Transapical Aortic Cannulation Research Articles

Transapical aortic perfusion using a deep hypothermic procedure during descending thoracic or thoracoabdominal aortic surgery.

In descending thoracic aortic aneurysm (DTAA) or thoracoabdominal aortic aneurysm (TAAA) surgery, though proximal anastomosis using deep hypothermic circulatory arrest (DHCA) is often selected, there are issues surrounding brain and heart protection. In this study, the usefulness of concomitant upper body perfusion via transapical aortic cannulation during deep hypothermic surgery was examined. Between October 2014 and May 2019, 5 patients (Crawford extent II chronic dissection, N.=3; extent IV aneurysms, N.=1; DTAA, N.=1) underwent DTAA/TAAA repair under deep hypothermia using transapical aortic perfusion. A proximal anastomosis and artery of Adamkiewicz (AKA) reconstruction were performed under continuous perfusion of the upper and lower body at 20 °C. The time from aortic cross-clamping to proximal anastomosis was 69±33 minutes, and it took 86±47 minutes to AKA reperfusion. There was no spinal cord ischemic injury or brain or heart complications. One patient required tracheostomy, and the average postoperative intubation time for the other patients was 57±52 hours. All patients were discharged, and the average postoperative hospital stay was 25.6±8.1 days. Concomitant upper body perfusion by the transapical aortic approach contributes to avoidance of brain and heart complications and maintaining spinal cord circulation under deep hypothermic DTAA/TAAA surgery.

Transapical aortic perfusion using a deep hypothermic procedure to prevent dissecting lung injury during re-do thoracoabdominal aortic aneurysm surgery

BackgroundAvoiding various complications is a challenge during re-do thoracoabdominal aneurysm surgery.Case presentationA 56-year-old man had undergone surgery for type I aortic dissection four times. The residual thoracoabdominal aortic aneurysm that had severe adhesions to lung parenchyma was resected. Since the proximal anastomotic site was buried in lung parenchyma, deep hypothermia was essential to avoid lung dissection and to protect the spinal cord during the proximal anastomosis. The deep hypothermia was induced with bilateral infusion of cardiopulmonary bypass by femoral artery cannulation for the lower body and by transapical cannulation for the upper body because of easy access. There was no hemorrhagic tendency after deep hypothermic bypass. The patient was discharged uneventfully.ConclusionsFor upper body perfusion, transapical aortic cannulation was a simple and effective procedure during left thoracotomy.

60-day survival rate under treatment of Acute Type A Aortic Dissection by Transapical Aortic Cannulation Technique

OBJECTIVE: The aim of this study was to show a technique and the results of 60-day survival rate under treatment of Acute Type A Aortic Dissection by Transapical Aortic Cannulation Technique.MATERIAL AND METHODS: The data has been investigated through 12 years surgery experience since June 2003 in Acute Type A Acute Aortic Dissection by Transapical Aortic Cannulation Technique. This study was approved and reviewed by the ethical committee of the Kawasaki Saiwai Hospital, Kawasaki, Japan. Statistical Analysis: Cox proportional hazard regression was employed to analyze risk ratio, and Kaplan Meier curve was used to estimate the survival time. Statistically were significant at p < 0.05.RESULTS: The study population (n =309) was investigated for survival analysis. The person-time was 6363.50 person/months. We found that, the death outcome was 29 persons (9.38%). The mortality rate was 4.55/1000 person/months (95% Confidence Interval = 3.17-6.56/1000 person-month)CONCLUSION: Risk factors influencing the survival rate in Acute Type A Aortic Dissection included Coronary Artery Disease, Preoperative Hemodynamic Deterioration, Total Arch Replacement, cardiopulmonary bypass technique using only Deep Hypothermic Circulatory Arrest, Deep Hypothermic Circulatory Arrest with Retrograde Cerebral Perfusion and Deep Hypothermic Circulatory Arrest with Antegrade Selective Cerebral Perfusion. The enlargement of Ascending Aortic diameter and Proximal Descending Aorta diameter increased the death rate by 11% and 18%, respectively. Each time the diameter expanded 1 mm, and the operation time extended 1 minute, the death rate was increased by 1%.

