgently scheduled for surgical intervention. After establishment of cardiopulmonary bypass and aortic crossclamping, the proximal ascending aorta was opened for aortic valve replacement in the patients with endocarditis or to replace the dissected portions of the ascending aorta in the others. Cardioplegic solution was applied under visual control by intubating the coronary ostia separately. After injection of nitroglycerin (0.2 mg) to avoid coronary spasm, the contrast dye (iopromide) was delivered through the cardioplegic solution catheters to the already arrested heart. Coronary angiography with a digital fluoroscopic device (BV Pulsera; Philips Nederland BV Medical Systems, Eindhoven, The Netherlands) was then performed.
The rotating angle of 135° of the C-arm and the ability to counterrotate the operating table allowed us to achieve both left anterior oblique and right anterior oblique depictions of the coronary system under sterile conditions with a reduced time lapse. This approach resulted in changes in the surgical procedure in 2 of our 7 patients. In the first case, we detected coronary artery disease in a 45-year-old patient with aortic valve endocarditis who had not previously undergone angiography because of vegetations next to the coronary ostia. Our intraoperative angiography showed stenoses in both the left anterior descending coronary artery and a diagonal branch (
Figure 1). After rinsing the coronary arteries with saline solution, we anastomosed a venous bypass to the left anterior descending coronary artery and continued uneventfully with the aortic valve replacement.
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The mean operative delay for the 7 patients caused by the angiographic examination was 12 minutes (range 8–17 minutes). The consumption of contrast medium was on average 11 mL (range 8–22 mL), and the radiation dose was 0.0344 Gy (range 0.0087–0.0931 Gy), or 2.40 Gy/cm2 (1.81–9.61 Gy/cm2). In-hospital survival of our patients was 100%.
Early surgical intervention is critical for the treatment of acute aortic dissection and acute aortic valve endocarditis, because the mortality increases from the onset of symptoms.2 Diagnostic imaging, however, including CT, echocardiography, and coronary angiography, along with preparation for operative correction, usually takes longer than 4 hours, increasing the patient's risk.1 Although surgical repair should only be performed after coronary diagnostic imaging to avoid ischemic complications, coronary angiography is often a high-risk procedure for these patients.4
To circumvent this problem, we propose a simplified approach involving intraoperative angiography. This diagnostic tool was initially used to evaluate the grafts after coronary artery bypass grafting.5 This method showed a high accuracy in the identification of coronary lesions without adverse effects on either the cardiac function or histologic appearance of the coronary arteries.3,4 Multislice CT could be an alternative diagnostic tool for the preoperative screening of coronary disease. CT presents some limitations relative to intraoperative angiography, however, such as 2-fold higher radiation doses (approximately 34 mGy versus approximately 80 mGy) and 10-fold higher contrast medium consumption (about 10 mL iopromide vs about 100 mL). This difference may be of relevance, especially for patients with aortic valve endocarditis and impaired renal function.
In our patients, intraoperative angiography allowed us to detect coronary anomalies that could be surgically corrected in 2 of 7 cases. In our opinion, aortic root angiography may reliably demonstrate coronary artery lesions in patients who undergo heart surgery without preoperative catheterization.
References
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  R. S. Bonser, A. M. Ranasinghe, M. Loubani, J. D. Evans, N. M. A. Thalji, J. E. Bachet, T. P. Carrel, M. Czerny, R. Di Bartolomeo, M. Grabenwoger, et al. Evidence, Lack of Evidence, Controversy, and Debate in the Provision and Performance of the Surgery of Acute Type A Aortic Dissection J. Am. Coll. Cardiol., December 6, 2011; 58(24): 2455 - 2474. [Abstract] [Full Text] [PDF]
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 V. W. S. Kung, O. A. Jarral, A. R. Shipolini, and D. J. McCormack Is it safe to perform coronary angiography during acute endocarditis? Interact CardioVasc Thorac Surg, August 1, 2011; 13(2): 158 - 167. [Abstract] [Full Text] [PDF]
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E. G. Kilian, A. Beiras-Fernandez, D. Bauerfeind, B. Reichart, and P. Lamm Reply to the Editor. J. Thorac. Cardiovasc. Surg., June 1, 2009; 137(6): 1577 - 1578. [Full Text] [PDF]
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E. G. Kilian, A. Beiras-Fernandez, B. Reichart, and P. Lamm Reply to the Editor: J. Thorac. Cardiovasc. Surg., March 1, 2009; 137(3): 789 - 790. [Full Text] [PDF]
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S. Lentini, F. Tancredi, and R. Gaeta Preoperative coronary study in patients with acute aortic dissection and endocarditis. J. Thorac. Cardiovasc. Surg., March 1, 2009; 137(3): 788 - 789. [Full Text] [PDF]
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