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Kramer B, Vekstein AM, Bishop PD, Lowry A, Johnston DR, Kapadia S, Krishnaswamy A, Blackstone EH, Roselli EE. Choosing transcatheter aortic valve replacement in porcelain aorta: outcomes versus surgical replacement. Eur J Cardiothorac Surg 2023; 63:ezad057. [PMID: 36852849 PMCID: PMC10894003 DOI: 10.1093/ejcts/ezad057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 12/16/2022] [Accepted: 02/12/2023] [Indexed: 03/01/2023] Open
Abstract
OBJECTIVES Porcelain aorta complicates aortic valve replacement and is an indication for transcatheter approaches. No study has compared surgical and transcatheter valve replacement in the setting of porcelain aorta. We characterize porcelain aorta patients undergoing aortic valve replacement and the association of aortic calcification and outcomes. METHODS Patients undergoing aortic valve replacement with porcelain aorta were identified. Aortic calcium volume was determined using 3D computed tomography thresholding techniques. Propensity scoring was performed to assess the effect of surgical versus transcatheter approaches. Risk factors for composite major hospital complications (death, stroke and dialysis) were identified using random forest machine learning. RESULTS From January 2006 to January 2015, 164 patients with porcelain aorta underwent aortic valve replacement [105 (64%) surgical replacement, 59 (36%) transcatheter replacement]. Propensity scoring matched 29 pairs (49% of transcatheter patients). Before matching, 5-year survival was 41% [(43% surgical, 35% transcatheter, P(log-rank) = 0.9]. After matching, mortality for surgical versus transcatheter replacement was 3.4% (n = 1) vs 10% (n = 3), stroke 14% (n = 4) vs 3.4% (n = 1) and dialysis 6.9% (n = 2) versus 11% (n = 3). Matched 5-year survival was 40% after surgical replacement and 29% after transcatheter replacement [P(log-rank) = 0.4]. Total aortic calcium volume was greater in transcatheter than surgical patients [18 (8.0) vs 17 (7.7) ml] and was associated with more major hospital complications after either approach. CONCLUSIONS Surgical and transcatheter approaches are complementary options for aortic stenosis with porcelain aorta. Surgical valve replacement remains an effective treatment for patients requiring concomitant procedures. Quantifying aortic calcium volume is a helpful risk predictor in all patients with porcelain aorta.
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Affiliation(s)
- Benjamin Kramer
- Aortic Valve Center, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Heart, Vascular, and Thoracic Institute, Cleveland, OH, USA
| | - Andrew M Vekstein
- Aortic Valve Center, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Heart, Vascular, and Thoracic Institute, Cleveland, OH, USA
| | - Paul D Bishop
- Department of Vascular Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Ashley Lowry
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Douglas R Johnston
- Aortic Valve Center, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Heart, Vascular, and Thoracic Institute, Cleveland, OH, USA
| | - Samir Kapadia
- Aortic Valve Center, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
- Department of Vascular Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Amar Krishnaswamy
- Aortic Valve Center, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
- Department of Vascular Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Eugene H Blackstone
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Heart, Vascular, and Thoracic Institute, Cleveland, OH, USA
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Eric E Roselli
- Aortic Valve Center, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Heart, Vascular, and Thoracic Institute, Cleveland, OH, USA
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Jacob KA, Rozemeijer R, Den Harder AM, Suyker WJL. Aortic homograft replacement in a patient with a porcelain aorta: A case report. J Thorac Cardiovasc Surg 2017; 154:409-411. [PMID: 28456363 DOI: 10.1016/j.jtcvs.2017.03.137] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Revised: 03/11/2017] [Accepted: 03/30/2017] [Indexed: 11/19/2022]
Affiliation(s)
- Kirolos A Jacob
- Department of Cardiothoracic Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - Rik Rozemeijer
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Willem J L Suyker
- Department of Cardiothoracic Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
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Yamashita K, Kobayashi J, Fujita T, Hata H, Shimahara Y, Kume Y, Matsumoto Y. Simultaneous transcatheter aortic valve implantation and off-pump coronary artery bypass grafting for Takayasu arteritis. J Cardiol Cases 2017; 15:158-160. [PMID: 30279767 DOI: 10.1016/j.jccase.2016.12.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Revised: 12/07/2016] [Accepted: 12/30/2016] [Indexed: 11/25/2022] Open
Abstract
We report a patient who underwent simultaneous transcatheter aortic valve implantation and off-pump coronary artery bypass grafting for Takayasu arteritis with diffuse porcelain aorta. The patient was a 59-year-old female with severe aortic stenosis and regurgitation, as well as both coronary ostial stenosis and porcelain aorta. Bilateral internal thoracic arteries were unavailable due to Takayasu arteritis. Therefore, composite radial artery with in-situ gastroepiploic artery was used as graft material. Radial artery was anastomosed to left anterior descending artery and posterior descending artery sequentially. Surgical procedures were successfully accomplished and major perioperative complications did not occur. <Learning objective: Takayasu arteritis is a rare disease with vasculitis of aorta and its main branches. In addition, it is associated with a low incidence of coronary ostial stenosis and coronary ischemia can be fatal. Porcelain aorta with aortic valve lesion also complicates with Takayasu arteritis and it makes difficult to perform cardiac surgery. The optimal surgical strategy and process for those who combined with coronary ostial stenosis, aortic valve lesion and porcelain aorta remains a subject of debate.>.
