- Email: [email protected]
Air in the Moustache Can Choke the Left Ventricle
CASE REPORTS
Air in the Moustache Can Choke the Left Ventricle Gianluca Torregrossa, MD,* Cindy Wang, MD,† Ramachandra Reddy, MD,* and Gregory W. Fischer, MD†
A
ORTIC ROOT PATHOLOGIES often require complex surgical repair techniques due to the involvement and manipulation of the coronary arteries. In 1981, Cabrol et al described a technique to reimplant the coronary arteries into the aortic conduit using a Dacron tube graft.1 In the 1980s and 1990s, the Cabrol technique and its modifications commonly were performed during aortic root surgery, but now are used less frequently due to the development of improved coronary ostial button mobilization techniques.2 The Cabrol technique still is considered a reasonable alternative when conventional coronary reimplantation is unsuccessful, such as in redo aortic root surgeries. The authors report a rare complication of this technique, in which echocardiography played a crucial role in the rapid and correct diagnosis. CASE REPORT
A 43-year-old male (123 kg, 195 cm) was admitted to the authors’ institution for evaluation of progressive dyspnea on exertion and worsening lower extremity edema. The patient had a history of Marfan syndrome, hypertension, and glaucoma. He had undergone an emergent ascending aortic replacement for a Stanford type-A dissection 1 year before the current admission. The perioperative course was complicated by a pulmonary embolism requiring the placement of an inferior vena cava filter and oral anticoagulation with warfarin. During this current admission, the preoperative work-up revealed the presence of a chronic aortic dissection, originating from the aortic arch and extending through the descending thoracic aorta to the level of the inferior mesenteric artery. Additionally, severe aortic regurgitation with a dilated aortic root was reported. Left ventricular function was preserved with no evidence of significant coronary artery disease. Consequently, the patient was scheduled for redo-sternotomy, a Bentall procedure, and a stage-I elephant trunk. After the patient was brought to the operating room, standard ASA monitors were placed and an indwelling left axillary artery catheter was inserted under local anesthesia. The patient was induced with 100 mg of propofol, 1,000 μg of fentanyl, and 10 mg of vecuronium. The airway was secured with a standard 8.0 cuffed endotracheal tube without difficulty. Subsequently, a 9French multi-lumen access catheter was placed into the right internal jugular vein under sonographic guidance. Additional monitoring included a pulmonary artery catheter, transesophageal echocardiography (TEE), cerebral oximetry, bispectral electroencephalography, and temperature measurement in both the nasopharynx and the bladder. General anesthesia was maintained with isoflurane and intermittent boluses of fentanyl, midazolam, and vecuronium. The initial intraoperative TEE showed normal right and left systolic function with an estimated left ventricular ejection
fraction of 50%-60% and no regional wall motion abnormalities, severe aortic regurgitation, an aortic root aneurysm measuring 5.2 cm in diameter, and an aortic dissection originating from the arch and extending throughout the descending aorta (Fig 1; Video clip 1). Because of the close proximity of the right ventricle to the sternum, the right axillary artery was cannulated before redosternotomy. The sternum then was divided uneventfully with an oscillating saw, and the cardiac structures carefully dissected. Cardiopulmonary bypass (CPB) was initiated using a double-stage venous cannula through the right atrium. The ascending aortic graft was cross-clamped. Cold blood cardioplegia was administered in an antegrade and retrograde fashion and the patient cooled to 21 degrees Celsius. A modified Bentall procedure was performed using a 27-mm St. Jude Medical mechanical valved graft (St. Jude Medical, Inc., St. Paul, MN). The right coronary button was implanted in a standard fashion into the valved conduit. Because of extreme tissue friability, an 8-mm Dacron graft conduit was anastomosed end-to-end with the left main coronary ostium (hemi-Cabrol technique). The proximal end of the graft then was directed behind the aortic root and connected to the side of the anterior surface of the aortic graft (Figs 2 and 3). The operation then was completed by replacing the aortic arch under deep hypothermic circulatory arrest with a trifurcated graft attached end-to-end to all of the 3 arch branches and end-to-side to the ascending aortic graft. Finally, the ascending aortic graft was anastomosed to the descending thoracic aorta using the elephant trunk technique (a small part of the prosthesis was inserted into the thoracic aorta). After removal of the cross-clamp, the heart was paced using an epicardial ventricular pacing wire. The transgastric shortaxis midpapillary view showed a severely dysfunctional left ventricle with severe hypokinesis in all regions while right ventricular function appeared to be preserved (Video clip 2). Because of the disparity in function of the 2 ventricles, it was concluded that the culprit was most likely a perfusion deficit in
From the Departments of *Cardiothoracic Surgery, and †Department of Anesthesiology, Icahn School of Medicine at Mount Sinai, New York, NY. Address reprint requests to Gianluca Torregrossa, MD, Department of Cardiothoracic Surgery, Mount Sinai Hospital, Guggenheim PavilionTwo West, 1190 5th Avenue New York, NY 10029. E-mail: gianluca. [email protected] © 2015 Published by Elsevier Inc. 1053-0770/2602-0033$36.00/0 http://dx.doi.org/10.1053/j.jvca.2014.05.029 Key words: cardiac surgery, aortic root surgery, air embolism
Journal of Cardiothoracic and Vascular Anesthesia, Vol 29, No 5 (October), 2015: pp 1291–1294
1291
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TORREGROSSA ET AL
Fig 1.
