Sutureless anastomoses: the main goal for a calcified aorta?

We read with great interest the article written by Dohmen et al. published in the EJCTS January 2011 [1]. The authors reported on their experience with the PAS-Port automated proximal aortic connector device (ACD) in 17 patients with heavily calcified aorta during coronary bypass surgery grafting (CABG). The early graft patency in every patient was proven by computed tomography (CT) scan after 30 days. To avoid aortic manipulation, every CABG procedure was performed in off-pump beating-heart technique, though two patients had to convert to cardiopulmonary bypass (CPB) in case of ventricular fibrillation and hemodynamic instability. These two patients suffered from prolonged reversible neurological deficits (PRIND) and another one from longlasting postoperative delirium. With respect to the older patient population, every heart surgeon is familiar with the problem of severe calcified aorta not only during CABG procedure. As described in the article, there are many different strategies in the literature to cope with this problem during CABG surgery, such as off-pump aortic ‘non-touch technique’ using tor y-arterial grafts to the internal thoracic arteries [2]. The use of ACDs in this special patient population, as stated in the article, is not new. Though many technical problems, for example, proper alignment of the vein graft and early graft thrombosis, were seen in the initial phase after using ACDs, the results are not worse than hand-sutured anastomoses. However, midterm results remain poor and led to abandonment of ACDs in the routine use. Long-term follow-up for ACD patients is hardly