Asian Cardiovasc Thorac Ann 2008;16:329-330
© 2008 Asia Publishing EXchange Ltd
A Simple Method of Inspection of Proximal Bleeding in Bentall Procedure
Min-Ho Song, MD,
Yoshiyuki Tokuda, MD1,
Tomohiro Nakayama, MD,
Keisuke Hattori, MD
Department of Cardiovascular Surgery, Gifu Prefectural Tajimi Hospital Tajimi
1 Department of Cardiothoracic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
For reprint information contact: Min-Ho Song, MD, Tel: 81 572 225 311, Fax: 81 572 251 326, Email: p41558{at}govt.pref.gifu.jp, Department of Cardiovascular Surgery, Gifu Prefectural Tajimi Hospital, 5-161 Maebata-cho, Tajimi, Gifu, 507-8522, Japan.
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ABSTRACT
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A simple method of checking for bleeding from the proximal anastomosis site in Bentall operations is described. After suturing a Carbo-Seal prosthesis to the aortic annulus, using a folding-over technique, the left ventricle is filled with cardioplegic solution through the prosthetic valve, and the heart is massaged to visualize possible leaks at the level of the suture.
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INTRODUCTION
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In the Bentall and De Bono1 aortic root replacement procedure, bleeding from the proximal anastomosis is one of the gravest complications. A comprehensive study showed relatively low early mortality and morbidity with the Carbo-Seal (Carbomedics, Inc., Austin, TX, USA) graft, but bleeding complications occurred in 9.79% of patients, which is 3-times higher than the 3.3% rate of bleeding needing reexploration in another study using a conventional composite graft.2,3 Since the approved introduction of Carbo-Seal in Japan in August 2005, its clinical use has grown rapidly. The implantation technique for the Carbo-Seal depends on the surgeon’s preference: either continuous running suture or mattress suture.4 As we are much concerned with bleeding, we have developed a simple method to inspect surgical bleeding from the proximal anastomosis.
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TECHNIQUE
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The heart is arrested in the usual manner under cardiopulmonary bypass, and the ascending aorta is transected just above the sinotubular junction, leaving approximately 1 cm of the aortic wall. Right and left coronary buttons are constructed and prepared for intermittent cold blood cardioplegia. The diseased aortic valve is excised. Ethibond sutures are placed first, from the folded-over aortic wall to beneath the supporting fibers of the aortic annulus. On completing all mattress sutures in the double folded aorta and deep aortic annulus, the needles are passed through the soft shallow sewing cuff. The proximal Carbo-Seal is seated in the aortic annulus. The left ventricle is filled with 200–250 mL of blood cardioplegic solution through the prosthetic valve. The vent is stopped, and the left ventricle is massaged several times with moderate pressure to check for surgical bleeding. The rest of the procedure is completed as usual. The left and right coronary buttons are anastomosed to the posterior and anterior sides of the Carbo-Seal using 5/0 Prolene with felt-strip reinforcement. The distal end of the graft is sewn using 4/0 Prolene with a felt strip.
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DISCUSSION
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We have used this method in 5 patients and we have not needed additional stitches for bleeding so far. We have only seen oozing of blood from the suture holes, which resolved unaided. We have not encountered fatal bleeding after removing the cross clamp since we adopted this method. Usually, surgeons check for bleeding from the proximal anastomosis by filling the composite graft with cardioplegic solution from the distal end of the graft. This method allows inspection of the hemostatic status of the coronary buttons only, and we cannot check the proximal site because there is no antegrade flow through the composite graft. Our method enables us to check for bleeding by producing antegrade blood flow by massaging the left ventricle, and it seems physiological. In addition, the pledgeted folded-over aortic wall, inside aortic wall, and deep aortic annulus contribute adaptable reinforcement to secure the cuff of the composite graft and ensure the least possibility of bleeding.5
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REFERENCES
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- Bentall H, De Bono A. A technique for complete replacement of the ascending aorta. Thorax 1968;23:338–9.[Abstract/Free Full Text]
- Langley SM, Rooney SJ, Dalrymple-Hay MJ, Spencer JM, Lewis ME, Pagano D, et al. Replacement of the proximal aorta and aortic valve using a composite bileaflet prosthesis and gelatin-impregnated polyester graft (Carbo-Seal): early results in 143 patients. J Thorac Cardiovasc Surg 1999;118:1014–20.[Abstract/Free Full Text]
- Pacini D, Ranocchi F, Angeli E, Settepani F, Pagliaro M, Martin-Suarez S, et al. Aortic root replacement with composite valve graft. Ann Thorac Surg 2003;76:90–8.[Abstract/Free Full Text]
- Vitale N, Owens WA, Hamilton JRL, Forty J, Dark JH, Hasan A. Early results with the Carbo-seal composite valve conduit for aortic root replacement. J Heart Valve Dis 1999;8:80–4.[Medline]
- Song MH, Tokuda Y, Ueda Y. A novel method of proximal suturing of Carbo-Seal: aorta folded-over technique. Gen Thorac Cardiovasc Surg 2007;55:270–1.[Medline]
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ABSTRACT
INTRODUCTION
