'No touch' techniques for porcelain ascending aorta: comparison between cardiopulmonary bypass with femoral artery cannulation and off-pump myocardial revascularization

2022 ACC/AHA guideline for the diagnosis and management of aortic disease: A report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

AIM

The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes).

METHODS

A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate.

STRUCTURE

Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.

2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

AIM

The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes).

METHODS

A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate. Structure: Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.

2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

AIM

The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes).

METHODS

A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate.

STRUCTURE

Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.

Extraanatomical coronary artery bypass grafting in patients with severely atherosclerotic (Porcelain) aorta

Background

Cannulation, cross clamping, or partial clamping of the aorta during a proximal anastomosis may cause embolic complications in patients with severely atherosclerotic (porcelain) aortas. These patients carry high morbidity and mortality risks due to intraoperative atheroembolism.

Methods

Between June 2008 and May 2010, 972 open heart surgery operations were performed in our department. In this group there were 41 patients who had severe atherosclerotic plaques in the aorta (porcelain aorta), and 9 of these underwent an extraanatomical coronary artery bypass grafting (CABG). These 9 patients were retrospectively analyzed and their demographic data, patient risk factors, and preferred surgical methods were reviewed.

Results

Seven patients underwent two-vessel CABG, while 2 underwent three-vessel CABG. Off-pump surgery was performed for 7 patients. CABG was performed with beating heart technique under cardiopulmonary bypass via femoral artery and right atrial cannulation without cross clamping in 2 of the patients. Postoperative course was uneventful in all patients. Mean length of stay in the intensive care unit was 2.11 ± 0.78 days. Mean hospitalization was 7.22 ± 0.97 days. Mean follow-up was 11.33 ± 3.67 months, and no cerebrovascular events were observed during this period. Postoperative evaluation of the grafts by multislice computed tomography revealed sufficient patency in all patients.

Conclusions

Innominate artery is an alternative inflow source for the untouchable ascending aorta caused by severe atherosclerotic disease (porcelain aorta). In this group of patients, the risk of systemic embolisation and perioperative neurologic complications can be minimized by avoiding manipulation of the ascending aorta and using the innominate artery.

Clampless technique during coronary artery bypass grafting for proximal anastomoses in the hostile aorta

OBJECTIVE

The incidence of stroke in patients undergoing coronary artery bypass grafting increases sharply in the face of significant atherosclerotic disease of the ascending aorta. We use a technique that allows full revascularization for this cohort of patients, while minimizing cerebral embolic risk.

METHODS

Intraoperative epiaortic ultrasound was used to screen for moderate or severe atherosclerotic disease of the ascending aorta and to precisely identify safe areas for cannulation and proximal anastomoses. By using a mildly hypothermic fibrillating technique, distal revascularization was then performed without clamping the aorta. Proximal anastomoses were accomplished under brief periods of circulatory arrest.

RESULTS

We routinely use this technique and examined our results in 71 consecutive patients found to have grade 3 or greater atherosclerotic plaque of the ascending aorta. This represented approximately 10.0% of our total population who underwent coronary artery bypass grafting over a 32-month period from January 2007 to September 2009. One patient (1.4%) had a mild stroke that resolved, and there were no other neurologic complications.

CONCLUSIONS

We have found that clampless fibrillating heart surgery with circulatory arrest for proximal anastomoses is a safe and effective technique for revascularizing patients with significant ascending aortic disease who are at high risk for cerebral embolic complications.

ECMO cannulation controversies and complications

Advances in extracorporeal life support have expanded indications for use extending beyond patients undergoing cardiac surgery. The approach to cannulation in patients requiring extracorporeal membrane oxygenation should be individualized and based on the specific clinical scenario in which the need arises. Adherence to proper techniques of vessel visualization, exposure, and cannulation along with accurate placement of cannulae will optimize flows and minimize complications in this setting. Patients in need of mechanical circulatory support require input from a multidisciplinary team approach with systematic clinical evaluation to optimize outcome. If hemodynamics do not initially permit the successful separation from mechanical support, then a systematic search for potentially reversible patient and/ or pump related factors should be undertaken. The success of this therapy is predicated on patient selection, a multidisciplinary team approach in the intensive care unit, adherence to precise technical principles, and repeated patient evaluation.

The topography of aortic atherosclerosis enhances its precision as a predictor of stroke

BACKGROUND

Atherosclerosis of the thoracic aorta is an independent risk factor for stroke after cardiac surgery. No attention had so far been paid to its topography. The relationship between the topography of aortic atherosclerosis and stroke was studied in patients admitted for coronary surgery.

