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Ann Thorac Surg 1998;66:609
© 1998 The Society of Thoracic Surgeons

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Correspondence

Aortic root hemorrhage and presealed composite grafts with porous sewing cuffs

^a Department of Surgery, MeritCare Children’s Hospital and UND School of Medicine, Fargo, ND 58122, USA

To the Editor

The informative reports by Copeland and associates [1, 2], Karma and Aichter [3], and Hilgenberg and associates [4] focus attention on the occurrence and prevention of diffuse aortic root hemorrhage (ARH) after aortic root replacement (ARR) but are without discussion of causes. We suggest that when employed, the sewing cuff porosities of commercial presealed composite grafts (PCGs) may be a contributory factor. This suggestion is based on clinical observations, in vitro test data, and a mini-survey of 10 surgeons experienced in ARR surgery.

We have encountered ARH in 3/7 patients having ARR with PCGs; ARH did not occur in 11 patients having ARR with non-PCGs sealed with 25% albumin plus flashing. We have tested 6 PCGs (sizes 20 to 23), two each of three types in vitro. Sewing cuff porosities (in mL · cm^-2 · min^-1 · 80 to 100 mm Hg [saline solution]) were greater than 150; graft segment porosities were less than 15. Serial implantation of these devices in porcine left ventricular outflow tracts resulted in proximal anastomotic leak rates as follows: unmodified cuffs, 121 (range, 91 to 161); cuffs covered with presealed graft segments, 13 (range, 8 to 18); and cuffs sealed with 25% albumin plus flashing, 21 (range, 16 to 28).

A survey of surgeons concerning preferred ARR techniques showed that 5/10 surgeons (group A) use unmodified PCGs and 5/10 surgeons do not (group B). All group A surgeons were familiar with ARH; none of the group B surgeons could recall a specific instance of ARH. Techniques of group B surgeons included adjunctive use of a commercial fibrin sealant (1), continued use of 25% albumin plus "flash" sealing of non-PCGs (1), construction of conduits at operation (2), and use of homografts or subcoronary "tailored" grafts with aortic valve repair (1).

We think these observations are consistent with the hypothesis that sewing cuff porosity is a contributory factor in the occurrence of ARH when PCGs are used for ARR. Three manufacturers of PCGs are currently considering or have undertaken redesign of these cuffs. We agree with the authors cited that caution should be used in employing unmodified PCGs for ARR in patients generally, particularly in those with other risk factors for ARH such as tissue fragility, coagulopathies, or aortic root anatomy not permitting construction of sealing sutures lines. As suggested by these authors and the responses of other surgeons as noted, reasonable alternative techniques are available that reduce the risk of ARH after ARR.

Acknowledgments

The assistance of the surgeons in this survey, the manufacturers of presealed composite grafts, and the personnel of the Department of Animal Physiology of North Dakota State University in these studies is gratefully acknowledged.

References

1. Copeland J.G., III, Rosada L.J., Snyder S.L. New technique for improving hemostasis in aortic root replacement with composite graft. Ann Thorac Surg 1993;55:1027-1029.[Abstract/Free Full Text]
2. Copeland J.G., III Hemostatic modification in aortic root replacement with composite graft. Ann Thorac Surg 1995;60:1162.
3. Khanna S.K., Akhter M. Hemostatic modification in aortic root replacement with composite graft. Ann Thorac Surg 1995;60:1161-1162.[Free Full Text]
4. Hilgenberg A.D., Akins C.W., Logan G.L., et al. Composite aortic root replacement with direct coronary artery implantation. Ann Thorac Surg 1996;62:1090-1095.[Abstract/Free Full Text]

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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): David A. Browdie R. Varick Bernstein Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Browdie, D. A. Articles by Bernstein, R. V. Search for Related Content PubMed PubMed Citation Articles by Browdie, D. A. Articles by Bernstein, R. V.