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eComment: Aortic connectors in coronary artery surgery

Division of Cardiothoracic Surgery, University of Miami, Miller School of Medicine, Miami, Fl 33136, USA

Successful six-year follow-up of a sutureless device for proximal anastomoses in a severely calcified ascending aorta

In this article, Puehler et al. [1] report one patient who underwent coronary artery bypass with use of the Symmetry device, and who needed aortic valve replacement (AVR) six years later. The authors report that at the time of AVR, the device was perfectly incorporated, and covered with a thin layer of endothelial cells.

The advent of aortic connectors to be used in coronary surgery for proximal anastomoses has generated interest among cardiac surgeons. With the introduction of the Symmetry^TM device (St Jude Medical, Inc, Minneapolis, MN) in the early 2000s, for the first time surgeons had an FDA-approved aortic connector which seemed easy to deploy and reliable.

After, the initial introduction, marketing and advertisement of this device became intense. Several early reports which appeared in the literature describing the advantages of this technology as well as early clinical results in small groups of patients were very encouraging [2]. As a result, surgeons worldwide began to use the Symmetry device. Shortly thereafter, however, reports began to appear in the literature describing early graft occlusion or stenosis in some patients [3]. In our own series of 132 patients [4] in whom 206 proximal anastomoses were constructed using the Symmetry^TM aortic connector, we found an early occlusion rate of 11%. As we could not identify the factors related to early graft failure, we stopped using this device. More recent clinical trials comparing hand-sewn aorta-graft anastomoses and mechanical anastomoses by using the aortic connector have continued to show a high rate of early graft occlusion and stenosis observed in the Symmetry connector group as compared to hand-sewn anastomoses [5]. Even though these findings were not confirmed by others, St Jude Medical informed surgeons worldwide that the device was being discontinued and removed from the market. Other companies interested in designing and manufacturing similar devices also elected to call off their programs.

What conclusion could one derive from this report? Since this particular device is no longer available commercially, it may be irrelevant to try to find more about the mechanisms that lead to failure in some patients and success in others. Clearly, a single case is not sufficient to make an argument in favor of aortic connectors, although the findings in this particular patient demonstrate that the aortic connector device can result in appropriate incorporation within the vessel wall and satisfactory long-term patency. Unfortunately, as the technology was removed from the market relatively early after development, factors potentially associated with failure could not be sufficiently investigated.

Notwithstanding the obvious limitations, reports such as this may reignite the interest for developing new aortic connectors. Although hand-sewn anastomoses continue to serve the population of cardiac surgeons well, and remain difficult to reproduce in terms of quality, safety, efficacy, and cost, investigators and industry should not completely discard the concept of developing a technology that can be used in coronary artery surgery from which patients could ultimately benefit.

	References

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1. Puehler T, Fraund-Cremer S, Cremer J, Boening A. Successful six-year follow-up of a sutureless device for proximal anastomoses in a severely calcified ascending aorta. Interact CardioVasc Thorac Surg 2008;7:670–672.[Abstract/Free Full Text]
2. Mack MJ, Emery RW, Ley LR, Cole PA, Leonard A, Edgerton JR, Dewey TM, Magee MJ, Flavin TS. Initial experience with proximal anastomoses performed with a mechanical connector. Ann Thorac Surg 2003;75:1866–1870.[Abstract/Free Full Text]
3. Bergsland J, Hol PK, Lingås PS, Lundblad R, Rein KA, Andersen R, Mørk BE, Halvorsen S, Mujanovic E, Kabil E, Svennevig JL, Fosse E. Intraoperative and intermediate-term angiographic results of coronary artery bypass surgery with Symmetry proximal anastomotic device. J Thorac Cardiovasc Surg 2004;128:718–723.[Abstract/Free Full Text]
4. Katariya K, Yassin S, Tehrani HY, Lombardi P, Masroor S, Salerno TA. Initial experience with sutureless proximal anastomoses performed with a mechanical connector leading to clampless off-pump coronary artery bypass surgery. Ann Thorac Surg 2004;77:563–567.[Abstract/Free Full Text]
5. Kachhy RG, Kong DF, Honeycutt E, Shaw LK, Davis RD. Long-term outcomes of the symmetry vein graft anastomosis device: a matchedcase-control analysis. Circulation 2006;114, 1 Suppl, I425–I4259.[Medline]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Marco Ricci Tomas A. Salerno Permission Requests Google Scholar Articles by Ricci, M. Articles by Salerno, T. A. PubMed Articles by Ricci, M. Articles by Salerno, T. A. Related Collections Related Article