TEE midesophageal long-axis view showing aortic root aneurysm.
the distribution territory of the left main coronary artery. The course of the Cabrol graft could be identified clearly by TEE. The more distal portion of the Cabrol graft that was anastomosed to the left main coronary artery could not be well
Fig 2.
visualized by TEE due to acoustic dropout from the trachea. Color-flow Doppler imaging of the Cabrol graft seen in the midesophageal ascending aorta views did not demonstrate flow in the graft despite reducing the Nyquist limit to 0.05 cm/s.
Drawing of a hemi-Cabrol technique.
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any apparent abnormalities. An epiaortic ultrasound probe (inserted into a sterile cover) then was placed directly onto the Cabrol graft, displaying a long-axis view of the graft with the proximal region closest to the probe and the distal region furthest away from the probe. By color-flow Doppler, the epiaortic images demonstrated proximal flow with a clear delineation more distally where flow became absent (Fig 4). It was hypothesized that the area lacking flow represented a true phenomenon caused possibly by an air embolus in the Cabrol graft and not an artifact. The surgeon placed a needle attached to a syringe into the graft and aspirated approximately 2 mL of air before blood entered the syringe, confirming the diagnosis of an air lock. Blood flow in the left anterior descending (LAD) artery then was confirmed using colorflow Doppler by epicardiac sonography (Video clip 3). The heart was allowed to reperfuse for 45 minutes. During this time left ventricle ejection fraction improved from 5% to 25%. Under high-dose inotropic support (epinephrine 200 ng/ kg/min) the patient eventually was weaned successfully from CPB. The patient’s condition continued to improve, hemostasis was obtained, the chest closed, and the patient transferred to the intensive care unit. The patient was extubated several days later, weaned from inotropes, transferred to the ward, and eventually discharged home. DISCUSSION
Fig 3. Surgical field picture with blue arrow pointing to Cabrol graft.
Inotropic support was initiated with an epinephrine infusion while further direct visual inspection of the Cabrol conduit and the various anastomotic sites (left main coronary to Cabrol conduit and Cabrol conduit to the Bentall graft) did not reveal
Fig 4.
The unanticipated severe left ventricular dysfunction seen after CPB in this case resulted in an immediate discussion among all team members. Differential diagnosis at the time included kinking of the Cabrol graft, kinking of the anastomosis between the Cabrol graft and left main coronary artery, embolization of air or thrombus into the graft or left main coronary artery, and poor myocardial protection. Poor myocardial protection and longer CPB times may make the heart more susceptible to reperfusion injury and the “stone-heart”
Epiaortic color-flow Doppler ultrasound of Cabrol graft demonstrating absence of color flow in the distal portion of the graft.
