Edwards Intuity Aortic Bioprosthesis in Patient with Bicuspid Aortic Valve.

Bicuspid aortic valve (BAV) is generally considered to be a contraindication to sutureless aortic valve replacement (AVR). Implantation of the Edwards Intuity aortic bioprosthesis is an innovative approach associated with superior hemodynamic performance, significantly reduced myocardial ischaemia and cardiopulmonary bypass times and proves to be suitable for type 1 and 2 of bicuspid aortic valves replacement. We report a case of successful AVR using a fast deployment bioprosthesis,the Edwards Intuity Valve System, in a 67-year-old woman with a bicuspid aortic valve and concomitant severe aortic stenosis.

[Incidental finding of a cardiac paraganglioma]. / Zufallsbefund eines kardialen Paraganglioms.

Cardiac paragangliomas are extremely rare neoplasms with an incidence of 1% of all cardiac tumors and can be completely asymptomatic, therefore, diagnosis is difficult. This article reports the case of an 18-year-old man with a heart murmur detected during a routine physical examination. Echocardiography revealed a heart tumor measuring 7 cm in size in the right atrium. Due to the tumor size and the threat of tricuspid valve insufficiency, tumor resection was performed. The histopathological examination revealed a cardiac paraganglioma with positive reactions of the tumor cells for chromogranin A, synaptophysin and CD56. Differentiating a primary cardiac paraganglioma from other more common cardiac tumors and particularly from metastases of neuroendocrine neoplasms from other locations is essential not only for the further clinical treatment but also for the prognosis of the patient.

Apoptosis and necrosis: two different outcomes of cigarette smoke condensate-induced endothelial cell death.

Cigarette smoking is one of the most important and preventable risk factors for atherosclerosis. However, because of the complex composition of cigarette smoke, the detailed pathophysiological mechanisms are not fully understood. Based on controversial reports on the pro-atherogenic activity of cigarette smoke condensate, also called tar fraction (CSC), we decided to analyse the effects of CSC on the viability of endothelial cells in vitro. The results of this study show that low concentrations of the hydrophobic tar fraction induces DNA damage resulting in a P53-dependent and BCL-XL-inhibitable death cascade. Western blot analyses showed that this cascade is caspase-independent and immunofluorescence analysis have shown that the apoptotic death signalling is mediated by the release of apoptosis-inducing factor. Higher CSC concentrations also induce apoptotic-like signalling but the signalling cascade is then redirected to necrosis. Despite the fact that CSC induces a profound increase in cellular reactive oxygen species production, antioxidants exhibit only a minimal cell death protective effect. Our data indicates that not only hydrophilic constituents of cigarette smoke extract, but also CSC is harmful to endothelial cells. The mode and the outcome of CSC-induced cell death signalling are highly concentration dependent: lower concentrations induce caspase-independent apoptosis-like cell death, whereas incubation with higher concentrations interrupts apoptotic signalling and induces necrosis.

Gender-related differences in patients undergoing mechanical aortic valve replacement with the CarboMedics valve.

AIM: The aim of this paper was to evaluate gender-related differences in patients undergoing mechanical aortic valve replacement with the CarboMedics valve. METHODS: During a 20 year period, 629 patients (median age 60 years) underwent mechanical aortic valve replacement with the CarboMedics valve. Of these, 215 patients were female (34%). The median follow-up for the entire cohort was 10.2 ± 6.2 years. RESULTS: In-hospital mortality for the entire cohort was 9% (male 7.3% vs. female 11.0%, P=0.005). Cox regression analysis revealed redo-surgery (HR=2.35, CI 1.35-4.08), LVEF<30% (HR=2.31, CI 1.36-3.93), age (HR=1.60, CI 1.27-2.02), as well as female gender (HR=2.07, CI 1.28-3.35) as independent predictors of survival. For male gender LVEF<30% (HR=2.47, CI 1.23-4.93) and age (HR=1.75, CI 1.25-2.43) were independent predictors of survival. For female gender, additional CABG (HR=2.15, CI 1.08-4.28), redo surgery (HR=3.64, CI 1.78-7.46) as well as age (HR=1.48, CI 1.06-2.06) were independent predictors of survival. CONCLUSION: Gender per se is an independent risk factor of survival after mechanical aortic valve replacement. Severely impaired LVEF independently predicts survival in males whereas additional CABG and redo surgery do in females. Age affects survival in both sexes. These findings may serve as a basis for further improving gender related outcome.

