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We appreciate the interest of Dr. Karamanoukian and colleagues in our study about the relation between postoperative stroke in cardiac surgery and presence, location and extent of atherosclerosis in the ascending aorta (1). Our study showed a 3.5% incidence of stroke due to atherosclerosis of the ascending aorta as detected by epiaortic ultrasound (in 26% of the patients) despite minor surgical modifications. Furthermore, a multivariate analysis showed that the two best predictors for perioperative stroke were atherosclerosis of the ascending aorta and diabetes mellitus. Age is usually associated with atherosclerosis in the ascending aorta. Consequently, atherosclerosis of the ascending aorta (detected by intraoperative ultrasound) is a better predictor than age. Therefore, we recommended a more radical change in surgical strategy in the presence of atherosclerosis of the ascending aorta, and especially when the disease of the aortic wall is extended.
One interesting option in this situation is off-pump coronary artery bypass (OPCAB). Still, partial clamping of the ascending aorta is usually used in OPCAB. Clamping of the ascending aorta has been shown to generate cerebral emboli (2–5). Thus, with OPCAB cross-clamping can be avoided, but usually partial clamping is conducted, unless an anastomotic device is employed or the ascending aorta is totally avoided. A further possibility is the use of intraoperative intraaortic filters, if clamping is necessary (5).
We congratulate Dr. Karamanoukian and colleagues for their successful results with OPCAB in octogenarians. Notably, approximately 12% of their patient cohort had atherosclerosis of the ascending aorta, presumably detected by palpation. It is unclear how these patients were handled in terms of proximal anastomosis on the ascending aorta. Considering that their patients received only on average 1.8 grafts, we assume that their conclusion should be that OPCAB incomplete revascularization without touching the ascending aorta may be the preferred operative technique in high-risk patients (i.e., octogenerians).
Recently, we employed OPCAB to achieve complete revascularization in 20 patients with extensive disease of the ascending aorta according to intraoperative ultrasound and totally avoided the ascending aorta in the majority of the patients. None of the 20 patients suffered a perioperative stroke.
In conclusion, we believe that OPCAB techniques may have a justified place in high-risk patients (i.e., with extended atherosclerosis the ascending aorta according to epiaortic ultrasound) in order to prevent perioperative stroke. However, well-designed randomized studies have to be conducted to prove the superiority of OPCAB over conventional coronary surgery.
- American College of Cardiology Foundation
- van der Linden J.,
- Hadjinikolaou L.,
- Bergman P.,
- Lindblom D.
- Barbut D.,
- Yau F.S.,
- Hager D.N.,
- et al.
- International Council of Emboli Management (ICEM) Study Group,
- Van Boven N.W.