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This Article 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 Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Haitham Abunasra Christos Alexiou Andrew Sosnowski Permission Requests Citing Articles Citing Articles via HighWire Google Scholar Articles by Abunasra, H. Articles by Sosnowski, A. PubMed Articles by Abunasra, H. Articles by Sosnowski, A. Related Collections Great vessels

Letters to the Editor

Arterial cannulation for acute type A aortic dissection

Department of Cardiac Surgery, Glenfield Hospital, Groby Road, Leicester, LE3 9QP, United Kingdom

Received 13 February 2009; accepted 11 March 2009.

^_* Corresponding author. Tel.: +44 116 2871471; fax: +44 116 2871471. (Email: haitham7{at}hotmail.com).

Key Words: Aortic dissection • Transapical cannulation • Malperfusion

We read with great interest the recent article by the Hannover group describing their method for ascending aortic cannulation in the type A dissection setting [1]. However, the ideal method for arterial access in this lethal condition remains controversial.

We agree with the authors that femoral artery cannulation for cardiopulmonary bypass in type A aortic dissection patients has possible complications such as cerebral embolisation and organ malperfusion. Axillary artery cannulation also involves problems because it requires a more precise technique and more time. It may result in insufficient flow rate in a small artery or cause retrograde carotid dissection and cerebral malperfusion when an intimal tear is present in the brachiocephalic artery or its branches [2].

Direct cannulation and clamping of the ascending aorta is risky in such a fragile aorta; furthermore, the Hannover group describe three patients (2.5%) with malperfusion [1], which is significant in our opinion. As a matter of principle, we never cross-clamp the dissected aorta. We apply the clamp to tube graft once distal anastomosis is completed on circulatory arrest.

In contrast, transapical aortic cannulation has the advantage of avoiding these problems; involves a simpler and quicker cannulation technique, provides a more physiological method of delivering antegrade arterial flow and is the only method to assure perfusion of true lumen. Recently, Wada and colleagues published their large series with excellent clinical results. In over 130 patients they had no malperfusion events with a low mortality of less than 20% and stroke rate of only 5.8% [3]. Our group has modified this technique to eliminate completely the risk of bleeding at the access site in the left ventricular apex, by using an epicardial 4 mm incision with a special cannula advanced under transoesophageal guidance through the aortic valve orifice [4]. Aortic valve leaflets rest against the cannula, which eliminates significant regurgitation [5]. Even in the rare case of left ventricular distention, this can be managed with pulmonary artery venting and regular squeeze of the ventricle. We remain convinced that transapical cannulation is the method of choice for quick and safe arterial cannulation in patients with type A aortic dissection. Our group has had excellent results since we started using it in 1995.

References

1. Khaladj N, Shrestha M, Peterss S, Strueber M, Karck M, Pichlmaier M, Haverich A, Hagl C. Ascending aortic cannulation in acute aortic dissection type A: the Hannover experience. Eur J Cardiothorac Surg 2008;34:792-796.[Abstract/Free Full Text]
2. Sinclair MC, Singer RL, Manley NJ, Montesano RM. Cannulation of the axillary artery for cardiopulmonary bypass: safeguards and pitfalls. Ann Thorac Surg 2003;75:931-934.[Abstract/Free Full Text]
3. Wada S, Yamamoto S, Honda J, Hiramoto A, Wada H, Hosoda Y. Transapical aortic cannulation for cardiopulmonary bypass in type A aortic dissection operations. J Thorac Cardiovasc Surg 2006;132:369-372.[Abstract/Free Full Text]
4. Sosnowski A, Jutly R, Masala N, Alexiou C, Swanevelder S. How I do it: transapical cannulation for acute type-A aortic dissection. J Cardiothorac Surg 2008;3:4.[CrossRef][Medline]
5. Jutley RS, Masala N, Sosnowski AW. Transapical aortic cannulation: the technique of choice for type A dissection. J Thorac Cardiovasc Surg 2007;133(5):1393-1394.[Free Full Text]

This article has been cited by other articles:

				N. Khaladj, M. Shrestha, A. Haverich, and C. Hagl Reply to Abunasra et al. The exciting question of cannulation site in acute aortic dissection type A Eur. J. Cardiothorac. Surg., July 1, 2009; 36(1): 228 - 228. [Full Text] [PDF]

This Article 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 Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Haitham Abunasra Christos Alexiou Andrew Sosnowski Permission Requests Citing Articles Citing Articles via HighWire Google Scholar Articles by Abunasra, H. Articles by Sosnowski, A. PubMed Articles by Abunasra, H. Articles by Sosnowski, A. Related Collections Great vessels