Deep Hypothermic Arrest for Aortic Valve Replacement in Case of Porcelain Aorta
Dimitrios C Iliopoulos, MD,
Aris-Rezar Deveja, MD,
Vasilios Satratzemis, MD,
Dimitrios G Koudoumas, MD
University of Athens School of Medicine Athens Medical Center Athens, Greece
Dimitrios G Koudoumas, MD Tel: +3 210 7781921 Fax: +3 210 6108743 Email: dimitrios.koudoumas{at}gmail.com, Argyrokastrou 24–26, Goudi, Zografou 15773, Athens, Greece.
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ABSTRACT
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A 71-year-old man presented with severe aortic stenosis and a heavily calcified aorta. Cardiopulmonary bypass was established with arterial cannula via the distal aortic arch. Deep hypothermic circulatory arrest and retrograde cerebral perfusion were initiated for excision of the ascending aorta. A tube graft was anastomosed to the proximal aortic arch, circulation was reestablished, the aortic valve was replaced with a bioprosthesis, and proximal anastomosis to the sinotubular junction was preformed.
Key Words: Aortic Valve Stenosis • Cardiopulmonary Bypass • Circulatory Arrest • Deep Hypothermia Induced
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INTRODUCTION
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An aorta with severe calcification is called a "porcelain" aorta. The operative management of a patient with porcelain aorta can be difficult because the aorta cannot be crossclamped and there are high risks of cerebral and systemic atheroembolism. Adhesions may hinder safe dissection and clamping. Such aortas require a modified operative strategy.
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CASE REPORT
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A 71-year-old man was admitted to our institute with dyspnea and weakness at rest for 6 months. He had undergone off-pump coronary bypass with the left internal thoracic artery grafted to the left anterior descending coronary artery. At that time, mild asymptomatic aortic stenosis was demonstrated by transthoracic echocardiography. Recent echocardiography showed aortic stenosis with a pressure gradient of 90 mm Hg and ejection fraction of 40%. Chest computed tomography revealed heavy calcification of the aorta from a point above the commissure level up to the proximal aortic arch. After sternal reentry and careful dissection of the surrounding tissues, the ascending aorta and the arch were evaluated by epicardial echocardiography, and a site on the distal aortic arch was found for safe arterial cannulation (Figure 1A
). The inferior vena cava was chosen to place a venous drainage cannula via the right atrium. The superior vena cava was also cannulated for retrograde cerebral perfusion. A retrograde cardioplegic line and a left ventricular vent line were inserted. Cardiopulmonary bypass was initiated using retrograde cold blood cardioplegia, and the patient was cooled down to a nasopharyngeal temperature of 15°C. The aorta was opened and retrograde cerebral perfusion was established. After excision of the ascending aorta, the stenotic aortic valve was carefully inspected (Figure 1B). Under deep hypothermic circulatory arrest for 18 min, a 30-mm Hemashield aortic graft was sewn to the proximal aortic arch. On completion of the distal anastomosis, circulation was reestablished and the patient was rewarmed. The stenotic aortic valve was excised and replaced with a 21-mm bioprosthetic valve (St. Jude Medical, St. Paul, MN, USA). The proximal edge of the graft was sutured above the level of the sinotubular junction, using 4/0 polypropylene suture in a continuous fashion (Figure 2A). During the operation, myocardial temperature was kept at 12°C. The patient was discharged from hospital 11 days later, without any complication.
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DISCUSSION
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Heavily calcified aortas are technically challenging because of increased risks of mortality and cerebral or systemic embolism.1,2 The aortotomy can cause debris from the aortic wall, which may result in cerebral embolism, and a porcelain aorta is unsuitable for clamping. Numerous techniques have been described to avoid catastrophic complications during aortic valve replacement. These include: forward placement of an occluding balloon in the ascending aorta during a brief period of circulatory arrest followed by reinstitution of circulation; endarterectomy of the ascending aorta; replacement of the ascending aorta and aortic valve; and repair under deep hypothermic circulatory arrest using atrial-femoral bypass, isolation and temporary occlusion of the innominate and carotid arteries, with subsequent aortic crossclamping.1–4 After endarterectomy, the aortic wall becomes fragile and reinforcement is necessary. This can be achieved with either pericardial strips or gelatin-resorcin-formal glue.5 Kazui and colleagues6 reported that use of this glue for aortic root reconstruction was associated with some risk of aortic root necrosis.
In our case, we used retrograde cardioplegia for circulatory arrest, and retrograde cerebral perfusion via the superior vena cava to protect the brain and wash out emboli. We also avoided antegrade cardioplegia to prevent coronary embolism from the porcelain aortic wall (Figure 2B
). We preferred to replace the ascending aorta and proximal aortic arch with a Hemashield graft. This is a safe alternative approach for porcelain aorta, especially if the distal arch is not heavily diseased. The proximal graft can be used for future coronary bypass surgery, and potential dangers with other sites of exposure and cannulation are avoided, which may reduce morbidity in elderly patients.
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REFERENCES
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- Cosgrove DM. Management of the calcified aorta: an alternative method of occlusion. Ann Thorac Surg 1983;36:718–9.[Abstract]
- Byrne JG, Aranki SF, Cohn LH. Aortic valve operations under deep hypothermic circulatory arrest for the porcelain aorta: "no-touch" technique. Ann Thorac Surg 1998;65:1313–5.[Abstract/Free Full Text]
- Svensson LG, Sun J, Cruz HA, Shahian DM. Endarterectomy for calcified porcelain aorta associated with aortic valve stenosis. Ann Thorac Surg 1996;61:149–52.[Abstract/Free Full Text]
- Jacobowitz IJ, Rose DM, Shevede K, Cunningham Jr JN. Use of profound hypothermia and circulatory arrest for the calcified aorta. Chest 1984;85:288–9.[Medline]
- Okamoto H, Fujimoto K, Tamenishi A, Itoh Y, Niimi T. Aortic valve replacement in a heavily calcified "porcelain" aorta. Jpn J Thorac Cardiovasc Surg 2001;49:453–6.[Medline]
- Kazui T, Washiyama N, Bashar AH, Terada H, Suzuki K, Yamashita K, et al. Role of biologic glue repair of proximal aortic dissection in the development of early and midterm redissection of the aortic root. Ann Thorac Surg 2001;72:509–14.[Abstract/Free Full Text]
Asian Cardiovasc Thorac Ann 2009;
17:415-416
© 2009 by SAGE Publications
DOI: 10.1177/0218492309338092
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ABSTRACT
INTRODUCTION