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phenomenon.3 However, right ventricular function was preserved and this disparity between the functional status of the 2 ventricles made the likelihood of poor global myocardial protection unlikely. The hypothesis of air in the Cabrol graft was supported by color-flow Doppler imaging of the Cabrol graft via epiaortic views. The acute dropout of color flow over the distal area of the unkinked graft suggested an obstruction to blood flow in that region. The aspiration of 2 mL of air from the Cabrol graft definitely confirmed the presence of an air embolus. Subsequent direct placement of the ultrasound probe over the Cabrol graft and LAD showed continuous color flow through the entire graft and LAD confirming adequate blood flow in both. This reassured the authors that there was no longer a problem at the level of the Cabrol graft to the left coronary anastomosis. The transgastric short-axis midpapillary view showed an improvement in myocardial contractility over the next few minutes. The transient period of ischemia, however, lasted for approximately 30 minutes and had a significant impact on overall left ventricular function. Besides inotropic support with epinephrine, additional support for the left ventricle was discussed to assist in recovery of function. Insertion of an intra-aortic balloon pump would increase coronary perfusion pressure while decreasing afterload and left ventricular work; however, this was contraindicated due to the presence of the chronic aortic dissection that extended throughout the descending aorta and would impose a high risk of rupture. Temporary placement of a left ventricular assist device also was discussed to allow time for the left ventricle to recover. After observing the patient for an additional 40 minutes on pharmacologic support, left ventricular function continued to improve without the need for further support, allowing successful weaning from cardiopulmonary bypass. Surgery on the proximal aorta for aneurysms and dissections almost invariably involve the use of an aortic conduit. The optimal method for a safe and effective conduit to the coronary anastomosis has been a matter of debate. A modified Bentall procedure with the use of ostial aortic buttons may provide superior results and currently constitutes the standard of care for aortic root reconstruction.2 In selected complex aortic cases with anatomic difficulties, such as extreme aortic dilatation/ calcification, reoperations, and fragile tissue, the direct anastomosis of the coronary buttons to a valved conduit can be challenging and technically demanding. In these situations, the Cabrol technique and its modifications still remain viable
options. The Cabrol technique, named originally by Cabrol as the “moustache” (because of the shape of the conduit connected end-to-end to both coronary ostia and side-to-side to the aortic graft),1 was used widely for aortic root replacements in the 1980s and 1990s. However, it currently is used less frequently, resulting in a paucity of experience by most cardiac surgeons. Complications resulting from the Cabrol technique and modifications can be challenging to recognize and treat.2 In the present case, echocardiography assisted in the diagnosis of air in the Cabrol graft. TEE has been described as a useful tool to identify and guide in the removal of air found in the heart after cardiotomy, which tends to collect in the most anterior locations.4,5 In certain instances, real-time visualization of intracardiac air by TEE may allow the anesthesiologist to directly guide the surgeon as to where to place a needle to aspirate air.6 A combination of TEE and epicardiac sonography by the anesthesiologist and surgeon allowed for the correct diagnosis of the cause of severe left ventricular dysfunction in this patient. The anterior and easily accessible location of the Cabrol graft allowed the surgeon to quickly aspirate air without the use of ultrasound guidance. Epiaortic and epicardial sonography provided confirmation that all of the air had been aspirated with adequate return of blood flow to the Cabrol graft and left coronary artery. Continuous TEE monitoring showed progressive recovery of left ventricular function over time. In summary, the authors present a case of severe left ventricular dysfunction caused by an air collection into the Cabrol graft due to its anterior anatomic position. Discussion among team members was crucial in determining and ultimately resolving the cause of the problem. The use of multiple modalities of echocardiography (TEE, epiaortic, and epicardiac ultrasound) allowed for the elimination of most causes and aided in proper deairing of the Cabrol conduit by needle aspiration. Prompt identification of left ventricular dysfunction and collaboration between the surgeons and anesthesiologists minimized the amount of ischemic time to the left ventricle, ultimately resulting in successful recovery of left ventricular function and the patient. APPENDIX A. SUPPORTING INFORMATION
Supplementary material cited in this article is available online at http://dx.doi.org/10.1053/j.jvca.2014.05.029.
