Sutureless aortic valve implantation in patient with porcelain aorta via unclamped aorta and deep hypothermic circulatory arrest

Abstract

Severe atherosclerotic calcification of the ascending aorta, the so-called porcelain aorta, precludes cardiac surgeons from placing an aortic cross-clamp and direct aortic cannulation due to the increased risk of systemic embolism and stroke. In the present report, we support the option of sutureless valve implantation in a case of a porcelain ascending aorta, with deep hypothermic circulatory arrest and also without aortic cross-clamp.

Off-pump coronary surgery combined with aortic valve replacement under hypothermic circulatory arrest within an unexpected porcelain aorta

“…Several strategies have been proposed to overcome this issue, combining OPCAB surgery with: (a) transapical TAVR [ 10 ] which represents a hybrid approach and less invasive alternative for resolving this critical clinical scenario, (b) SAVR with sutureless Perceval valve, in order to reduce the HCA duration [ 11 ], (c) aortic root replacement with a composite valve graft during a relatively brief HCA [ 12 ]. (d) the use of aortic endoclamps to replace aortic valve only requires a brief period of HCA, but there is still the risk of embolization [ 12 ], (e) extensive ascending aortic endarterectomy combined with HCA, which carries a postoperative stroke rate of 34.9% and an unknown risk of aneurysmal degeneration [ 12 ], (f) apicoaortic conduits where the risk is the formation of thrombus or the occurrence of stagnation due to competition between antegrade and retrograde flow [ 12 ].…”

How to tackle an unexpected pocelain aorta in the setting of planned aortic valve replacement combined with coronary surgery?

“…Several strategies have been proposed to overcome this issue, combining OPCAB surgery with: (a) transapical TAVR [9], (b) SAVR with sutureless Perceval valve in order to reduce its HCA duration [10], (c) aortic root replacement with a composite valve graft during a relatively brief HCA [4]. (d) the use of aortic endoclamps to replace aortic valve only requires a brief period of HCA, but there is still the risk of embolization [4], (e) extensive ascending aortic endarterectomy combined with HCA, which carries a postoperative stroke rate of 34.9% and an unknown risk of aneurysmal degeneration [4], (f) apicoaortic conduits where the risk is the formation of thrombus or the occurrence of stagnation due to competition between antegrade and retrograde flow [4].…”