60-Day Survival Rate under Treatment of Acute Type A Aortic Dissection by Transapical Aortic Cannulation Technique

60-Day Survival Rate under Treatment of Acute Type A Aortic Dissection by Transapical Aortic Cannulation Technique

Left Ventricular Pseudo-Aneurism after Transapical Aortic Cannulation in Ehlers-Danlos Syndrome Type IV: A Case Report

Introduction: We report a case of Ehlers-Donlos syndrome which raised left ventricular pseudo-aneurism at the site of transapical aortic cannulation after acute aortic dissection repair. Case Report: A 49-year-old male underwent total arch replacement for type A aortic dissection using transapical aortic cannulation. CT revealed a pseudoaneurysm at the left ventricular apex 2 weeks after the initial surgery, and the size of pseudoaneurysm increased in another 2 weeks. We performed reoperation and found suture dehiscence of transapical cannulation closure. Post-operative course was uneventful. He was diagnosed as Ehlers-Donlos syndrome by genetic examination after the second surgery. Conclusion: Ehlers-Danlos syndrome might be attributed to vulnerability of cardiac muscle and suture dehiscence, and transapical cannulation should be carefully applied in the patients with Ehlers-Danlos syndrome.

Transcutaneous Ultrasound Measurements of Carotid Flow to Monitor for Cerebral Malperfusion During Type-A Aortic Dissection Repair

HE REPAIR OF TYPE-A aortic dissection often requires alternative sites for arterial cannulation for cardiopulmonary bypass (CPB). The risks of cannulation of the femoral artery for the institution of CPB are well known and include retrograde perfusion of the false lumen with potential worsening of the dissection with compromise of organ perfusion, and retrograde embolization. Some techniques, including axillary artery, 1 transapical aortic, 2 and central aorta cannulation, have been described to minimize this complication.3 Some of these techniques require more time and may not be appropriate for all patients. Monitoring the adequacy of cerebral perfusion is of vital importance in all aortic surgical cases and even more whenever the femoral artery is used for CPB. Different methods have been described, including bilateral radial arterial monitoring in addition to transesophageal echocardiographic (TEE) imaging of the descending aorta, 4 right radial artery with left femoral artery monitoring, 5 cerebral oximetric monitoring using nearinfrared spectroscopy, 6,7 transcranial Doppler ultrasonography, 8 ophthalmic artery Doppler ultrasonography, 9 and color-flow Doppler transcutaneous carotid artery ultrasound imaging.10 The authors describe a case of chronic type-A dissection requiring surgical repair in which axillary artery cannulation for the institution of CPB was impossible, requiring femoral artery cannulation. They illustrate a method to quantify carotid artery flow velocity and monitor for intraoperative cerebral malperfusion using transcutaneous Doppler ultrasound of the carotid arteries.

Transapical aortic cannulation via left lateral thoracotomy for descending thoracic and thoracoabdominal aortic surgery

Two patients underwent surgery for a chronic type B dissection using a total cardiopulmonary bypass (CPB) with transapical arterial cannulation. At surgery, a total CPB was established by cannulating the left femoral artery and the ascending aorta via the ventricular apex. The patients were cooled to 30 degrees C. The proximal anastomosis was done after cross-clamping the aortic arch between the left carotid artery and the left subclavian artery in both cases. In the first case, the entire descending thoracic aorta was replaced, and two pairs of intercostal arteries were reconstructed. The other patient underwent replacement of the proximal descending thoracic aorta. Neither patient experienced any complications. Transapical aortic cannulation is a useful option during descending thoracic and thoracoabdominal aortic surgery. It can provide more stable circulation during the cross-clamping, more gentle manipulation of the aorta by nonpulsatile flow, and more liberty in temperature control.