REFERENCES 1. Cabrol C, Pavie A, Gandjbakhch I, et al: Complete replacement of the ascending aorta with reimplantation of the coronary arteries: New surgical approach. J Thorac Cardiovasc Surg 81:309-315, 1981 2. Kourliouros A, Soni M, Rasoli S, et al: Evolution and current application of the Cabrol procedure and its modifications. Ann Thorac Surg 91:1636-1641, 2011 3. Piper HM, Abdallah Y, Schäfer C: The first minutes of reperfusion: A window of opportunity for cardioprotection. Cardiovasc Res 61:365-371, 2004
4. Akiyama K, Arisawa S, Ide M, et al: Intraoperative cardiac assessment with transesophageal echocardiography for decision-making in cardiac anesthesia. Gen Thorac Cardiovasc Surg 61:320-329, 2013 5. Orihashi K, Matsuura Y, Hamanaka Y, et al: Retained intracardiac air in open heart operations examined by transesophageal echocardiography. Ann Thorac Surg 55:1467-1471, 1993 6. Wellford AL, Lawrie G, Zoghbi WA: Transesophageal echocardiographic features and management of retained intracardiac air in 2 patients after surgery. J Am Soc Echocardiogr 9:182-186, 1996
Air in the Moustache Can Choke the Left Ventricle Gianluca Torregrossa, MD,* Cindy Wang, MD,† Ramachandra Reddy, MD,* and Gregory W. Fischer, MD†
A
ORTIC ROOT PATHOLOGIES often require complex surgical repair techniques due to the involvement and manipulation of the coronary arteries. In 1981, Cabrol et al described a technique to reimplant the coronary arteries into the aortic conduit using a Dacron tube graft.1 In the 1980s and 1990s, the Cabrol technique and its modifications commonly were performed during aortic root surgery, but now are used less frequently due to the development of improved coronary ostial button mobilization techniques.2 The Cabrol technique still is considered a reasonable alternative when conventional coronary reimplantation is unsuccessful, such as in redo aortic root surgeries. The authors report a rare complication of this technique, in which echocardiography played a crucial role in the rapid and correct diagnosis. CASE REPORT
A 43-year-old male (123 kg, 195 cm) was admitted to the authors’ institution for evaluation of progressive dyspnea on exertion and worsening lower extremity edema. The patient had a history of Marfan syndrome, hypertension, and glaucoma. He had undergone an emergent ascending aortic replacement for a Stanford type-A dissection 1 year before the current admission. The perioperative course was complicated by a pulmonary embolism requiring the placement of an inferior vena cava filter and oral anticoagulation with warfarin. During this current admission, the preoperative work-up revealed the presence of a chronic aortic dissection, originating from the aortic arch and extending through the descending thoracic aorta to the level of the inferior mesenteric artery. Additionally, severe aortic regurgitation with a dilated aortic root was reported. Left ventricular function was preserved with no evidence of significant coronary artery disease. Consequently, the patient was scheduled for redo-sternotomy, a Bentall procedure, and a stage-I elephant trunk. After the patient was brought to the operating room, standard ASA monitors were placed and an indwelling left axillary artery catheter was inserted under local anesthesia. The patient was induced with 100 mg of propofol, 1,000 μg of fentanyl, and 10 mg of vecuronium. The airway was secured with a standard 8.0 cuffed endotracheal tube without difficulty. Subsequently, a 9French multi-lumen access catheter was placed into the right internal jugular vein under sonographic guidance. Additional monitoring included a pulmonary artery catheter, transesophageal echocardiography (TEE), cerebral oximetry, bispectral electroencephalography, and temperature measurement in both the nasopharynx and the bladder. General anesthesia was maintained with isoflurane and intermittent boluses of fentanyl, midazolam, and vecuronium. The initial intraoperative TEE showed normal right and left systolic function with an estimated left ventricular ejection
fraction of 50%-60% and no regional wall motion abnormalities, severe aortic regurgitation, an aortic root aneurysm measuring 5.2 cm in diameter, and an aortic dissection originating from the arch and extending throughout the descending aorta (Fig 1; Video clip 1). Because of the close proximity of the right ventricle to the sternum, the right axillary artery was cannulated before redosternotomy. The sternum then was divided uneventfully with an oscillating saw, and the cardiac structures carefully dissected. Cardiopulmonary bypass (CPB) was initiated using a double-stage venous cannula through the right atrium. The ascending aortic graft was cross-clamped. Cold blood cardioplegia was administered in an antegrade and retrograde fashion and the patient cooled to 21 degrees Celsius. A modified Bentall procedure was performed using a 27-mm St. Jude Medical mechanical valved graft (St. Jude Medical, Inc., St. Paul, MN). The right coronary button was implanted in a standard fashion into the valved conduit. Because of extreme tissue friability, an 8-mm Dacron graft conduit was anastomosed end-to-end with the left main coronary ostium (hemi-Cabrol technique). The proximal end of the graft then was directed behind the aortic root and connected to the side of the anterior surface of the aortic graft (Figs 2 and 3). The operation then was completed by replacing the aortic arch under deep hypothermic circulatory arrest with a trifurcated graft attached end-to-end to all of the 3 arch branches and end-to-side to the ascending aortic graft. Finally, the ascending aortic graft was anastomosed to the descending thoracic aorta using the elephant trunk technique (a small part of the prosthesis was inserted into the thoracic aorta). After removal of the cross-clamp, the heart was paced using an epicardial ventricular pacing wire. The transgastric shortaxis midpapillary view showed a severely dysfunctional left ventricle with severe hypokinesis in all regions while right ventricular function appeared to be preserved (Video clip 2). Because of the disparity in function of the 2 ventricles, it was concluded that the culprit was most likely a perfusion deficit in
From the Departments of *Cardiothoracic Surgery, and †Department of Anesthesiology, Icahn School of Medicine at Mount Sinai, New York, NY. Address reprint requests to Gianluca Torregrossa, MD, Department of Cardiothoracic Surgery, Mount Sinai Hospital, Guggenheim PavilionTwo West, 1190 5th Avenue New York, NY 10029. E-mail: gianluca. [email protected] © 2015 Published by Elsevier Inc. 1053-0770/2602-0033$36.00/0 http://dx.doi.org/10.1053/j.jvca.2014.05.029 Key words: cardiac surgery, aortic root surgery, air embolism
Journal of Cardiothoracic and Vascular Anesthesia, Vol 29, No 5 (October), 2015: pp 1291–1294
1291
1292
TORREGROSSA ET AL
Fig 1.
