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Ann Thorac Surg 1999;68:1878-1880
© 1999 The Society of Thoracic Surgeons

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How to Do It

Direct aortic cannulation for port-access mitral or coronary artery bypass grafting

^a Departments of Surgery and Anesthesia, Duke University Medical Center, Durham, North Carolina, USA

Address reprint requests to Dr Glower, Department of Surgery, Duke University Medical Center, Box 3851, Durham, NC 27710

	Abstract

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A technique is described for direct aortic arterial cannulation during Port-Access mitral valve or coronary artery bypass grafting. Femoral arterial cannulation is avoided, and endoaortic balloon occlusion is used for cardioplegic arrest. To date, excellent results have been obtained in 45 patients.

	Introduction

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The minimally invasive Port-Access approach to cardiac operations originally required cannulation of the femoral artery for cardiopulmonary bypass and for insertion of an EndoClamp aortic catheter. We report preliminary results of transthoracic direct aortic return cannulation (DARC) in the chest to avoid aortoiliac arterial disease, the groin incision, and possible femoral arterial injury associated with femoral arterial cannulation.

	Technique

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After intubation with a dual lumen endotracheal tube, an anterolateral thoracotomy is performed for Port-Access coronary or mitral operation (Fig 1) [1,2]. The bed of the right fourth rib is opened for mitral procedures. For coronary operations, the left fourth costal cartilage is detached from the sternum and the left third or fourth intercostal space is entered. A reusable chest retractor (Heartport, Inc, Redwood City, CA) provides upward lift on the second and third ribs. The pericardium is opened to the base of the innominate artery, exposing the ascending aorta.

View larger version (53K): [in this window] [in a new window]   Fig 1. (Left) The operative field through a right anterolateral thoracotomy for mitral operation. The patient’s head is to the left and feet are on the right. The Direct Flow aortic cannula passes through an 11.5-mm port in the chest wall and through a pursestring in the distal ascending aorta. The EndoClamp aortic catheter is inflated in the ascending aorta. (Right) The operative field through a left anterolateral thoracotomy for coronary operation. The patient’s head is to the right and feet are on the left. The Direct Flow aortic cannula passes through a chest wall port and pursestring in the distal ascending aorta. The EndoClamp aortic catheter is inflated in the ascending aorta.

A 16-gauge needle is passed through the first intercostal space in the lateral clavicular line, with the needle directed toward the chosen cannulation site 1 to 1.5 cm proximal to the base of the innominate artery (Fig 1). A standard 11.5-mm port is then inserted along the path of the 16-gauge needle after withdrawing the needle. It is important that the aortic cannula and introducer (Direct Flow arterial kit; Heartport; Fig 2) inserted through the 11.5-mm port now points directly at the chosen cannulation site and that the direct aortic cannula points towards the aortic valve and not down the aortic arch (Fig 1). Two concentric pursestrings of pledgeted 2-0 polyester are placed at the cannulation site, and the pursestrings are passed through plastic tourniquets and out through either the incision or the 11.5-mm port. Using a retractable blade incorporated into the aortic cannula introducer, the direct aortic cannula is easily passed through the 11.5-mm port into the pursestring and the aorta, and is then secured with the tourniquets. The end hole of the aortic cannula should face the aortic valve. Aortic cannulation was done using direct vision, although the technique is amenable to use of video control.

View larger version (58K): [in this window] [in a new window]   Fig 2. The Direct Flow aortic cannula (top) (Heartport, Inc, Redwood City, CA) with side and end holes for aortic perfusion and a Y connector for insertion of an EndoClamp aortic catheter (bottom).

View larger version (68K): [in this window] [in a new window]   Fig 3. Transesophageal echocardiograms showing typical positions of the EndoClamp balloon (arrows) 1 to 2 cm above the aortic valve. Position was similar using the Direct Flow aortic cannula (top) and the femoral cannula (bottom).

	Results

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Forty-five patients underwent transthoracic DARC for Port-Access cardiac mitral valve operation (n = 36) or coronary artery bypass grafting (n = 9). The new, specifically designed Direct Flow arterial cannula (Heartport) and EndoClamp aortic catheter were used in 23 patients undergoing mitral valve operation and in 9 patients undergoing coronary artery bypass grafting, whereas the remaining 13 mitral operations were performed using ventricular fibrillation and standard arterial cannulas. Specific indications for DARC were femoral arterial size less than 21F (n = 6), aortoiliac disease (n = 15), or obesity (n = 7). Comparison of the 23 EC patients undergoing mitral valve operation using transthoracic direct aortic cannulation to the last 23 EC patients with femoral arterial cannulation demonstrated no significant difference in cardiopulmonary bypass times (DARC 189 ± 37 minutes versus 192 ± 47 minutes, p > 0.8) and slightly longer surgical procedure times (DARC 349 ± 49 minutes versus 317 ± 50 minutes, p = 0.03). Arterial line pressures on cardiopulmonary bypass with the EC in place were 201 ± 27 mm Hg (n = 10) with DARC versus 269 ± 16 mm Hg (n = 12) with femoral arterial cannulae (Heartport).

