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J Thorac Cardiovasc Surg 2003;126:391-400
© 2003 The American Association for Thoracic Surgery

Surgery for acquired cardiovascular disease

Modification of surgical technique for ascending aortic atherosclerosis: impact on stroke reduction in coronary artery bypass grafting

^a Department of Cardiac Surgery, Innsbruck University Hospital, Innsbruck, Austria

Received for publication July 24, 2002; revisions received September 10, 2002; revisions received October 28, 2002; accepted for publication November 1, 2002.

^* Address for reprints: Herbert Bernd Hangler, MD, Department of Cardiac Surgery, Innsbruck University Hospital, Anichstrasse 35, 6020, Innsbruck, Austria
herbert.hangler{at}uibk.ac.at

OBJECTIVE: Use of epiaortic scanning in coronary surgery is still a matter of debate. It is unclear whether the findings obtained by epiaortic scanning lead to effective changes in surgical technique that may reduce stroke rates.

METHODS: Epiaortic scanning was performed in 352 patients undergoing primary coronary artery bypass grafting before opening the pericardium using a 7.5-MHz ultrasonic probe. In the presence of moderate atherosclerosis (maximum aortic wall thickness of 3 to 5 mm), primarily single aortic crossclamping was carried out. In cases of severe sclerosis (maximum aortic wall thickness > 5 mm), aortic no-touch techniques on the beating heart were used.

RESULTS: The degree of ascending aortic atherosclerosis was normal or mild in 151 patients (42.9%), moderate in 167 patients (47.5%), and severe in 34 patients (9.6%). The operative technique was modified in 31.1% of patients with moderate aortic sclerosis and in 91.2% of patients with severe aortic sclerosis. Perioperative mortality was 0.0% for mild disease, 3.0% for moderate disease, and 8.8% for severe disease (P = .005). Corresponding stroke rates reached 2.0%, 2.4%, and 2.9% (P = .935). Logistic regression adjusting for EuroSCORE showed that ascending aortic atherosclerosis was an independent predictor of perioperative mortality (P = .013, odds ratio 1.67, confidence interval 1.11-2.50). The influence of aortic disease on the stroke prevalence was probably due to chance (P = .935), demonstrating a potentially positive effect of operative modifications concerning stroke caused by aortic manipulation.

CONCLUSIONS: We conclude that intraoperative screening of coronary artery bypass grafting patients by epiaortic scanning can reveal useful information about the operative risk and with an aortic no-touch concept, perioperative stroke rates in high-risk patients may be lower than predicted.