Evaluation of aortic cannula jet lesions in a porcine cardiopulmonary bypass (CPB) model.

In cardiosurgery patients atherosclerotic debris displaced from the cannulation site but also from the opposite aortic wall by the "sandblast-like" effect of the high-pressure jet emanating from the cannula is a potential source of intraoperative arterial embolization and consequently postoperative neurologic dysfunction. The present study examined the extent to which shear stress exerted on the intact aortic intima by an aortic cannula jet stream can cause endothelial lesions that promote thrombogenesis and consequently thrombembolism. A single-stream, straight-tip aortic cannula was used in a porcine cardiopulmonary bypass (CPB) model. Following a 120-minute CPB pump run, a 60-minute stabilization period was allowed before sacrificing the pigs (N.=40) for histological evaluation of the ascending aorta and the brain. Opposite the cannulation site endothelial lesions (diameter: 3.81±1.3 mm; depth: 0.017±0.003 mm) were present in 22.5% (9/40) of aortic specimens. Cerebral thrombembolic lesions were not found. The present study showed that single-stream, straight-tip aortic cannulas caused jet lesions of the formerly intact aortic endothelium opposite the cannulation site in 22.5% of cases in a porcine CPB model.

Considerations for patients awaiting heart transplantation.

The aim of this study is to provide a description of patients on the waiting list for heart transplants in Germany; the focus is on comparing the era after implementation of the new transplant law with the former era. This study used data from the Eurotransplant registry. The population consisted of all patients who registered for heart transplantation in Germany between January 1990 and May 2009. Patients were followed up to the earliest of the following events: heart transplantation, death, or end of the observation period. The actual mortality rates were calculated using a competing risk methodology. The proportion of patients on the waiting list aged 65 years or older has increased from 1.9 % in 1990 to 8.3 % in 1997, 7.8 % in 2000 and 12.6 % on December 31, 2008. The 1-year waiting list mortality rate, expressed as the proportion of patients who die within 1 year after being listed for heart transplantation decreased in the period 2001-2009 compared to the period 1991-2000. Patients registered in the period from 1991-2000 had a 25.9 % chance of dying prior to heart transplantation compared to 18.9 % for patients who were registered in the years 2001-2009. In the registration period 1981-1990, a transplant candidate had a 64.3 % chance of undergoing heart transplantation within the first year after being listed, while for patients who were registered in the period 2001-2009 this probability has been reduced to 40.2 %. Despite the fact that patient profiles have worsened and access to transplantation decreased, mortality rates of patients on the heart transplant waiting list have decreased. These data show that treatment of patients with advanced heart disease has improved in Germany.

Connective tissue changes in a mouse model of vein graft disease.

AIM: The extracellular matrix plays an important physiological role in the architecture of the vascular wall. In arterialized vein grafts severe early changes, such as thrombosis and neointimal hyperplasia occur. Paclitaxel is in clinical use as antiproliferative coating of coronary stents. We aimed to investigate the early connective tissue changes in arterialized vein grafts and the influence of perivascular paclitaxel treatment in an in vivo model. METHODS: C57 black mice underwent interposition of the vena cava into the carotid artery. Neointimal hyperplasia, thrombosis, acid mucopolysaccharides (Alcian), collagen fibers (trichrome Masson), elastic fibers, and apoptosis rate (TUNEL) were quantified in paclitaxel treated veins and controls. RESULTS: In both, controls and paclitaxel treated vein grafts acid mucopolysaccharides and elastic fibers were found predominantly in the neointima, whereas collagen fibers were found mainly in the media and adventitia. At 4 weeks postoperatively the neointimal thickness in controls was 52 (13-130) microm, whereas in 0.6 mg/mL l paclitaxel treated veins it was 103 (43-318) microm (P=0.094). At 8 weeks postoperatively paclitaxel treated veins showed a significantly increased neointimal thickness of 136 (87-199) microm compared with 79 (62-146) microm in controls (P=0.032). There was no difference in apoptosis rate between the two groups (P=NS). Even with the lowest concentration of 0.008 mg/mL paclitaxel veins showed a neointimal thickness of 67 (46-205) microm at 4 weeks postoperatively (P=NS vs controls). CONCLUSION: Early vein graft disease is characterised by an accumulation of acid mucopolysaccharides and elastic fibers in the thickened neointima. Paclitaxel treatment increases the neointimal hyperplasia in mouse vein grafts in vivo.