How I do it: transapical cannulation for acute type-A aortic dissection

Aortic dissection is the most frequently diagnosed lethal disease of the aorta. Half of all patients with acute type-A aortic dissection die within 48 hours of presentation. There is still debate as to the optimal site of arterial cannulation for establishing cardiopulmonary bypass in patients with type-A aortic dissection.Femoral artery cannulation with retrograde perfusion is the most common method but because of the risk of malperfusion of vital organs and atheroembolism related to it different sites such as the axillary artery, the innominate artery and the aortic arch are used. Cannulation of these sites is not without risks of atheroembolism, neurovascular complications and can be time consuming. Another yet to be popularised option is the transapical aortic cannulation (TAC) described in this article. TAC consists of the insertion of the arterial cannula through the apex of the left ventricle and the aortic valve to lie in the sinus of Valsalva. Trans-oesophageal guidance is necessary to ensure correct placement of the cannula.TAC is an excellent method of establishing cardiopulmonary bypass as it is quick, provides a more physiological method of delivering antegrade arterial flow and is the only method to assure perfusion of the true lumen.

急性Ａ型解離緊急手術における心尖部送血の意義―すみやかな体外循環の導入―

Stanford A型急性大動脈解離症例における送血部位の選択として経心尖部大動脈送血法を用いている。その手技の有用性について検討を行った。2002年1月から2006年3月までに施行したStanford A型急性大動脈解離症例の40例について、経心尖部大動脈送血法を用いた症例をA群(27例)、右腋窩動脈・大腿動脈送血併用法を用いた症例をB群(13例)とし、手術時間、執刀から体外循環導入までの時間、体外循環時間、大動脈遮断時間、循環停止時間、脳灌流時間、心肺水分バランス、術中出血量などのパラメータについて検討を行った。執刀から体外循環導入までの時間はA群53±13min、B群118±31minでA群が有意に短かった(P<0.05)。本送血法は準備が容易で手技も単純であるが、挿入時の血行動態の維持、カニューレ挿入時の位置確認、体外循環開始時の左室ベンティングを確実に行うことが重要である。経心尖部大動脈送血法は、右腋窩動脈・大腿動脈送血併用法に比べて執刀から体外循環確立までの時間が短縮でき、迅速な体外循環の導入が可能であった。

Transapical aortic cannulation for cardiopulmonary bypass in type A aortic dissection operations

The femoral artery is the customary site for arterial cannulation for cardiopulmonary bypass in treating type A aortic dissections. However, because of concerns regarding complications caused by retrograde perfusion, the number of surgeons who prefer using the axillary artery as the site for cannulation is increasing. However, axillary artery cannulation also involves some problems. Thus we prefer transapical aortic cannulation for repair of type A aortic dissection. Transapical aortic cannulation was performed in 138 patients (83 men and 55 women; mean age, 60.1 years; 129 acute and 9 chronic; 120 hemiarch repair and 15 total arch replacement) with type A aortic dissection. A 1-cm incision is made in the apex of the left ventricle, and a 7-mm soft and flexible cannula is passed through the apex and across the aortic valve until positioned in the ascending aorta transesophageal echocardiographic guidance. There were no cases in which conversion to cannulation of another artery was necessary. In all cases cardiopulmonary bypass flow was sufficient (>2.5 L/m(-2)/min(-1)). There were no malperfusion events. Eight (5.8%) patients had cerebrovascular accidents. Twenty-six (18.8%) patients died in the hospital of complications not related to transapical aortic cannulation. Our results show that transapical aortic cannulation is safe and useful for repair of type A aortic dissection. There are advantages to transapical aortic cannulation, such as simple and quick cannulation technique, sufficient antegrade aortic flow, and the reliability of true lumen perfusion with decreased risk of stroke and malperfusion.

Ｓｔａｎｆｏｒｄ Ａ型急性大動脈解離手術における経心尖部大動脈送血法の検討

Stanford A型大動脈解離手術において左室心尖部より経左室的に上行大動脈送血を行う経心尖部大動脈送血法の有用性と術後早期成績について検討した.対象はStanford A型急性大動脈解離手術症例36例で,これらを経心尖部大動脈送血法を行ったA群(19例)とそれ以外のC群(17例)に分類し,比較検討を行った.術前背景,病態,術中・術後出血量,輸血量,ドレーン留置日数,術後入院期間はA群とC群で有意差はなかった.予定送血部位からの送血が困難で他の送血方法へ変更した症例はなかった.入室から体外循環までの時間(分)はA群74.2±16.2対C群88.8±12.5(p=0.005),体外循環時間(分)はA群175.2±55.5対C群216.6±58.1(p=0.036)でいずれもA群がC群より短かった.手術時間(分)はA群309.3±112.5対C群363.4±130.9(p=0.198)で有意差はなかった.経心尖部大動脈送血法に直接起因する合併症はなかった.術後脳障害はA群1例(5.3%),C群5例(29.4%)でA群が少ない傾向にあった(p=0.081).両群に術中死亡はなく,手術死亡はA群1例(5.3%)対C群4例(23.5%)で有意差はなかった(p=0.167).経心尖部大動脈送血法は体外循環導入までの時間,体外循環時間,術後合併症の点で優れる傾向にあった.経心尖部大動脈送血法による手術は準備が簡易で,迅速かつ安全に行うことができ,手術侵襲が少ないため有用な方法と考えられる.

