Transesophageal echocardiography is commonly used in cardiac surgery, but the interposition of the bronchus between the aorta and the esophagus causes an ultrasound “blind spot” in the ascending aorta and proximal arch, such that it does not offer improved detection compared to manual palpation. Accurate detection of atheroma requires direct ultrasound assessment using epiaortic scanning, with a high-frequency, Inhibitors,research,lifescience,medical linear-array

probe. This allows the surgeon to assess and localize any atheroma correctly. Yamaguchi et al. explored the efficacy of intraoperative epiaortic ultrasound scanning (EAS) for preventing cerebral emboli following CABG by evaluating the ascending aorta in 909 consecutive CABG patients.9 The ascending aorta was manipulated only if the scanning documented more than 3 mm of atheromatous thickness Inhibitors,research,lifescience,medical or plaque; 196 selleck inhibitor patients (21.6%) underwent off-pump CABG using composite grafts (85 cases, 9.4%) or in situ grafts (111 cases, 12.2%) with no aortic manipulation. The ascending aorta

was confirmed to be free from significant atheromatous plaque by the EAS in 713 patients (78.4%). On-pump CABG was performed using aortic cannulation and total aortic clamping in 429 patients (47.2%). Off-pump CABG with aortocoronary bypass grafts was performed using side-bite aortic Inhibitors,research,lifescience,medical clamping in 165 cases (18.2%) or the other anastomotic devices in 63 cases (6.9%). Results demonstrated that five hospital deaths occurred (0.6%), but no postoperative strokes. Postoperative coronary angiography revealed 98.8% (1,659/1,680) patency of the bypassed grafts. Inhibitors,research,lifescience,medical These findings suggest that the application of aortic clamping or cardiopulmonary bypass was not a risk factor of cerebral emboli when the ascending aorta was evaluated using the EAS. Furthermore, the application of aortic clamping with free grafts may provide eligible bypass graft patterns, leading to sufficient graft patency. PROXIMAL ANASTOMOSIS WITHOUT CLAMPING Inhibitors,research,lifescience,medical Avoidance of manipulation of diseased ascending aorta has been shown to be associated

with a reduced risk of postoperative stroke after OPCAB—an extremely desired outcome in the cardiovascular surgery setting where postoperative stroke is the Achilles’ heel of CABG compared with percutaneous coronary intervention. Ribonucleotide reductase The use of the Heartstring device (Guidant, Indianapolis, IN, USA) to accomplish a proximal aortic anastomosis without aortic clamping has been suggested in such patients. Biancari et al. addressed the use of the Heartstring anastomotic device in 19 patients with diseased, calcified ascending aorta who underwent OPCAB.10 The diagnosis of diseased ascending aorta was made intraoperatively by epiaortic ultrasound scanning. Biancari et al. demonstrated that 18 vein grafts and three radial artery grafts had been successfully anastomosed to the ascending aorta by employing the Heartstring device.