Ann Thorac Surg 2007;84:355
© 2007 The Society of Thoracic Surgeons
Correspondence
Use of Aortic Connector Device for Porcelain Aorta: To Touch or Not to Touch? That is the Question
Arnaud Mommerot, MD,
Louis P. Perrault, MD, PhD
Department of Cardiovascular Surgery, Université de Montréal, Montreal Heart Institute, 5000 Belanger St Montreal, Quebec H1T 1C8, Canada
(Email: louis.perrault{at}icm-mhi.org).
To the Editor:
We have read with great interest the letter to the editor sent by Schreiber and Lange [1] in response to the article published by Aranki and colleagues [2] on the use of deep hypothermic circulatory arrest for aortic valve replacement in patients with an unclampable aorta. Reading the end of the letter, we were seriously puzzled by the therapeutical option suggested to use the Symmetry aortic connector device (St. Jude Medical Inc, St. Paul, MN) for coronary artery bypass grafting (CABG) among patients with a porcelain aorta in a so-called "near no touch" technique [1] as referred to by the authors.
The concept of a "near no touch" approach is very perturbing. It is either a "no touch" technique or not, but it can not be half one thing and half another. Avoidance of any aortic manipulation or surgical trauma should be the rule in these cases, and the use of an aortic connector device can certainly not be considered and proposed as a "no touch" option because the proximal anastomosis is performed on a severely atherosclerotic ascending aorta with high potential for solid debris embolism. It is well known that cerebral embolic events are the major debilitating complications that occur after CABG. Manipulation of a severely atheromatous aorta is a contributing mechanism for postoperative stroke [3]. Thus, a total "no touch" and "no cannulation" technique should be provided when feasible for myocardial revascularization of such patients, as adverse neurologic events are likely to be significantly greater with the use of a cardiopulmonary bypass even with femoral cannulation [4]. Otherwise, as discussed by Aranki and colleagues [2], axillary cannulation could be a satisfactory alternative especially among patients requiring a combined valvular procedure. And in the latter case, the coronary time of the operation follows the same principles unless the ascending aorta is replaced [1].
The use of the Symmetry aortic connector device is invasive and might be harmful (even life-threatening) knowing the non-negligible risk of serious complications reported, such as anastomotic leakage or aortic dissection [5], cerebral gas embolism [6], or major cardiac events at 1 year [7] due to severe graft stenosis and closure [8] that led to the voluntary withdrawal of the device from the market in December 2004 [7]. In fact, several other strategies allow achieving complete "no touch" myocardial revascularization, such as coronary-coronary bypass, composite veno-arterial grafts [9], or axillocoronary bypass [10] with satisfactory results.
In conclusion, unless a complex, combined valvular-coronary procedure is needed, the off-pump "real no touch" approach should be the only option in the surgical management of patients with a porcelain aorta requiring myocardial revascularization.
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References
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- Schreiber C, Lange R. Porcelain aorta therapeutical options for aortic valve replacement and concomitant coronary artery bypass grafting Ann Thorac Surg 2006;82:381.[Free Full Text]
- Aranki SF, Nathan M, Shekar P, Couper G, Rizzo R, Cohn LH. Hypothermic circulatory arrest enables aortic valve replacement in patients with unclampable aorta Ann Thorac Surg 2005;80:1679-1686.[Abstract/Free Full Text]
- Kapetanakis EI, Stamou SC, Dullum MK, et al. The impact of aortic manipulation on neurologic outcomes after coronary artery bypass surgery: a risk-adjusted study Ann Thorac Surg 2005;78:1564-1571.
- Lev-Ran O, Ben-Gal Y, Matsa M, et al. "No touch" techniques for porcelain ascending aorta: comparison between cardiopulmonary bypass with femoral artery cannulation and off-pump myocardial revascularization J Card Surg 2002;17:370-376.[Medline]
- Lahtinen J, Biancari F, Mosorin M, et al. Fatal complications after use of the Symmetry Aortic Connector in coronary artery bypass surgery Ann Thorac Surg 2004;77:1817-1819.[Abstract/Free Full Text]
- Skjelland M, Bergsland J, Lundblad R, et al. Cerebral microembolization during off-pump coronary artery bypass surgery with Symmetry Aortic Connector device J Thorac Cardiovasc Surg 2005;130:1581-1585.[Abstract/Free Full Text]
- Kachhy RG, Kong DF, Honeycutt E, Shaw LK, Davis RD. Long-term outcomes of the Symmetry vein graft anastomosis device: a match case-control analysis Circulation 2006;114(Suppl 1):I425-I429.[Medline]
- Melero JM, Porras C, Such M, Olalla E, Alonso J. Severe stenosis of anastomoses by using the Symmetry Aortic Connector System Ann Thorac Surg 2004;78:1831-1833.[Abstract/Free Full Text]
- Bittner HB, Savitt MA, Ching PV, Ward HB. Off-pump coronary artery revascularization: ideal indication for patients with porcelain aorta and calcification of great vessels J Cardiovasc Surg 2003;44:217-221.[Medline]
- Bonatti J, Hangler H, Oturanlar D, et al. Beating heart axillocoronary bypass for management of the untouchable ascending aorta in coronary artery bypass grafting Eur J Cardiothorac Surg 1999;16(Suppl 2):S18-S23.[Abstract/Free Full Text]
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References