Right Axillary Artery Cannulation in Aortic Valve Replacement

Peripheral cannulation and endoaortic balloon occlusion for management of porcelain aorta during cardiac surgery

Porcelain aorta with extensive calcification of the ascending aorta complicates cardiac surgery and increases perioperative risk. Aortic cannulation and cross-clamping in these patients increase the risk of serious complications including perioperative embolic stroke. Although different techniques have been proposed, surgery in these patients remains a challenge. We present the clinical implications of the porcelain aorta and surgical strategies involving axillary arterial cannulation and endoaortic balloon to allow for the institution of cardiopulmonary bypass and cardioplegic arrest during surgery. The surgery included a redo sternotomy with bioprosthetic mitral valve replacement, tricuspid valve repair with an annuloplasty, and closure of the left atrial appendage. In appropriately selected patients, endoaortic balloon occlusion was a valuable tool to facilitate the safe conduct of an operation. Careful preoperative evaluation and planning by a multidisciplinary team are essential in these cases.

Strategies and pitfalls during minimally invasive total coronary artery revascularization via left anterior minithoracotomy: a promising future

For many years up to date coronary artery bypass surgery has been performed via sternotomy as a gold standard approach. However recently there has been alternative approaches for coronary artery bypass grafting in minimal invasive ways to reduce complications associated with sternotomy such as sternal wound infections, impared pulmonary functions and cosmetic related problems. Most of these minimal invasive procedures have been associated with long learning curve, high costs and sophiscated instruments used during surgery. Minimal invasive coronary artery bypass grafting via left anterior mini-thoracotomy is equally effective as a gold standard sternotomy with the same principles of suturing techniques and provides a great comfort in many aspects as sternotomy. It is safe and does not require sophiscated tools which require long learning curve and high expanses. This type of surgery requires the use of novel strategies, especially in patients who hold the highest potential for postoperative morbidity. In this paper, we will highlight the strategies and pitfalls associated with minimally invasive total coronary revascularization via left anterior minithoracotomy.

Aortic Cannulation around Grade 5 Aortic Arch Atheroma Utilizing Transesophageal Echocardiography

A 61-year-old male with severe aortic valve stenosis was scheduled for a minimally invasive bioprosthetic aortic valve replacement. Intraoperative transesophageal echocardiography (TEE) showed a unicuspid aortic valve and extensive aortic atheromatous disease. A large atheroma with mobile components existed near the distal aortic arch. A 17-French aortic cannula was successfully placed using TEE guidance with the tip proximal to the mobile atheroma to avoid inadvertent disruption and subsequent embolic sequelae. The patient had no evidence of perioperative stroke or other complications postoperatively. This case demonstrates one strategy to manage severe atheromatous disease intraoperatively. We also review additional management options.

Usefulness of routine use of bilateral axillary artery perfusion in total arch replacement

OBJECTIVES

To avoid cerebral infarction for aortic arch aneurysm and malperfusion for acute aortic dissection, the site of cannulation during total arch replacement remains important. Recently, we have used bilateral axillary artery perfusion in total arch replacement and in acute aortic dissection. Herein, we report the surgical outcomes.

METHODS

Seventy-eight patients with aortic arch aneurysm and 45 patients with acute aortic dissection were enrolled in this study. During surgery, translocation of the total arch was performed on 67 patients using a 'frozen elephant trunk technique'.

RESULTS

In patients with aortic arch aneurysm, there was no postoperative cerebral infarction. New postoperative cerebral infarction was observed in only one patient who underwent acute aortic dissection. Two patients who had aortic arch aneurysm and 2 patients who had acute aortic dissection died at the hospital. Complications related to bilateral axillary perfusion were not observed.

CONCLUSIONS

The routine use of bilateral axillary artery perfusion in total arch replacement for aortic arch aneurysm to avoid cerebral infarction has the potential to be a useful procedure. It can facilitate the frozen elephant trunk procedure in acute aortic dissection.