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

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.