Axillary artery and transapical aortic cannulation as an alternative to femoral artery cannulation.

We present an experience with axillary artery and transapical aortic cannulation for cardiopulmonary bypass according to our indication. We could simply achieve antegrade flow using the two methods with satisfactory result.

Transapical aortic cannulation for acute aortic dissection with diffuse atherosclerosis

Transapical aortic cannulation for acute aortic dissection with diffuse atherosclerosis

Transapical aortic cannulation for hypothermic aortic operation through a left thoracotomy: An alternative to avoid retrograde arterial perfusion

With increasing frequency, hypothermic total cardiopulmonary bypass with or without periods of circulatory arrest has been used for aortic reconstruction through a left thoracotomy. ~'2 In these cases, arterial return is usually by the femoral artery. However, total bypass with retrograde femoral arterial perfusion may be hazardous or impossible in the presence of severe downstream atherosclerotic disease. It also can result in malperfusion of the vital organs when aortic dissection is present. Although the aortic arch has been described as an alternative cannulation site, 3 the limitation is obvious, because the indication for hypothermic circulatory arrest is frequently proximal aortic involvement or technical difficulties during the operation.1 We used transapical aortic cannulation as an alternative cannulation technique for hypothermic total cardiopulmonary bypass through a left thoracotomy. The patient and technical detail are described. Clinical summary. The technique was applied in a 60-year-old man with chronic expanding type B aortic dissection. In June 1994, he was referred for treatment of an acute type A aortic dissection and occlusion of the superior mesenteric artery. Because dissection in the ascending aorta and aortic arch was retrograde and completely thrombosed, the patient was treated by infrarenal fenestration with Y grafting alone. The thrombosed false lumen in the ascending aorta and aortic arch completely disappeared subsequently. In November 1996, he was readmitted to our service for surgical treatment of aneurysmal expansion of the dissected thoracoabdominal aorta. The left subclavian artery was also dilated and required a separate graft for reconstruction. An echocardiogram revealed no regurgitation on the aortic valve. To avoid placing a clamp on the previously dissected aortic arch and to protect the spinal cord from ischemia during reconstruction of the intercostal arteries, 2 we planned to use profound hypothermia for the operation. However, because the true lumen was narrow in the thoracoabdominal portion and the superior mesenteric artery was also dissected, retrograde arterial perfusion was considered to carry the risk of malperfusion of the superior mesenteric artery. Therefore a technique that provided antegrade blood flow was considered necessary. The operation was performed on November 20, 1996. The entire thoracoabdominal aorta was exposed through a thoracoabdominal incision with the left hemidiaphragm divided circumferentially. The pleural cavity was entered through the fifth intercostal space. At first, partial cardiopulmonary bypass was initiated from the right femoral vein to the right femoral artery. A second venous cannula was placed into the right ventricle through the pulmonary artery, because the femoral venous cannula was a smallbore (23F) cannula. Then a 24F straight venous cannula (Polystan, Copenhagen, Denmark) was introduced into the ascending aorta through the ventricular apex across the aortic valve, and total cardiopulmonary bypass was established through it (Fig. 1). Correct positioning of the cannula could be confirmed either by palpation from the transverse sinus or by transesophageal echocardiography.

Transapical Aortic Cannulation in Pediatric Patients

We describe transapical aortic cannulation in pediatric patients. This technique may help to establish cardiopulmonary bypass in small children in whom aortic root cannulation is undesirable or not feasible.(Ann Thorac Surg 1997;63:1149–50)