Ann Thorac Surg 2001;72:955-956
© 2001 The Society of Thoracic Surgeons
How to do it
Transventricular aortic cannulation for repair of aortic dissection
John B. Flege, Jr, MDa,
Torkel Åberg, MDb
a Department of Cardiac Surgery, The Christ Hospital, Cincinnati, Ohio, USA
b Department of Cardio-Thoracic Surgery, Norrlands University Hospital, Ume
, Sweden
Accepted for publication April 19, 2001.
Address reprint requests to Dr Flege, 2123 Auburn Ave, Suite 401, Cincinnati, OH 45219
e-mail: john_flege{at}trihealth.com
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Abstract
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We have used transventricular aortic cannulation as arterial inflow from the heart-lung machine in seven consecutive operations done in 1 year for acute aortic dissection. Satisfactory cardiopulmonary bypass was achieved in all patients.
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Introduction
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Cannulation of the ascending aorta through the left ventricular apex and across the aortic valve for arterial input from the heart-lung machine was described by Chardack and colleagues [1] as a way of returning blood drained from the left ventricle in an experimental preparation of acute myocardial occlusion. Mansfield [2] used transapical aortic cannulation for arterial return from the heart-lung machine in puppies and suggested that it could be used in infants. Tanaka and colleagues [3] reported using transapical aortic cannulation in 156 routine cardiac operations not including procedures on the aortic valve. Golding [4] described the use of transapical aortic cannulation in a coronary bypass operation where the ascending aorta was severely atherosclerotic. Watanabe and colleagues [5] used the technique in an infant with a complex cardiac anomaly in which the exposure of the ascending aorta was difficult. Robicsek [6] reported the use of transapical aortic cannulation in four operations for acute ascending aortic dissection. Despite these reports, transventricular aortic cannulation for arterial return from the heart-lung machine has not been widely adopted. We have used this technique successfully in seven consecutive operations with hypothermic circulatory arrest for acute ascending or arch aortic dissection. Again, we bring it to the attention of cardiac surgeons and suggest that it is a satisfactory method for aortic cannulation in operations for acute aortic dissection.
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Technique
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A 24F flexible cannula is used. It is passed through the chest wall over the apex of the left ventricle, usually the fifth intercostal space in the anterior axillary line, which keeps it away from the operative field and from being kinked. The heart is elevated to expose the ventricular apex, the epicardium near the apex incised, and the wall of the ventricle is penetrated with the tip of a hemostat, not incised. Then the cannula is inserted and directed across the aortic valve, which takes only a few moments. A pursestring suture may be used to prevent slippage of the cannula. After the distal repair and anastomosis are complete, the cannula is removed and inserted into an 8-mm sidearm graft and antegrade perfusion is resumed. The ventricular apex is repaired with a mattress suture reinforced with felt pledgets (Fig 1).
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Comment
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Cannulation of the ascending aorta through the ventricular apex for arterial inflow from the heart-lung machine was used in seven consecutive cases of acute aortic dissection beginning in the ascending aorta or the arch. The first had no femoral pulses, the second had dissection into the femoral and brachiocephalic arteries, the seventh had no pulse in his right leg, and in the other four, who had good femoral pulses, transventricular aortic cannulation was used electively. Two patients exhibited significant aortic insufficiency when ventricular fibrillation ensued; this was managed in 1 patient by briefly interrupting the circulation while the aorta was incised and the cannula was relocated directly to the true lumen, and in the other patient by partially cross-clamping the aorta as suggested by Robicsek [6]. The only 2 patients with severe preoperative aortic insufficiency had no ventricular distension after fibrillation ensued.
Insertion of the cannula into the aorta ordinarily takes only a few moments making this technique useful in situations where rapid institution of cardiopulmonary bypass is needed.
Paar and colleagues [7] and Robicsek and colleagues [8] each described a patient in which retrograde femoral arterial perfusion was used for cardiopulmonary bypass with hypothermic circulatory arrest for the repair of acute aortic dissection in which there was no blood flow in the true lumen of the aorta after the repair was completed and circulation was resumed. We have had a similar experience. Transventricular aortic cannulation obviates the need for retrograde perfusion.
A disadvantage of this technique is that repair of the aortic root and valve cannot be done until the cannula is removed and placed in the graft.
Other than the two instances of aortic insufficiency mentioned above, we had no problems that could be attributed to the method of cannulation. One of our patients died from bleeding associated with coagulopathy and 1 patient had multiple cerebral emboli thought to be caused by particles of a hemostatic sealant. Tanaka and colleagues [3], Golding [4], and Watanabe and colleagues [5] did not report any significant complications related to transventricular aortic cannulation.
Based on our experience in 7 patients, we believe that transventricular cannulation of the ascending aorta during operations with hypothermic circulatory arrest for acute dissection of the aorta is a satisfactory way of providing arterial inflow from the heart-lung machine.
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References
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Chardack W.M., Gage A.A., McRonald R.E., Souther S. Fibrillation in empty and loaded ventricles: an experimental study of coronary artery ligation during partial and complete cardiac bypass. Arch Surg 1966;93:795-801.[Abstract/Free Full Text]
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Mansfield P.B. Transventricular aortic cannulation for cardiopulmonary bypass in newborn infants. J Pediatr Surg 1972;7:398-403.[Medline]
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Tanaka T., Kawamura T., Ohara K., Natsumoto M., Maeta H. Transapical aortic perfusion with a double-barreled cannula. Ann Thorac Surg 1978;25:209-214.[Abstract]
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Golding L.A.R. New cannulation technique for the severely calcified ascending aorta. J Thorac Cardiovasc Surg 1985;90:626-627.[Abstract]
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Watanabe H., Eguchi S., Miyamura H., et al. Transapical aortic cannulation in pediatric patients. Ann Thorac Surg 1997;63:1149-1150.[Abstract/Free Full Text]
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Robicsek F. Apical aortic cannulation: application of an old method with new paraphernalia. Ann Thorac Surg 1991;51:330-332.[Abstract]
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Paar G.V.S., Manley N.J., Williams D.R., Montesano R.M. Obstruction of the true lumen during retrograde perfusion of Type I aortic dissections. Ann Thorac Surg 1980;30:495-498.[Abstract]
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Robicsek F., Zimmern S., Howe H. Subintimal retrograde perfusion during repair of aortic dissection: a potential cause of disaster. Ann Vasc Surg 1988;2:298-302.[Medline]
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Abstract
Introduction
