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Ann Thorac Surg 2002;73:1691
© 2002 The Society of Thoracic Surgeons

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Correspondence

Open heart surgery and abdominal aortic aneurysm

^a Onassis Cardiac Surgery Center, 356 Sygrou Ave, 176 74 Athens, Greece

e-mail: geconomo{at}otenet.gr

To the Editor

We read with interest the recent article by Ascione and associates [1]. Although we agree in principle with one-stage treatment of combined coronary and abdominal diseases, we have serious reservations regarding the surgical strategy followed. We refer to the adverse hemodynamic effects imposed on the myocardium by suprarenal aortic clamping (and unclamping) during abdominal aortic aneurysm (AAA) resection. It has been documented that this maneuver causes serious and adverse alterations in diastolic and systolic myocardial function [2, 3].

With that in mind, we devised a protocol in 11 patients with the dual pathological process. If the preoperative evaluation (angiographic, viability, and echocardiographic studies) suggests that optimal myocardial recovery can be expected, AAA resection followed the open heart surgical procedure (with or without cardiopulmonary bypass [CPB]). When CPB is used, the patient is weaned from CPB, half of the protamine sulfate is given, the aortic cannula remains in place, and AAA resection follows—a "wean and resect" strategy.

On the other hand, if the immediate postoperative myocardial function is expected to be questionable or problematic (eg, bad targets, ischemic cardiomyopathy, or diastolic dysfunction from valvular heart disease), AAA resection is performed after the cardiac procedure but with the patient on CPB support—"resect on CPB" strategy. The hemodynamic and metabolic effects of suprarenal aortic clamping and unclamping are nullified by the CPB support, and myocardial recovery was uneventful in the 5 patients in the "resect on CPB" group. We were impressed by the safety and efficacy provided by CPB support in 2 patients in whom a huge (>9 cm) or a difficult (no neck) AAA was resected. Transesophageal echocardiography was used in all patients. There were no deaths and no major morbidity in this small series during a follow-up ranging from 9 to 46 months.

References

1. Ascione R., Iannelli G., Lim K.H.H., Imura H., Spampinato N. One-stage coronary and abdominal aortic operation with or without cardiopulmonary bypass: early and midterm follow-up. Ann Thorac Surg 2001;72:768-775.[Abstract/Free Full Text]
2. Westaby S., Parry A., Grebenik C.R., Pillai R., Lamont P. Combined cardiac and abdominal aortic aneurysm operations. The dual operation on cardiopulmonary bypass. J Thorac Cardiovasc Surg 1992;104:990-995.[Abstract]
3. Mohr F.W., Falk V., Autschbach R., et al. One-stage surgery of coronary arteries and abdominal aorta in patients with impaired left ventricular function. Circulation 1995;91:379-385.[Abstract/Free Full Text]

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): George Economopoulos Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Economopoulos, G. Articles by Iliopoulos, J. Search for Related Content PubMed PubMed Citation Articles by Economopoulos, G. Articles by Iliopoulos, J. Related Collections Coronary disease Related Article