Ascending aorta cannulation in acute type A aortic dissection.

OBJECTIVE: Antegrade perfusion for type A acute aortic dissection prevents malperfusion and retrograde cerebral embolism during cardiopulmonary bypass. Prompt establishment of antegrade perfusion via ascending aorta may improve the surgical results of type A dissections, especially in the situations of hemodynamic instability. Thus, we evaluated the efficacy of use of the dissected ascending aorta as an alternative arterial inflow. METHODS: Between 2002 and 2006, 32 patients underwent prosthetic graft replacement of the ascending aorta or hemiarch for acute type A aortic dissection. The ascending aorta was routinely cannulated, in addition to the femoral artery, with a heparin-coating flexible cannula for arterial inflow, using Seldinger technique, and by epiaortic ultrasonographic guidance (n=6). Antegrade systemic perfusion via ascending aorta was performed. RESULTS: Ascending aorta cannulation was safely performed in all cases. There was no malperfusion or thromboembolism due to ascending aorta cannulation. Cardiopulmonary bypass was established within 30 min after skin incision. There was one in-hospital death due to duodenal bleeding (1/32=3.1%), two cases of cerebral infarction (2/32=6.3%), and one case of pulmonary embolism. Twenty-nine patients (29/32=90.6%) were discharged in New York Heart Association class I and have been followed up uneventfully for a mean of 17 months. CONCLUSIONS: Antegrade perfusion via the ascending aorta was successfully performed with low mortality and morbidity. With ultrasound-guided Seldinger technique, ascending aorta cannulation has a potential to be a simple and safe option that enables rapid establishment of antegrade systemic perfusion in patients with acute type A aortic dissection.

Left ventricular outflow obstruction after mitral valve replacement preserving native anterior leaflet.

Left ventricular outflow obstruction may result from preserving the anterior leaflet after mitral valve replacement. A 79-year-old woman, who had a mitral valve replacement with the native mitral leaflets left intact 16 years before, was admitted to our hospital with severe dyspnea due to heart failure. Echocardiography showed systolic anterior motion of preserved anterior mitral leaflet, and continuous wave Doppler detected severe left ventricular outflow tract jets during systole without mitral chordal rupture. Surgical incising of the anterior mitral leaflet through the aortic root relieved the obstruction without removing the prosthetic mitral valve.

Beating-heart epicardial radiofrequency ablation: optimal temperature setting.

PURPOSE: Pulmonary vein isolation is a simple procedure, which has recently been reported as an effective treatment for the termination of atrial fibrillation. Although there are several clinical reports of beating-heart epicardial ablation, the optimal temperature has not been experimentally investigated. We evaluated the effective temperature for the placement of circular lesions around the pulmonary vein-left atrial junction. DESCRIPTION: Twelve swine underwent epicardial ablation to create linear conduction block lesions around the pulmonary vein-left atrial junction by a seven-electrode ablation catheter. The ablation was performed at 60 degrees C (group I), 70 degrees C (group II), 80 degrees C (group III), and 90 degrees C (group IV) for 120 seconds. The creation of a firm conduction block across the ablated lesion under pacing was compared. EVALUATION: Complete conduction block was observed in all groups except group I. However, heat injury to adjacent structures in group IV and transient discoloration of the tissue surrounding coronary arteries in groups III and IV were observed. CONCLUSIONS: The effective temperature for epicardial radiofrequency pulmonary vein isolation was 120 minutes and above 70 degrees C.

Aortic intramural hematoma with severe aortic regurgitation.

A 71-year-old Japanese woman with severe chest pain was diagnosed with Stanford type A acute aortic dissection. After 3 months of medical treatment, she was operated on under a diagnosis of dissecting aneurysm of the ascending aorta and severe aortic regurgitation. Operative findings showed prolapse of the redundant aortic leaflets and a dilated ascending aorta without intimal tears. Operative and computed tomography findings differed from those of a classical dissection, which was the primary diagnosis of this patient, and were compatible with a diagnosis of aortic intramural hematoma (IMH). Few reports of IMH include concomitant aortic regurgitation. Surgery involved aortic root remodeling and prosthetic graft replacement of the ascending aorta.