The aging cardiomyocyte: a mini-review.

BACKGROUND: Aging per se is a risk factor for reduced cardiac function and heart diseases, even when adjusted for aging-associated cardiovascular risk factors. Accordingly, aging-related biochemical and cell-biological changes lead to pathophysiological conditions, especially reduced heart function and heart disease. OBJECTIVE: In this review, we summarize the changes that occur as the heart ages from youth to old age on the basis of the cardiac myocyte. Aging phenotypes and underlying mechanisms shall be discussed that affect cardiomyocyte repair, signaling, structure, and function. METHODS: Review of the literature. RESULTS: The following factors play vital roles in the aging of cardiomyocytes: oxidative stress, inflammation, cellular protection and repair, telomere integrity, survival and death, metabolism, post-translational modifications, and altered gene expression. Importantly, non-cardiomyocyte-based aging processes (vascular, fibroblast, extracellular matrix, etc.) in the heart will interfere with cardiomyocyte aging and cardiac function. CONCLUSION: Based on our analyses, we postulate that the physiological aging process of the heart and of the cardiomyocyte is primarily driven by intrinsic aging factors. However, extrinsic aging factors, e.g. smoking, also make an important contribution to pathologically accelerated aging of the heart.

Do manual assisting maneuvers increase speed and technical performance in robotically sutured coronary bypass graft anastomoses?

BACKGROUND: Robotic endoscopic coronary artery bypass grafting procedures usually are performed as solo surgery operations. This study aimed to investigate whether manual assistance can reduce suturing times and anastomotic suturing problems in robotic coronary artery surgery. METHODS: In isolated pig hearts, the right coronary artery was excised from the epicardium as a pedicle. This pedicled vessel, which resembles the internal mammary artery, was sutured to the left anterior descending artery using the daVinci telemanipulation system. The anastomosis was performed in a running fashion using 7/0 Pronova. In group 1 (n = 20), the suture was performed by the console surgeon as a solo operation. In group 2 (n = 20), the anastomosis was assisted by a team member using an endo forceps. The operations were performed by five surgeons of different training levels. RESULTS: The overall anastomotic time was 24 +/- 15 min in group 1 and 22 +/- 12 min in group 2. The difference was not significant. The rate for anastomotic suturing problems (thread rupture, knot formation, sling formation, needle bending) was 8 in 20 (40%) in group 1 and 8 in 20 (40%) in group 2 (no difference). Anastomotic times and anastomotic suturing errors were dependent on surgeon experience. All anastomoses in both groups showed correct suture alignment and were probe patent. CONCLUSION: In a wet lab model of robotic coronary anastomoses, assisting maneuvers do not decrease suturing speed. Similar suturing quality can be achieved whether the suture is performed in a solo fashion or in an assisted manner.

Superior prevention of acute rejection by tacrolimus vs. cyclosporine in heart transplant recipients--a large European trial.

We compared efficacy and safety of tacrolimus (Tac)-based vs. cyclosporine (CyA) microemulsion-based immunosuppression in combination with azathioprine (Aza) and corticosteroids in heart transplant recipients. During antibody induction, patients were randomized (1:1) to oral treatment with Tac or CyA. Episodes of acute rejection were assessed by protocol biopsies, which underwent local and blinded central evaluation. The full analysis set comprised 157 patients per group. Patient/graft survival was 92.9% for Tac and 89.8% for CyA at 18 months. The primary end point, incidence of first biopsy proven acute rejection (BPAR) of grade >/= 1B at month 6, was 54.0% for Tac vs. 66.4% for CyA (p = 0.029) according to central assessment. Also, incidence of first BPAR of grade >/= 3A at month 6 was significantly lower for Tac vs. CyA; 28.0% vs. 42.0%, respectively (p = 0.013). Significant differences (p < 0.05) emerged between groups for these clinically relevant adverse events: new-onset diabetes mellitus (20.3% vs. 10.5%); post-transplant arterial hypertension (65.6% vs. 77.7%); and dyslipidemia (28.7% vs. 40.1%) for Tac vs. CyA, respectively. Incidence and pattern of infections over 18 months were comparable between groups, as was renal function. Primary use of Tac during antibody induction resulted in superior prevention of acute rejection without an associated increase in infections.