TEE midesophageal long-axis view showing aortic root aneurysm.
the distribution territory of the left main coronary artery. The course of the Cabrol graft could be identified clearly by TEE. The more distal portion of the Cabrol graft that was anastomosed to the left main coronary artery could not be well
Fig 2.
visualized by TEE due to acoustic dropout from the trachea. Color-flow Doppler imaging of the Cabrol graft seen in the midesophageal ascending aorta views did not demonstrate flow in the graft despite reducing the Nyquist limit to 0.05 cm/s.
Drawing of a hemi-Cabrol technique.
1293
AIR IN THE MOUSTACHE
any apparent abnormalities. An epiaortic ultrasound probe (inserted into a sterile cover) then was placed directly onto the Cabrol graft, displaying a long-axis view of the graft with the proximal region closest to the probe and the distal region furthest away from the probe. By color-flow Doppler, the epiaortic images demonstrated proximal flow with a clear delineation more distally where flow became absent (Fig 4). It was hypothesized that the area lacking flow represented a true phenomenon caused possibly by an air embolus in the Cabrol graft and not an artifact. The surgeon placed a needle attached to a syringe into the graft and aspirated approximately 2 mL of air before blood entered the syringe, confirming the diagnosis of an air lock. Blood flow in the left anterior descending (LAD) artery then was confirmed using colorflow Doppler by epicardiac sonography (Video clip 3). The heart was allowed to reperfuse for 45 minutes. During this time left ventricle ejection fraction improved from 5% to 25%. Under high-dose inotropic support (epinephrine 200 ng/ kg/min) the patient eventually was weaned successfully from CPB. The patient’s condition continued to improve, hemostasis was obtained, the chest closed, and the patient transferred to the intensive care unit. The patient was extubated several days later, weaned from inotropes, transferred to the ward, and eventually discharged home. DISCUSSION
Fig 3. Surgical field picture with blue arrow pointing to Cabrol graft.
Inotropic support was initiated with an epinephrine infusion while further direct visual inspection of the Cabrol conduit and the various anastomotic sites (left main coronary to Cabrol conduit and Cabrol conduit to the Bentall graft) did not reveal
Fig 4.
The unanticipated severe left ventricular dysfunction seen after CPB in this case resulted in an immediate discussion among all team members. Differential diagnosis at the time included kinking of the Cabrol graft, kinking of the anastomosis between the Cabrol graft and left main coronary artery, embolization of air or thrombus into the graft or left main coronary artery, and poor myocardial protection. Poor myocardial protection and longer CPB times may make the heart more susceptible to reperfusion injury and the “stone-heart”
Epiaortic color-flow Doppler ultrasound of Cabrol graft demonstrating absence of color flow in the distal portion of the graft.
