Asian Cardiovasc Thorac Ann 2004;12:376-378
© 2004 Asia Publishing EXchange Ltd
Aortic Valve Replacement in a Patient with Takayasu’s Disease without Cross-clamping The Calcified Ascending Aorta
Thanos Athanasiou, PhD,
Pankaj Kumar, FRCS,
Hutan Ashrafian, MBBS,
Sujit Nair, MRCS,
Alex Charitou, MRCS,
Rex D Stanbridge, FRCS
Department of Cardiothoracic Surgery St Mary’s Hospital London, UK
For reprint information contact: Thanos Athanasiou, PhD Tel: 44 207 886 6147 Fax: 44 207 886 6777 Email: tathan5253{at}aol.com Department of Cardiothoracic Surgery, St Mary’s Hospital, 70 St. Olaf’s Road, London SW6 7DN, UK.
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ABSTRACT
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The case of a 42-year-old female requiring surgical management of aortic regurgitation, secondary to Takayasu’s disease, with a co-existing heavily calcified ascending aorta is described. In order to address aortic valve surgery with such calcific disease affecting the ascending aorta and peripheral vessels, we present a simple and safe technique that allows aortic valve replacement using a vascular intra-aortic occlusion catheter.
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CLINICAL CASE
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A 42-year-old South Asian female was referred to our unit for aortic valve replacement. She had a 10-year history of Takayasu’s arteritis and an occluded left subclavian artery in which stenting had failed three times. In the previous 6 months, she had suffered from atypical chest pain unrelated to exercise and also complained of dyspnea with an exercise tolerance reduced to ten meters. A grade 2 early diastolic murmur was audible over the aortic area. Vasculitic (CRP, ESR, C3, C4, ANA) and treponemal screens were negative.
Transthoracic echocardiogram showed a mildly dilated aortic root with moderate central aortic regurgitation, however no stenosis was evident. Whilst overall bi-ventricular function was preserved, surgery was considered since dilatation of the left ventricle deteriorated significantly following serial echocardiograms (end-diastolic diameter increased from 5.9 mm to 7.2 mm during a six month interval). Angiography showed no ostial stenosis or aneurysmal proximal coronary arteries with smaller aneurysms distally. The left subclavian stent was seen to be occluded and Magnetic Resonance Angiography (MRA) confirmed a mildly dilated aortic root of 31 mm and a solidly calcified ascending aorta.
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TECHNIQUE
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The procedure was performed through a standard middle sternotomy, with cannulation as well as cross-clamping of the ascending aorta being avoided. Extracorporeal circulation was established by femoral arterial and right atrial cannulation, with moderate hypothermia and intermittent cold blood cardioplegia for myocardial protection. Under transesophageal echocardiographic (TEE) guidance, to avoid unsuitable and calcific sites, a diameter 12 French Pruitt aortic occlusion catheter (Cryolife Company, USA, Figure 1
) was placed through a small hole at the medial aspect of the ascending aorta, with a 4-0 prolene purse-string and a snugger around the site of catheter insertion. The tip of the catheter was directed without difficulty from the medial aspect, on the under surface of the arch, passing in a retrograde fashion down the ascending aorta towards the aortic valve at the lateral end of the aortotomy, and was controlled by manipulating the malleable stylet of the catheter. The balloon of the catheter was subsequently inflated with 60 mL of normal saline in order to achieve effective and secure positive pressure on the aortic wall. A tape, with a snugger around the proximal aorta and a malleable retractor pushing towards the cranial axis, increased the stability of the inflated balloon and facilitated adequate exposure of the aortic valve and the left coronary ostium in the operative field (Figure 2).
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Figure 2. Intra-operative field revealing the exposure of the aortic valve apparatus following insertion and application of the Pruitt intra-aortic balloon catheter.
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Due to heavy calcification of the aortic wall, there was no "ideal" area for aortotomy, which was therefore made in a standard transverse manner, approximately 1 cm above the sino-tubular junction. The aortic valve replacement procedure was then completed with a 23 mm mechanical valve and interrupted suturing. Endarterectomy and decalcification of the aortotomy edges were performed and the aorta was closed in two layers with 4-0 polypropylene sutures buttressed with polytetrafluroethylene felt. The catheter balloon was then deflated and used as an aortic vent to facilitate the de-airing procedure. The patient had an uncomplicated recovery and was discharged home on the sixth postoperative day.
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DISCUSSION
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Takayasu’s disease is a systemic inflammatory condition of unknown etiology, involving the aorta and its main branches, which predominantly affects young women. Initially a granulomatous aortitis leads to intimal thickening, fibrosis and calcification, which in 13%–44% of cases results in annular dilatation and aortic regurgitation that may require operative management.1,2 However, clamping of a calcified aorta during cardiac surgery predisposes to cerebral embolism, aortic rupture and laceration of the diseased aorta with increased risk of perioperative stroke, neurobehavioral changes and death. The risk of stroke is dependent on the presence, location (with increased likelihood at middle and lateral segments) and extent of disease.3
Different surgical strategies have been developed in order to prevent macro and microemboli in addition to myocardial and peripheral embolism, by minimizing manipulation on any type of intimal plaque of the ascending aorta. Not only can embolism result from dislodged debris mainly after cross-clamping, it can also occur during cannulation or even palpation of the ascending aorta. Over the last 20 years, Foley catheters have been used for intra-aortic occlusion as an alternative to cross-clamping, and more recently the HeartportTM endoclamp (Heartport, Redwood City, CA) has been introduced for minimally invasive procedures.4,5
In our case we used the Pruitt Occlusion Catheter, which has previously been used for rapid control and tamponade of aortic bleeding as well as in the peripheral arteries including the iliac, femoral and popliteal arteries. The Pruitt catheter can facilitate injection of heparin, contrast media and thrombolytic agents through the central irrigation lumen, although this was not employed for achieving cardioplegic arrest. There are also several advantages of this catheter in comparison to the Foley catheter which is bulkier and more difficult to locate into a desirable position without a malleable stylet. Furthermore, the Heartport Endoaortic Clamp is currently costlier than both Pruitt and Foley catheters. The main disadvantage of this method is the potential risk of dislodgement of atheromatous material that may occur during catheter insertion or displacement of the balloon, although in this case we felt that the benefits outweighed the comparable risks from cross-clamping the aorta.
We would also like to emphasize two technical points for consideration. Firstly the site of catheter insertion can be determined by several methods: TOE, Intra-operative Epiaortic Ultrasound (EAU), MRA, or aortogram in combination with Intravascular Ultrasound and Computed Tomography. Simple palpation is not safe and it is more likely the medial part of the aorta will be free of calcium in comparison to the anterior and lateral part. We used TOE and MRA for targeting the surgical site on the ascending aorta, although previous reports suggest that EAU, which is not available in our institution, is more sensitive in this context.6 Secondly, the balloon should be filled with fluid, since in the case of rupture there is the risk of air embolism, which can be caused during closure of the aortotomy as the balloon is very close to the aortic edges.
The technique described can be used as an alternative to profound hypothermia and total circulatory arrest7 for aortic valve replacement in patients with a calcified aorta not suitable for cross-clamping. Since an atherosclerotic aorta is a manifestation of the aging process, and also since the number of elderly patients requiring coronary revascularization, valve replacement or re-do operations is increasing, this intra-aortic occlusion catheter technique could be used more frequently in selected patients, combined with femoral or axillary artery cannulation.
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REFERENCES
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ABSTRACT
CLINICAL CASE
