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Fibrillation without Cross-Clamping in the Pesence of Sclerotic Ascending Aorta

¹ Business Hospital, Cardiovascular Surgery Clinic, Istanbul
² Anadolu Health Center, Cardiovascular Surgery Clinic, Istanbul
³ JFK Hospital, Cardiovascular Surgery Clinic, Istanbul

Dr. Murat Ugurlucan Tel: +90 535 431 67 86 Fax: +90 212 235 25 68 Email: muratugurlucan{at}yahoo.com, Atasehir, Zumrut Sitesi, Blok: 9, Daire: 9, Merkez Atasehir/Istanbul, Turkey.

We read with great interest the manuscript by Stygall J et al. comparing intermittent crossclamp fibrillation and cardioplegic arrest during coronary artery bypass grafting on microemboli and neuropsychology.¹ We believe the manuscript requires certain points to be stressed on. Additionally, we would like to comment on the issue about the use of fibrillation technique with our modification.

Coronary artery bypass grafting is one of the most commonly performed cardiovascular surgery daily practice procedures. Among the patients, only about 10–20% requires additional special care and alternative protective measures; otherwise, surgery is routinely performed on-pump, off-pump, intermittant cross-clamp fibrillation . . . etc. There is not a widely accepted concensus about the best technique for the high risk patients and the real difference between myocardial protection techniques would come true when tested among high risk patients.²

At our institution, the sole indication of fibrillation technique is atherosclerotic thickening and/or calcification at the ascending aorta. The technique is devoid of intermittant cross-clamping. Cardiopulmonary bypass is instituted by cannulation of right atrium and aortic arch, axillary artery, femoral artery, or disease free segment of ascending aorta. A left ventricular vent through the right superior pulmonary vein and/or a pulmonary arterial vent is instituted for unloading (Pulmonary arterial vent is safer and does not require special care of the perfusionist against air embolism). As soon as the cooling started, distal anastomosis of the grafts to the easily accessible coronary arteries of the left and right system at the front surface of the heart are initiated. Around 29–30°C, the heart fibrillates spontaneously. The patient is cooled down to 28°C. Mean arterial pressure is kept around 65mmHg. After each distal anastomosis the heart is defibrillated for obtaining a brief period of 20–30 seconds of hypothermic stand still and then fibrillation is reinstituted before starting the consequent distal anastomosis. During this period we believe the conduction tissues replenish the energy stores which probably prevents bundle or branch blocks rarely seen postoperatively. After the right and circumflex coronary systems distal anastomoses, before the internal thoarcic artery to left anterior descending artery bypass, the proximal anastomoses are performed. Proximal anastomoses are performed to the disease free segments of the ascending aorta if available on low flow with mean arterial pressure of 20–25mmHg. If the ascending aorta is not suitable for proximal anastomosis, the innominate artery or the internal thoracic artery are used for the proximal graft implantation. During low flow, trandelenburg position is given to the table and ice bags are placed around the head of the patient. Between each proximal anastomosis flow is increased to normal and then again decreased. Each proximal anastomosis lasts around 3 minutes and well tolerated. Internal thoracic artery to left anterior descending artery bypass is performed during the re-warming phase which allows shorter hypothermia interval. At the end of the bypass procedure, heart is defibrillated on demand. We believe fibrillation with hypothermia on low flow without cross clamp is a safe alternative to off-pump or hypothermic circulatory arrest techniques with which surgeons may achieve complete revascularization in patients with calcified aorta.³

In the authors series the mean age, diabetes mellitus incidence, and calculated body mass index in fibrillation and cardioplegia groups were 65.5 ± 7.7 years and 66.9 ± 8.2 years; 14.9% and 16.0%; and 28.7 ± 3.7 kg.m^–2 and 28.3 ± 4.3 kg.m^–2, respectively. The manuscript does not give detailed infromation regarding the status of ascending aorta. Have the authors or primary surgeons performing the CABG noted about the calcifications or sclerosis at the ascending aorta? Has the sclerotic ascending aorta been regarded as an exclusion criteria? Or, could there be a relationship between sclerotic ascending aorta and cerebral embolism?

The conventional cross-clamp cardioplegia or intermittant cross-clamp fibrillation techniques may not be suitable for patients with calcified ascending aorta. Clamping of calcified ascending aorta carries high neurologic hazards and the risk increases with multiple consecutive clamp institutions during intermittent cross-clamp fibrillation technique. On the other hand, fibrillation with modification including non-clamping of the ascending aorta is a promising method in this particular group of patients.³

REFERENCES

1. Stygall J, Suvarna S, Harrington J, Hayward M, Walesby RK, Newman SP. Effect on the brain of two techniques of myocardial protection. Asian Cardiovasc Thorac Ann 2009 Jun;17(3)259–65.[Abstract/Free Full Text]

2. Ibrahim MF, Refaat AA. eComment. Myocardial protection in high risk coronary surgery Interactive CardioVascular and Thoracic Surgery 2009, doi:10.1510/icvts.2009.209437A.

3. Ogus NT, Ogus H, Yildirim T, Selimoglu O, Basaran M. An alternative technique of proximal anastomosis in patients with an atherosclerotic ascending aorta. Heart Surg Forum. 2006;9(6)E846–8.[Medline]

Asian Cardiovasc Thorac Ann 2010; 18:94-95
© 2010 by SAGE Publications
DOI: 10.1177/0218492309355490

This article has been cited by other articles:

				M. Ugurlucan, O. Selimoglu, T. N. Ogus, and O. Isik Aorta non-clamp technique in case of sclerotic ascending aorta during coronary artery bypass grafting Eur J Cardiothorac Surg, November 1, 2010; 38(5): 648 - 648. [Full Text] [PDF]

This Article Extract 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 Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Murat Ugurlucan Murat Basaran Omer Isik Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Ugurlucan, M. Articles by Isik, O. Search for Related Content PubMed Articles by Ugurlucan, M. Articles by Isik, O.