Electromechanical synchronization of the heterotopic and native heart by dual atrial stimulation following heart transplantation.

After heterotopic heart transplantation, a 59-year-old woman presented with remarkable symptoms of breathlessness and fatigue, despite excellent donor heart function. Asynchrony of donor and native heart provoked haemodynamic instability. Dual atrial pacemaker implantation lead to linkage and synchronization of atrial and ventricular contraction in both the donor and native heart with the faster organ executing the synchronization. Remarkable relief of symptoms has been evident during the long-term follow-up.

Technical challenges in totally endoscopic robotic coronary artery bypass grafting.

OBJECTIVE: Robotic technology is a prerequisite for performance of totally endoscopic coronary artery bypass grafting. During the implementation phase of totally endoscopic coronary artery bypass, surgeon-related technical difficulties might be encountered. It was the aim of this study to assess the incidence of these challenges, to find risk factors, and to describe clinical results associated with technical errors. METHODS: From October 2001 through October 2004, 40 patients received robotically assisted totally endoscopic left internal thoracic artery grafts to the left anterior descending coronary artery system with the da Vinci telemanipulation device. All patients underwent remote access cardiopulmonary bypass perfusion through groin access, and all anastomoses were performed on the arrested heart. RESULTS: Undesirable technical events of various grades occurred in 20 (50%) of 40 patients: bleeding from a port hole in 3 (8%), left internal thoracic artery damage in 3 (8%), epicardial lesion in 3 (8%), remote access perfusion problems in 9 (23%), bleeding from the anastomosis in 4 (10%), and anastomotic stenosis in 2 (5%). There was no hospital mortality. The following differences were noted between patients without technical difficulties (group 1) and those in whom problems occurred (group 2): total operative time of 314 minutes (260-540 minutes) versus 418 minutes (270-690 minutes; P = .007), ventilation time of 6 hours (0-26 hours) versus 14 hours (0-278 hours; P = .004), intensive care unit stay of 20 hours (11-70 hours) versus 44 hours (16-336 hours; P=.183), hospital stay of 7 days (4-13 days) versus 8 days (5-21 days; P = .038), and cumulative freedom from angina at 36 months of 93% versus 100% (P = .317). CONCLUSION: We conclude that technical difficulties during totally endoscopic coronary artery bypass grafting translate into markedly increased operative time, moderately prolonged postoperative ventilation time, and slightly increased hospital stay. Short-term survival and freedom from angina, however, do not seem to be compromised.

Factors associated with mortality and long time survival in patients undergoing modified Bentall operations.

AIM: We report our results on mortality, morbidity and long time events after composite graft replacement of the aortic root and ascending aorta/aortic arch and factors associated with them. METHODS: Seventy-four patients, aged 52 years (15-73) underwent modified ''button'' Bentall operation. The indication for operation was acute dissection in 29 (39%) patients, chronic dissection in 3 (4%), aortic regurgitation after previous replacement of the ascending aorta because of aortic dissection in 2 (3%) and non dissecting aneurysm in 40 (54%). Concommitant procedures were (partial) replacement of the aortic arch in 11 (15%) and coronary artery bypass grafting in 5 (7%). Six patients (8%) had undergone previous cardiac surgery. Mean follow up was for 49 +/- 46 months (maximum 198). RESULTS: Length of intensive care unit (ICU) stay was 3 days (1-72). Hospital mortality was 12%. Factors significantly associated with hospital mortality were: aortic dissection, cardiopulmonary bypass time, aortic cross clamp time, deep hypothermic circulatory arrest, low cardiac output syndrome, revision due to bleeding, renal failure requiring hemofiltration, multisystemic organ failure and sepsis. None of these factors was significantly associated with long term survival. Survival rates including hospital deaths were 86%, 84%, 75% and 75% after 1, 3, 5 and 7 years respectively. Pseudoaneurysm at the composite graft occurred in 3%, infection of the prosthesis in 1%. Neither valve thrombosis nor thromboembolic events occurred postoperatively. CONCLUSIONS: Modified Bentall operation is a demanding operation with acceptable hospital mortality. The long time survival rates are good and the big majority of patients is eventfree after operation.

Hybrid coronary artery revascularization: logistics and program development.

