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

Abstract

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.

Figure 1

The DLP^® 22-French EOPA arterial cannula. It measures 30.5 cm and is wire-reinforced to prevent kinking.

Figure 2

A stab incision is made in the left ventricular apex using a No 11 bladed knife.

Figure 3

The cannula inserted so that the tip lies beyond the aortic valve.

Figure 4

This TOE shows the tip of the cannula lying at the level of the sinus of Valsalva with perfusion of the true lumen.

Figure 5

Once the distal anastomosis is completed CPB is recommenced through the side arm of the graft. The distal part of the operation can then be performed.