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eComment. Clamping a calcified aorta: note of caution
eComment. Cross-clamping the heavily calcified ascending aorta after a preoperative computed tomography evaluation
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Bartolo Zingone 22, vicolo Scaglioni, 34141 Trieste, Italy
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bartolo.zingone{at}gmail.com Bartolo Zingone
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Interactive CardioVascular and Thoracic Surgery 2009, doi:10.1510/icvts.2009.216242B © 2009 European Association of Cardio-Thoracic Surgery I congratulate the Authors for effectively managing 11 patients with severely atherosclerotic ascending aorta by computer tomography (CT)-guided aortic cross- clamping [1]. However, I would briefly add a few notes of caution. 1. Although there are no published data, experience with direct ultrasonographic interrogation of the aorta at surgery shows that the distribution of calcifications seen on CT scan does not necessarily correspond to the full extension of the disease. 2. In patients with obvious calcium seen on x-ray or angiograms, CT is probably a helpful adjunct. On the other hand, regular CT screening would be difficult to justify due to the large number of patients to irradiate in order to pick up some less than 5% of them having calcified aortas. 3. Before accepting that clamping across calcifications can be safely and reproducibly done, we should ignore that emboli are produced even by a normal-appearing aorta at the time of cannulation and cross-clamping. The likelihood that this will occur with a bad aorta is far too obvious. In addition, it may be difficult to place a clamp “parallel” to the calcification if that involved, as it often does, the anterior or the posterior third only of the aortic circumference. 4. When a problem has no easy solution it may be worth considering taking the bull by the horns. In this setting, echo-guided cannulation of either the aorta, the brachiocefalic or the axillary artery followed by replacement of the ascending aorta may be quite rewarding, unless the planned procedure can be converted to a no-clamp approach. To conclude, I am glad that the Authors were successful with an approach we all have used in the era of aortic assessment by palpation. While CT scanning provides useful maps of aortic calcifications, I doubt it has sufficiently greater sensitivity than palpation in assessing the usual cannulation and clamping sites. Perhaps a study with a larger number of patients might be convincing, though I regret to say I would definitely not participate in such a study. References [1] Nishi H, Mitsuno M, Ryomoto M, Miyamoto Y. Comprehensive approach for clamping severely calcified ascending aorta using computed tomography Interact CardioVasc Thorac Surg doi:10.1510/icvts.2009.216242. |
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Jamshid H. Karimov Adult Cardiac Surgery Department, G. Pasquinucci Heart Hospital, Via Aurelia Sud, 54100 Massa, Italy, Kakhaber Latsuzbaia, Mattia Glauber
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asr_uz_2003{at}yahoo.com Jamshid H. Karimov, et al.
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Interactive CardioVascular and Thoracic Surgery 2009, doi:10.1510/icvts.2009.216242A © 2009 European Association of Cardio-Thoracic Surgery We read with interest the report of Nishi and co-workers presenting their approach for cross-clamping the severely calcified ascending aorta based on preoperative computed tomography [1]. Reading this contribution some questions arise. In your opinion, how could a calculated calcified score defined as a ratio of the circumferential length of calcification to the entire ascending aortic circumference be useful in quantifying the protruding calcification; the plaque can be huge and problematic, even if the entire or main length of aortic circumference is not engaged. Cardiac surgery in patients with extremely calcified ascending aorta is challenging as an interruption of aortic (calcified aorta) tissue integrity takes place, caused by factors as a central and peripheral cannulation, cross-clamping, aortotomy and other manipulations/steps during the procedure when touching the aorta is inevitable. Do you have any experience with an Embol-X aortic cannula with incorporated filter (Edwards Lifesciences, Irvine, CA) in some other patients and could you make a comment on this. The authors found that the extent of calcification just below the innominate artery was significantly less than the usual ascending aorta clamping site. Interestingly, in our experience, we observed the severely plaqued ascending aorta with the supra-annular zone free from any detectable calcium deposits. In two of these cases, the calcium free supra -annular zone made possible a stentless aortic bioprosthesis implantation [2]. A heavy calcification of the ascending aorta makes a cardiac surgery procedure more difficult and is a major risk factor for perioperative stroke. The individual approach in preoperative assessment is crucial to treat these patients effectively, in order to provide an uneventful surgery without neurological complications and the authors approach can be an excellent example in this matter. References [1] Nishi H, Mitsuno M, Ryomoto M, Miyamoto Y. Comprehensive approach for clamping severely calcified ascending aorta using computed tomography. Interact CardioVasc Thorac Surg doi:10.1510/icvts.2009.216242. [2] Karimov JH, Cerillo AG, Solinas M, Murzi M, Latsuzbaia K, Bevilacqua S, Glauber M. Stentless aortic valve implantation in heavily calcified aorta. J Cardiovasc Med (Hagerstown). 2009;10(10):813-4. |
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