Planning hybrid coronary artery revascularization--a combination of cardiac surgery with percutaneous procedures--requires, at first sight, a very complex logistical setup. Technical and equipment related details should be defined as early as possible in order to have time for training of all OR personnel involved. The most challenging aspect in OR-located hybrid coronary revascularization remains a very close cooperation of cardiac surgeons and interventional cardiologists. This teamwork does include indication findings and subsequent referral of multivessel coronary artery disease patients to hybrid procedures, as well as high individual flexibility of interventionalists and surgeons. The major prerequisite for this cooperation is a mutual acceptance of different revascularization approaches and the intent to combine their most striking advantages. Intraoperative graft angiography during coronary artery bypass grafting (CABG) procedures is one important step toward simultaneous hybrid coronary revascularization procedures. We describe our experience with on table angiography using a mobile C-arm for intraoperative imaging. This fluoroscopy system can in selected cases be used for simultaneous hybrid procedures.

Ongoing procedure development in robotically assisted totally endoscopic coronary artery bypass grafting (TECAB).

BACKGROUND: Totally endoscopic coronary artery bypass grafting (TECAB) using robotics requires stepwise introduction into a heart surgery program. It is the aim of this study to evaluate the state of procedure development after continued application of telemanipulation techniques in the clinical setting. We also sought to assess perioperative and intermediate term clinical results after robotically assisted CABG. PATIENTS AND METHODS: From June 2001 to March 2005, robotically assisted CABG using the daVinci system was carried out in 107 patients with single and multi-vessel coronary artery disease. The following procedures were performed: robotically assisted endoscopic left internal mammary artery (LIMA) harvesting and completion of the procedure as conventional CABG, MIDCAB, or OPCAB (n = 22), robotically assisted suturing of LIMA-to-LAD anastomoses during conventional CABG (n = 28), TECAB on the arrested heart using remote access perfusion (n = 48), TECAB on the beating heart using an endostabilizer (n = 8), takedown of adhesions (TECAB intended) (n = 1). RESULTS: Hospital mortality was 0% and cumulative risk adjusted mortality reached 1.6 lives saved versus EuroSCORE predictions. Undesirable surgical events (USE) such as conversion, on table revision, or postoperative revision procedures occurred in 34 out of 107 (32%) patients. Median ventilation time and ICU stay, however, were 11(0-278) hours and 21(11-389) hours, respectively. Cumulative 3 years survival was 100% and freedom from angina at 3 years was 97%. CONCLUSIONS: We conclude that despite being surgically challenging robotically assisted coronary artery surgery can be implemented with acceptable safety. TECAB procedures have reached a reproducible state. Perioperative mortality after robotically assisted CABG may be lower than predicted. Intermediate term clinical results are very satisfactory.

A variation of the radial artery and its clinical implications for coronary artery bypass grafting.

Since the radial artery is increasingly harvested as a bypass graft, surgeons are confronted with its anatomical variations. We report on a radial artery running laterally around the distal part of the radius, while a superficial palmar branch is running straight down. The radial artery can be dissected distally to get enough length for the bypass graft, but attention has to be paid to the superficial branch of the radial nerve running nearby to prevent postoperative paresthesias and numbness. The superficial palmar branch of the radial artery can be ligated. Allen's test in such a case is not valid because it is always negative.

On the fate of skeletal myoblasts in a cardiac environment: down-regulation of voltage-gated ion channels.

We have analysed the voltage-gated ion channels and fusion competence of skeletal muscle myoblasts labelled with green fluorescent protein (GFP) and the membrane dye PKH transplanted into the infarcted myocardium of syngenic rats. After cell transplantation the animals were killed and GFP(+)-PKH(+) myoblasts enzymatically isolated for subsequent studies of ionic currents through voltage-gated sodium, calcium and potassium channels. A down-regulation of all three types of ion channels after engraftment was observed. The fraction of cells with calcium (68%) and sodium channels (65%) declined to zero within 24 h and 1 week, respectively. Down-regulation of potassium currents (90% in control) occurred within 2 weeks to about 30%. Before injection myoblasts expressed predominantly transient outward potassium channels whereas after isolation from the myocardium exclusively rapid delayed rectifier channels. The currents recovered completely between 1 and 6 weeks under cell culture conditions. The down-regulation of ion channels and changes in potassium current kinetics suggest that the environment provided by infarcted myocardium affects expression of voltage-gated ion channels of skeletal myoblasts.

