The unclampable ascending aorta in coronary artery bypass patients - A surgical challenge of increasing frequency

Background-The unclampable ascending aorta (UAA) is a condition increasingl y encountered during CABG procedures. We report our experience with CABG pa tients with UAA and place particular emphasis on the preoperative diagnosis and surgical management. Methods and Results-UAA was diagnosed in 211 of 4812 consecutive CABG patie nts (4.3%). On the basis of the chest radiograph, echocardiogram, and coron ary angiograph, a preoperative diagnosis was achieved in only 58 patients ( 27.4%). An age of >70 years, diabetes, smoking, unstable angina, diffuse co ronaropathy, and peripheral vasculopathy were all predictors of UAA, Patien ts were treated with hypothermic ventricular fibrillation (no-touch techniq ue n=129) or beating heart revascularization (no-pump technique n=82) depen ding on the possibility of founding an arterial cannulation site. The overa ll in-hospital mortality rate was 2.8% (6 of 211) with no differences betwe en the 2 surgical strategies. The no-touch technique was associated with a greater incidence of neurological complications (stroke and transient ische mic attack), renal insufficiency, and stay in the intensive care unit and h ospital. However, at midterm follow-up, more patients of the no-pump group had ischemia recurrence. Conclusions-A preoperative diagnosis of UAA is achievable only in a minorit y of patients, which highlights the necessity revising the current diagnost ic protocols. The use of the no-touch technique is associated with an high perioperative risk but a superior possibility of complete revascularization , whereas adoption of the no-pump strategy ensures a smoother postoperative course at the expense of an higher incidence of ischemia recurrence.