Bednarkiewicz, Marek

Khatchatourov, Gregory

Murith, Nicolas

Panos, Aristotelis

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Letters to the Editor / European Journal of Cardio-thoracic Surgery 30 (2006) 813—818816cannulation. The other subject that we wonder about is thecause of mortality in one case. It could be more favorable ifthe authors pointed out this issue.Antegrade cerebral perfusion is being performed evenwhen the point of deep or moderate hypothermic perfusion iscontroversial [4]. We believe that the safety and quality ofdistal anastomosis is the most important factor for mortalityand morbidity, so we think that the quality of distalanastomosis is more considerable than wasting time. Weuse deep hypothermia, but moderate hypothermia can alsobe used with more experience.An additional comment is that in case of dissection thatadvanced to left main and right coronary arteries with high-grade aortic insufficiency, bicuspid aorta and degenerativeaortic valve disease, we prefer inserting composite graft firstand then fixating the upper side of left main coronary arterywith pledgeted sutures and suturing just lateral and upperside without down side because of intensive fragility duringBentall operation. Punching the composite graft near thevalve and in a slightly horizontal position is enough to achievethis procedure.In our opinion, the surgeon should avoid Bentall procedureas far as possible because resuspension of aortic valve issufficient in 90% of the cases in acute terms; because of this,tissues become very fragile.References[1] Panos A, Murith N, Bednarkiewicz M, Khatchatourov G. Axillary cerebralperfusion for arch surgery in acute type A dissection under moderatehypothermia. Eur J Cardiothorac Surg 2006;29:1036—9.[2] Miller JS, Lemaire SA, Coselli JS. Evaluating aortic dissection: when iscoronary angiography indicated? Heart 2000;83:615—6.[3] Ates M. Which suture technique is better in acute type A aortic dissection?Eur J Cardiothorac Surg 2006;30:199.[4] LeMaire SA, Carter SA, Volguina IV, Laux AT, Milewicz DM, Borsato GW,Cheung CK, Bozinovski J, Markesino JM, VaughnWK, Coselli JS. Spectrum ofaortic operations in 300 patients with confirmed or suspected Marfansyndrome. Ann Thorac Surg 2006;81:2063—78 [discussion 2078].* Corresponding author. Address: Merdivenkoy Mah., Sairarsi Cad., Eminci-narpasa Sok. No: 6/24, Goztepe/Kadikoy, Istanbul, Turkey.Tel.: +90 216 360 0272; fax: +90 216 360 0272.E-mail address: drmates@yahoo.com (M. Ates).doi:10.1016/j.ejcts.2006.08.001Reply to the Letter to the EditorReply to Ates and GulluAristotelis Panosa, Nicolas Muritha,Marek Bednarkiewiczb, Gregory Khatchatourovc,*aClinic for Cardiac Surgery,University Hospital of Geneva, SwitzerlandbCardiac Surgery, Hoˆpital La Tour-Geneva, SwitzerlandcCardiac Surgery, Clinic Cecil, Avenue Ruchonnet 53,CH-1003 Lausanne, SwitzerlandReceived 31 July 2006; accepted 2 August 2006; Available online7 September 2006Keywords: Aortic dissection; Cerebral perfusion; Circulatory arrestWe thank Ates [1] for his remarks and interest in our work[2]. Regarding technical aspects, the prefered type of aorticsuture can be a matter of debate. We did not experience anyparticular problem with the continuous suture or even withthe application of narrow teflon felt strip. We believe thatwhen the suture bites are equally distributed and adequatelyspaced, the anastomosis is bloodproof. Concerning the director graft-interposed axillary canulation, we believe that ourtechnique is not traumatic, is less time-consuming, and lesshemorrhagic during the operation than the one with the graftinterposition. Ku¨c¸u¨ker et al. [3] performed 181 right brachialartery cannulations for aortic arch operations with only onevascular problem on the brachial artery. The cause of the leftarm paralysis in one of our patients was of central origin andnot attributed to the cannulation technique. The secondpatient who was treated with the stent graft suffered from aright arm malperfusion syndrome attributed to the dynamicmalperfusion of the right subclavian artery as a result of therecurrence of an intimal flap on the level of the innominateartery. Therefore, we really do not find any ground for DrAtes’s concern about the hypothetical additional risks of thedirect axillary canulation. Indeed,aspointedout inourarticle,one patient died following an acute respiratory distresssyndrome on the 20th postoperative day and this was notrelated to the aortic operation. To answer DrAtes’s last remarkconcerning the question of deep or moderate hypothermia,we have to say that, of course, it is still a matter of debateand it would be very interesting if Dr Ates and his grouppublished their results and technique on this topic.References[1] Ates M, Gullu AU. Which is more appropriate for the right axillary arterycannulation in acute type A aortic dissection—directly or with graft? Eur Jcardiothorac Surg 2006;30:815—6.[2] Panos A, Murith N, Bednarkiewicz M, Khatchatourov G. Axillary cerebralperfusion for arch surgery in acute type A dissection under moderatehypothermia. Eur J Cardiothorac Surg 2006;29:1036—9.[3] Ku¨c¸u¨ker S, Ozatik M, Saritas A, Tasdemir O. Arch repair with unilateralantegrade cerebral perfusion. Eur J Cardiothorac Surg 2005;27:638—43.* Corresponding author. Tel.: +41 21 3111424; fax: +41 21 3235153.E-mail address: g.khatchatourov@bluewin.ch (G. Khatchatourov).doi:10.1016/j.ejcts.2006.08.002Letter to the EditorVentricular myocardial band concept and ventricularresynchronization device therapy: crossing the roads?Dusan B. Velimirovic*Clinic for Cardiac Surgery,Institute for Cardiovascular Diseases,UC Clinical Center of Serbia,11000 Belgrade, Serbia and Montenegrohttp://www.ctsnet.org/home/dvelimirovicReceived 29 July 2006; accepted 28 August 2006; Available online26 September 2006Keywords: Helical myocardial ventricular bend; Cardiac resynchronizationtherapy

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