DARC prevented EC balloon migration with EC balloon repositioning required in 0 of 23 DARC patients versus 4 of 23 femoral patients (p = 0.05). In a single patient, overinflation of the EC balloon did partially obstruct innominate artery flow, and this was corrected by decreasing EC balloon volume. The only complication directly attributable to direct aortic cannulation was an injury to the right internal mammary artery in 1 patient. There were no patient deaths. Two patients required reexploration for bleeding due to coagulopathy. One patient suffered an embolic stroke secondary to left atrial thrombus and mitral annular debris.

	Comment

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Femoral arterial cannulation, whether using Port-Access or standard techniques, is associated with an incidence of wound infection, arterial injury requiring reconstruction, aortic dissection, atheroembolism, and limb ischemia [1–6]. These potential complications along with the incidence of aortoiliac disease precluding femoral arterial cannulation prompted surgeons to move from femoral arterial to central aortic cannulation more than 25 years ago [4]. Because of limited intrathoracic exposure and lack of specially designed cannulae, catheters, and instrumentation, the initial Port-Access experience used femoral arterial cannulation as opposed to the direct central aortic cannulation [1,2,5,6]. The reported incidence of aortic dissection has varied from 2 in 51 patients (4%) in the early Port-Access experience [6] to 1 in 532 patients (0.5%) in more recent series [5].

The results presented herein demonstrate that central aortic cannulation for Port-Access is safe, technically easy in a wide variety of patients, allows easy use of endoaortic occlusion, and avoids the limitations and morbidity of femoral arterial cannulation. The slight increase in procedure time may reflect a learning curve and elimination of concurrent operation in two incisions (chest and groin). Although none occurred in the current series, aortic cannulation using a trocar has the potential for aortic "back wall" injury. This complication can be avoided by proper centering of the pursestring on the aorta and releasing the trocar blade as soon as the blade penetrates the aortic wall. Alternative cannulas using the Seldinger technique also have potential for "back wall" injuries, which have prompted manufacturers to recall some Seldinger cannulas. Despite the small thoracotomy incision, intrathoracic control of aortic injury is possible using direct pressure on the aorta, placement of partial occluding clamps on the aorta, or conversion to transverse or median sternotomy.

Direct aortic cannulation should expand the pool of patients eligible for Port-Access operation, and may become the standard for Port-Access operations. Relative indications for direct aortic cannulation include the presence of aortoiliac arterial disease, femoral arterial size less than 21F, and obesity. The relative contraindications for direct aortic cannulation are few and include significant atherosclerosis or significant dilation (> 4 cm diameter) of the ascending aorta, severe deformity of the chest wall, and inability to obtain one lung ventilation. The primary relative contraindication to use of the endoaortic balloon clamp with direct aortic cannulation is aortic diameter more than 3.5 cm, in which case ventricular fibrillation or external aortic clamping are alternatives.

	Footnotes

 
Doctor Donald D. Glower has received an honorarium from Heartport, Inc. Doctor Jan Komtebedde is an employee of Heartport, Inc. Doctor Mark Stafford-Smith has received a research grant from Heartport, Inc.

	References

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1. Glower D.D., Clements F.M., Debruijn N.P., et al. Comparison of direct aortic and femoral cannulation for Port-Access cardiac operations. Ann Thorac Surg 1999;68:1529-1531.[Abstract/Free Full Text]
2. Ribakove G.H., Miller J.S., Anderson R.V., et al. Minimally invasive Port-Access coronary bypass grafting with early angiographic follow-up. J Thorac Cardiovasc Surg 1998;115:1101-1110.[Abstract/Free Full Text]
3. Hendrickson S.C., Glower D.D. A method for perfusion of the leg during cardiopulmonary bypass via femoral cannulation. Ann Thorac Surg 1998;65:1807-1808.[Abstract/Free Full Text]
4. Serry C., Najafi H., Dye W.S., Javid H., Hunter J.A., Goldin M.D. Superiority of aortic over femoral cannulation for cardiopulmonary bypass, with specific attention to lower extremity neuropathy. J Cardiovasc Surg 1978;19:277-279.[Medline]
5. Galloway A.C., Shemin R.J., Glower D.D., et al. First report of the Port-Access International Registry. Ann Thorac Surg 1999;67:51-58.[Abstract/Free Full Text]
6. Mohr F.W., Falk V., Diegeler A., Walther T., van Son J.A.M., Autschbach R. First results with video-assisted minimally invasive mitral valve repair using the Port-Access system. J Thorac Cardiovasc Surg 1998;115:567-576.[Abstract/Free Full Text]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map 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): Donald D. Glower Mark F. Newman Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Glower, D. D. Articles by Newman, M. F. Search for Related Content PubMed PubMed Citation Articles by Glower, D. D. Articles by Newman, M. F.