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Intraclude Device: Tips and Tricks in Presence of a Particular Aortic Configuration
Monica Contino1, Massimo Giovanni Lemma1, Andrea Mangini1, Claudia Romagnoni1, Simone Colombo1, Antonietta Delle Fave1, Carlo Antona2.
1Ospedale Luigi Sacco, Milan, Italy, 2UniversitÓ degli Studi di Milano, Milan, Italy.

OBJECTIVE: Minimally invasive valve surgery was first introduced into clinical practice during the mid 1990s; this technique is nowadays getting a growing diffusion especially because of the significant improvement in patients quality of life in the post-operative course. The more recent introduction of an intra-aortic balloon for aortic clamping is further facilitating this kind of surgery. In this case report we explain how to manage aortic balloon positioning in presence of a particular aortic configuration.
METHODS: From August 2012 to November 2015, 33 patients (20 male) underwent minimally invasive valve surgery with the use of IntraClude® (Edwards); mean age was 58±9,2 years. 22 were repair, 11 replacement, 2 redo surgeries. All these patients have been selected basing on the analysis of a pre-operative thoracic and abdominal CT scan performed to analyze aortic course and diameters. In three cases the radiological exam analysis detected some particular aspects: two patients had a bovine aortic arch associated to a very narrow curving at this level, while in the last case the aorta showed only a very close curving at the level of the arch. All these patients were young, with a wide aortic compliance and we experienced some problems at the moment of balloon positioning.
RESULTS: After femoro-femoral extra-corporeal circulation starting, under trans-esophageal control we began the Intraclude positioning by advancing the guide-but we didn’t succeed in visualizing it at the level of the ascending aorta because, due to the particular aortic arch configuration, the wire went straight into the supra-aortic vessels. At that moment we thought to use the kite effect: we inflated the balloon with 5 ml of saline solution and we advanced it alone without the wire taking advantage of the femoro-femoral flow directed towards the ascending aorta; this tip worked well and we could proceed with surgery.
CONCLUSIONS: Intra-aortic balloon for aortic clamping represent an important tool in minimally invasive valve surgery. In presence of a particular aortic configuration we can experience some problems but this shouldn’t be considered a reason for exclusion because thanks to some tricks it is possible to easily overcome the positioning difficulty.

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