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Department of Cardiothoracic and Vascular Surgery, Johannes Gutenberg-University, Langenbeckstr. 1, Mainz, 55131 Germany
(Email: lars.conzelmann{at}gmx.de).
We would like to thank the authors [1] for their constructive comments on our article [2].
We congratulate the authors for their successful management of a patient "with an aortic dissection who had a 360° circumferential separation of the true lumen from the false lumen near the sinotubular junction." This is a rare case in acute type A aortic dissection, similar to those patients presenting with a true lumen collapse of the ascending aorta. However, we do disagree with the authors' [1] comment that the technique of direct true lumen cannulation (DTLC) is something like an "ultima ratio" strategy if peripheral cannulation fails. On the contrary, in our experience the major advantage of DTLC is to appropriately identify the true lumen of the aorta, and thus, assure antegrade organ perfusion. Once the patient is exsanguinated into the cardiopulmonary bypass circuit (ie, a systolic blood pressure less than 30 mm Hg), the ascending aorta is transected into the region between the sinotubular junction and the innominate artery. Thus, the ascending aorta can be inspected and the true lumen can be identified, even in cases with a free-floating intimal layer or a total collapse of the true lumen. For this delicate step of identification and arterial cannulation, a short, normothermic circulatory arrest of as much as 7 minutes (under prior ventilation with pure oxygen) is feasible. In addition, inspection of the aortic arch for presence or absence of further entries or re-entries allows for the precise definition of the consecutive surgical procedure with respect to temperature management or cerebral protection regime, or both. The only somewhat "tricky" part of the DTLC technique we describe is the part of the procedure when the ascending aorta is snared with the Mersilene tape (Ethicon Inc, Norderstedt, Germany). Most important is the careful preparation between the adventitial layer of the ascending aorta and the pulmonary artery; the adventitial layer of the aorta has to stay intact when the tape is placed around it.
In conclusion, DTLC is a simple, quick, and safe method to cannulate the true aortic lumen, and should thus not be considered as a "desperate approach" when other techniques have failed, but rather as the initial procedure providing antegrade flow in acute type A aortic dissection.
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