Ascending Aortic Atherosclerosis – A Complex and Challenging Problem for the Cardiac Surgeon

(#1999-43132 ... May 21, 1999)

Johannes Bonatti, MD

Innsbruck University Hospital, Division of Cardiac Surgery, University of Innsbruck, Austria

ABSTRACT

Ascending aortic atherosclerosis is an increasingly recognized problem in cardiac surgery. It is the most important risk factor for perioperative stroke and seems to be in part responsible for postoperative neurobehavioral changes. Patients exhibiting ascending aortic atherosclerosis have a significantly reduced survival rate and are at considerable risk for spontaneous embolic stroke during the long-term postoperative course. Preoperative noninvasive diagnosis and intraoperative assessment by inspection or palpation of the aorta are insensitive. Intraoperative epiaortic ultrasound scanning has emerged as a most helpful tool for the diagnosis of ascending aortic atherosclerosis and has revealed major insights into the nature and distribution of this disease. Management strategies range from minimally invasive aortic "no touch" techniques to maximally invasive procedures, including application of deep hypothermic circulatory arrest. Operative modifications in coronary artery bypass grafting include avoidance of aortic crossclamping, alternative methods of aortic crossclamping and placement of all arterial in situ bypass conduits, Y-grafts or extra-anatomical bypass grafts. Other operative strategies include modifications of the arterial cannulation site, replacement of the ascending aorta or ascending aortic endarterectomy. One of the most recently developed methods is embolic capture by intraaortic filters. Increased awareness of ascending aortic atherosclerosis is critical in order to prevent the devastating complications it can cause during cardiac surgery.

AUTHOR/ARTICLE INFORMATION

Reprint requests to: Johannes Bonatti, MD, Innsbruck University Hospital, Division of Cardiac Surgery, Anichstrasse 35 A-6020, Innsbruck, Austria; Phone: ++43 51 504 2529 or 3806; Fax: ++43 512 504 2528; Email: johannes.o.bonatti@uibk.ac.at

Submitted on: May 19, 1999;Accepted on: May 21, 1999

Keywords: Heart surgery; aorta; ascending aorta; atherosclerosis; ascending aortic atherosclerosis; aortic crossclamping; embolism; stroke; transesophageal ultrasound; epiaortic ultrasound; intravascular ultrasound; coronary artery bypass grafting; beating heart coronary surgery; arterial bypass grafts; extraanatomical bypass grafts; valve replacement; heart transplantation; cannulation; cardiopulmonary bypass; intraaortic filtration; intraaortic balloon; deep hypothermic cardiocirculatory arrest; aortic replacement; aortic endarterectomy