Combined transplantation of skeletal myoblasts and bone marrow stem cells for myocardial repair in rats.

OBJECTIVES: To prove whether intramyocardial transplantation of combined skeletal myoblasts (SM) and mononuclear bone marrow stem cells is superior to the isolated transplantation of these cell types after myocardial infarction in rats. METHODS: In 67 male Fischer rats myocardial infarction was induced by direct ligature of the LAD. Seven days postinfarction baseline echocardiography and intramyocardial cell transplantation were performed. Via lateral thoracotomy 200 microl containing either 10(7) SMs or 10(7) bone marrow-derived mononuclear cells (BM-MNC) or a combination of 5x10(6) of both cell types (MB) were injected in 10-15 sites in and around the infarct zone. In controls (C) 200 microl of cell-free medium were injected in the same manner. Before injection both cell types were stained using a fluorescent cell linker kit (PKH, Sigma). In addition, SMs were transfected with green fluorescent protein. Nine weeks postinfarction follow-up echocardiography was performed and animals were sacrificed for further analysis. RESULTS: At baseline echocardiography there was no difference in left ventricular ejection fraction (LVEF; C, SM, BM-MNC, MB: 60.1+/-3.2, 53.3+/-10.2, 53.1+/-8.7, 49+/-9.0%) and left ventricular end diastolic diameter (LVEDD; C, SM, BM-MNC, MB: 6.5+/-0.8, 5.17+/-0.8, 5.77+/-1.4, 6.25+/-0.8 mm) between the different therapeutic groups. Eight weeks after cell transplantation LVEDD was significantly increased in all animals except those that received a combination of myoblasts and bone marrow stem cells (MB; C, SM, BM-MNC, MB: 7.7+/-0.6 mm, P=0.001; 7.7+/-1.5 mm, P<0.001; 7.7+/-1.1 mm, P=0.005; 6.6+/-1.7 mm, P=0.397. At the same time LVEF decreased significantly in the control group (C), stayed unchanged in animals that received bone marrow stem cells (BM-MNC) and increased in animals that received myoblasts (SM) and a combination of both cell types (MB; C, SM, BM-MNC, MB: 45.3+/-7.0%, P=0.05; 63.9+/-15.4%, P=0.044; 54.3+/-6.3%, P=0.607; 63.0+/-11.5%, P=0.039). CONCLUSIONS: The present data show that the concept of combining SMs with bone marrow-derived stem cells may be of clinical relevance by merging the beneficial effects of each cell line and potentially reducing the required cell quantity. Further studies are required to identify the exact mechanisms underlying this synergy and to allow full exploitation of its therapeutic potential.

Is the axillary artery a suitable cannulation site in aortic surgery?

AIM: The axillary artery is currently gaining interest as an alternative to femoral artery cannulation in aortic surgery. It was the aim of our study to evaluate the feasibility, safety, and efficacy of axillary artery cannulation in a series of patients undergoing surgery of the ascending aorta and/or the aortic arch. METHODS: From 1998 to 2002 cardiopulmonary bypass (CPB) perfusion via the axillary artery was intended in 35 patients (28 male), median age 61 (22-77) years. The underlying disease was acute aortic dissection type A in 22/35 (63%), chronic aortic dissection type A in 2/35 (6%), ascending aortic aneurysm in 8/35 (22%), aortic regurgitation after previous ascending aortic replacement in 1/35 (3%), pseudoaneurysm after Bentall operation in 1/35 (3%) and coronary artery disease with severe arteriosclerosis of the aorta in 1/35 (3%). RESULTS: Conversion to femoral artery or ascending aortic cannulation was necessary in 3 patients. In the other cases, adequate CPB flows of 2.4 l/m2/min were achieved. In 1 case local dissection of the axillary artery occurred after emergency cannulation. No postoperative complications related to axillary artery cannulation, such as upper extremity ischemia, brachial plexus injury, or local wound infection occurred. No new postoperative stroke was noted, hospital mortality was 4/35 (11%) patients. CONCLUSION: Axillary artery cannulation is feasible in the majority of cases and seems to be a safe and effective method in surgery of the ascending aorta and aortic arch. Several disadvantages of femoral artery cannulation and perfusion can be avoided.