1294
TORREGROSSA ET AL
phenomenon.3 However, right ventricular function was preserved and this disparity between the functional status of the 2 ventricles made the likelihood of poor global myocardial protection unlikely. The hypothesis of air in the Cabrol graft was supported by color-flow Doppler imaging of the Cabrol graft via epiaortic views. The acute dropout of color flow over the distal area of the unkinked graft suggested an obstruction to blood flow in that region. The aspiration of 2 mL of air from the Cabrol graft definitely confirmed the presence of an air embolus. Subsequent direct placement of the ultrasound probe over the Cabrol graft and LAD showed continuous color flow through the entire graft and LAD confirming adequate blood flow in both. This reassured the authors that there was no longer a problem at the level of the Cabrol graft to the left coronary anastomosis. The transgastric short-axis midpapillary view showed an improvement in myocardial contractility over the next few minutes. The transient period of ischemia, however, lasted for approximately 30 minutes and had a significant impact on overall left ventricular function. Besides inotropic support with epinephrine, additional support for the left ventricle was discussed to assist in recovery of function. Insertion of an intra-aortic balloon pump would increase coronary perfusion pressure while decreasing afterload and left ventricular work; however, this was contraindicated due to the presence of the chronic aortic dissection that extended throughout the descending aorta and would impose a high risk of rupture. Temporary placement of a left ventricular assist device also was discussed to allow time for the left ventricle to recover. After observing the patient for an additional 40 minutes on pharmacologic support, left ventricular function continued to improve without the need for further support, allowing successful weaning from cardiopulmonary bypass. Surgery on the proximal aorta for aneurysms and dissections almost invariably involve the use of an aortic conduit. The optimal method for a safe and effective conduit to the coronary anastomosis has been a matter of debate. A modified Bentall procedure with the use of ostial aortic buttons may provide superior results and currently constitutes the standard of care for aortic root reconstruction.2 In selected complex aortic cases with anatomic difficulties, such as extreme aortic dilatation/ calcification, reoperations, and fragile tissue, the direct anastomosis of the coronary buttons to a valved conduit can be challenging and technically demanding. In these situations, the Cabrol technique and its modifications still remain viable
options. The Cabrol technique, named originally by Cabrol as the “moustache” (because of the shape of the conduit connected end-to-end to both coronary ostia and side-to-side to the aortic graft),1 was used widely for aortic root replacements in the 1980s and 1990s. However, it currently is used less frequently, resulting in a paucity of experience by most cardiac surgeons. Complications resulting from the Cabrol technique and modifications can be challenging to recognize and treat.2 In the present case, echocardiography assisted in the diagnosis of air in the Cabrol graft. TEE has been described as a useful tool to identify and guide in the removal of air found in the heart after cardiotomy, which tends to collect in the most anterior locations.4,5 In certain instances, real-time visualization of intracardiac air by TEE may allow the anesthesiologist to directly guide the surgeon as to where to place a needle to aspirate air.6 A combination of TEE and epicardiac sonography by the anesthesiologist and surgeon allowed for the correct diagnosis of the cause of severe left ventricular dysfunction in this patient. The anterior and easily accessible location of the Cabrol graft allowed the surgeon to quickly aspirate air without the use of ultrasound guidance. Epiaortic and epicardial sonography provided confirmation that all of the air had been aspirated with adequate return of blood flow to the Cabrol graft and left coronary artery. Continuous TEE monitoring showed progressive recovery of left ventricular function over time. In summary, the authors present a case of severe left ventricular dysfunction caused by an air collection into the Cabrol graft due to its anterior anatomic position. Discussion among team members was crucial in determining and ultimately resolving the cause of the problem. The use of multiple modalities of echocardiography (TEE, epiaortic, and epicardiac ultrasound) allowed for the elimination of most causes and aided in proper deairing of the Cabrol conduit by needle aspiration. Prompt identification of left ventricular dysfunction and collaboration between the surgeons and anesthesiologists minimized the amount of ischemic time to the left ventricle, ultimately resulting in successful recovery of left ventricular function and the patient. APPENDIX A. SUPPORTING INFORMATION
Supplementary material cited in this article is available online at http://dx.doi.org/10.1053/j.jvca.2014.05.029.
REFERENCES 1. Cabrol C, Pavie A, Gandjbakhch I, et al: Complete replacement of the ascending aorta with reimplantation of the coronary arteries: New surgical approach. J Thorac Cardiovasc Surg 81:309-315, 1981 2. Kourliouros A, Soni M, Rasoli S, et al: Evolution and current application of the Cabrol procedure and its modifications. Ann Thorac Surg 91:1636-1641, 2011 3. Piper HM, Abdallah Y, Schäfer C: The first minutes of reperfusion: A window of opportunity for cardioprotection. Cardiovasc Res 61:365-371, 2004
4. Akiyama K, Arisawa S, Ide M, et al: Intraoperative cardiac assessment with transesophageal echocardiography for decision-making in cardiac anesthesia. Gen Thorac Cardiovasc Surg 61:320-329, 2013 5. Orihashi K, Matsuura Y, Hamanaka Y, et al: Retained intracardiac air in open heart operations examined by transesophageal echocardiography. Ann Thorac Surg 55:1467-1471, 1993 6. Wellford AL, Lawrie G, Zoghbi WA: Transesophageal echocardiographic features and management of retained intracardiac air in 2 patients after surgery. J Am Soc Echocardiogr 9:182-186, 1996