METHODS

The extent and location of atherosclerosis in the ascending aorta and arch was assessed intraoperatively with epiaortic ultrasound and transesophageal echocardiography in 611 consecutive patients. They were followed for 5.5 +/- 1.7 years (mean +/- SE), amounting to 3,358 patient-years.

RESULTS

The incidence of early postoperative (<30-day) stroke was 6.4% in patients with atherosclerosis of the ascending aorta and 1.5% in those without (p = 0.004). The five-year stroke-free survival rates (>30 days after the operation) for patients without aortic disease, with less than 50%, and with greater than 50% of the ascending aorta affected, were 95.3 +/- 0.9%, 91.8 +/- 2.1%, and 65.0 +/- 14.6%, respectively (p < 0.0001).

CONCLUSIONS

Atherosclerosis of the ascending aorta stands out as a predictor of late stroke. High risk is predominantly linked to atheromas in its distal part and lesser curvature.

Open and closed chest extrathoracic cannulation for cardiopulmonary bypass and extracorporeal life support: methods, indications, and outcomes

Extrathoracic cannulation to establish cardiopulmonary bypass has been widely applied in recent years and includes: (a) repeat surgery, (b) minimally invasive surgery, and (c) cases with diseased vessels such as porcelain, aneurysmal, and dissecting aorta. In addition, the success and relative ease of peripheral cannulation, among other technological advances, has permitted the development of closed chest extracorporeal life support, in the form of cardiopulmonary support and extracorporeal membrane oxygenation. With this development have come applications for cardiopulmonary bypass based support outside the traditional cardiac theatre setting, including emergency circulatory support for patients in cardiogenic shock and respiratory support for patients with severely impaired gas exchange. This review summarises the approach to extrathoracic cannulation for the generalist.

Propensity case-matched analysis of off-pump coronary artery bypass grafting in patients with atheromatous aortic disease

OBJECTIVE

Atheromatous aortic disease is a risk factor for excessive mortality and stroke in patients undergoing coronary artery bypass grafting. Outcomes of off-pump coronary artery bypass grafting and coronary artery bypass grafting with cardiopulmonary bypass in patients with severe atheromatous aortic disease were compared by propensity case-match methods.

METHODS

Routine intraoperative transesophageal echocardiography identified 985 patients undergoing isolated coronary artery bypass grafting with severe atheromatous disease in the aortic arch or ascending aorta. Off-pump coronary artery bypass grafting was performed in 281 patients (28.5%). Propensity matched-pairs analysis was used to match patients undergoing off-pump coronary artery bypass grafting (n = 245) with patients undergoing coronary artery bypass grafting with cardiopulmonary bypass.

RESULTS

Univariate analysis revealed decreased hospital mortality (16/245, 6.5% vs 28/245, 11.4%; P =.058) and stroke prevalence (4/245, 1.6% vs 14/245, 5.7%; P =.03) in off-pump coronary artery bypass grafting compared with coronary artery bypass grafting with cardiopulmonary bypass. Freedom from any postoperative complication was higher in off-pump coronary artery bypass grafting compared with coronary artery bypass grafting with cardiopulmonary bypass (226/245, 92.2% vs 196/245, 80.0%; P <.001). Multivariable analysis of preoperative risk factors showed that increased hospital mortality was associated with coronary artery bypass grafting with cardiopulmonary bypass (odds ratio = 2.7; P =.01), fewer grafts (P =.05), acute myocardial infarction (odds ratio = 11.5; P <.001), chronic obstructive pulmonary disease (odds ratio = 2.4; P =.03), previous cardiac surgery (odds ratio = 10.2, P =.05), and peripheral vascular disease (odds ratio = 2.1; P =.05). Cardiopulmonary bypass was the only independent risk factor for stroke (odds ratio = 3.6, P =.03). At 36 months' follow-up, comparable survival was observed in the off-pump coronary artery bypass grafting and coronary artery bypass grafting with cardiopulmonary bypass groups (74% vs 72%). Multivariable analysis revealed that renal disease (P <.001), advanced age (P <.001), previous myocardial infarction (P =.03), and lower number of grafts (P =.02) were independent risks for late mortality.

CONCLUSIONS

Patients with severe atherosclerotic aortic disease who undergo off-pump coronary artery bypass grafting have a significantly lower prevalence of hospital mortality, perioperative stroke, and overall complications than matched patients who underwent coronary artery bypass grafting with cardiopulmonary bypass. Routine intraoperative transesophageal echocardiography identifies severe atheromatous aortic disease and directs the choice of surgical technique.