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Affiliation(s)
- Kizuku Yamashita
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Junjiro Kobayashi
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Tomoyuki Fujita
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Hiroki Hata
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Yusuke Shimahara
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Yuta Kume
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Yorihiko Matsumoto
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
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Li G, Qiao W, Zhang W, Li F, Shi J, Dong N. The shift of macrophages toward M1 phenotype promotes aortic valvular calcification. J Thorac Cardiovasc Surg 2017; 153:1318-1327.e1. [PMID: 28283241 DOI: 10.1016/j.jtcvs.2017.01.052] [Citation(s) in RCA: 83] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Revised: 12/31/2016] [Accepted: 01/25/2017] [Indexed: 10/20/2022]
Abstract
OBJECTIVE The purpose of the present study was to comprehensively compare the phenotype profile of infiltrated macrophages in human noncalcified and calcific aortic valves, and to determine whether the shift of macrophage polarization modulates valvular calcification in vitro. METHODS Cell surface markers of macrophages and inflammatory cytokines expression in 90 cases of human noncalcified and calcific aortic valve leaflets were analyzed. The normal aortic valve interstitial cells were isolated and cultured in vitro. After incubation with nonconditioned medium and conditioned medium from unstimulated or lipopolysaccharide-stimulated U937 monocytes, valve interstitial cells were evaluated by osteogenic differentiation markers. RESULTS Infiltration of macrophages was enhanced in the calcific aortic valves, and M1 phenotype was the predominant macrophage subsets. In addition, both proinflammatory and anti-inflammatory cytokines were significantly upregulated in the calcific aortic valves. Furthermore, lipopolysaccharide-stimulated monocytes presented with increased expression of inducible nitric oxide synthase and high proportional CD11c-positive (M1) macrophages. Conditioned medium from unstimulated monocytes promoted the osteogenic differentiation of valve interstitial cells in vitro, as evidenced by increased markers such as bone morphogenetic protein 2, osteopontin, and alkaline phosphatase. Conditioned medium from M1 macrophages further enhanced valve interstitial cells calcification. Enzyme-linked immunosorbent assay showed that M1 phenotype macrophages secreted tumor necrosis factors α and interleukin 6, and neutralizing antibodies to these 2 proinflammatory cytokines attenuated induction of osteogenic differentiation and calcification by the conditioned media. CONCLUSIONS Both total numbers and polarization of macrophage influence the process of calcification in human aortic valve. The shift toward M1 phenotype might promote valve interstitial cell calcification.
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Affiliation(s)
- Geng Li
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
| | - Weihua Qiao
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
| | - Wenjing Zhang
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
| | - Fei Li
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China
| | - Jiawei Shi
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China.
| | - Nianguo Dong
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People's Republic of China.
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Okamoto K, Fukui T. Bilateral axillary artery cannulation for severely calcified aorta and branches: a case report. J Cardiothorac Surg 2016; 11:98. [PMID: 27390936 PMCID: PMC4939062 DOI: 10.1186/s13019-016-0492-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Accepted: 06/24/2016] [Indexed: 02/07/2023] Open
Abstract
Background Aortic valve surgery in patients with severely calcified aortas is technically challenging. Additionally, the choice of arterial cannulation site and whether to perform an aortic clamp to prevent neurological complications are poorly defined. Case presentation We describe a patient with a severely calcified aorta and stenosis of its side branches. He successfully underwent aortic valve replacement with bilateral axillary artery cannulation and short-term moderate hypothermic circulatory arrest for cross-clamping of a severely calcified aorta to prevent neurological complications. Conclusions Bilateral axillary artery cannulation and short-term moderate hypothermic circulatory arrest for cross-clamping of the porcelain aorta is a suitable option to prevent neurological complications in patients with a severely calcified aorta and stenosis of its side branches who need aortic valve replacement.
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Affiliation(s)
- Ken Okamoto
- Department of Cardiovascular Surgery, Kumamoto University Hospital, 1-1-1 Honjo, Kumamoto, 860-8556, Japan
| | - Toshihiro Fukui
- Department of Cardiovascular Surgery, Kumamoto University Hospital, 1-1-1 Honjo, Kumamoto, 860-8556, Japan.
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Fernando R, Gutsche JT, Augoustides JGT, Kukafka JD, Spitz W, Frogel J, Fabbro M, Patel PA. Transcatheter Aortic Valve Replacement After Intraoperative Discovery of Porcelain Aorta in a Patient With Aortic Stenosis. J Cardiothorac Vasc Anesth 2016; 31:738-747. [PMID: 27543996 DOI: 10.1053/j.jvca.2016.04.031] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2016] [Indexed: 11/11/2022]
Affiliation(s)
- Rohesh Fernando
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jacob T Gutsche
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - John G T Augoustides
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
| | - Jeremy D Kukafka
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Warren Spitz
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jonathan Frogel
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Michael Fabbro
- Cardiothoracic Anesthesiology, Department of Anesthesiology, Perioperative Medicine and Pain Management, Miller School of Medicine, University of Miami, Miami, FL
| | - Prakash A Patel
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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Nishimori H, Yamamoto M, Orihashi K. Cerebral infarction occurs particularly in patients with porcelain aorta. J Thorac Cardiovasc Surg 2015; 150:744-5. [PMID: 26319474 DOI: 10.1016/j.jtcvs.2015.05.041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2015] [Accepted: 05/18/2015] [Indexed: 10/23/2022]
Affiliation(s)
- Hideaki Nishimori
- Department of Surgery II, School of Medicine, Kochi University, Nankoku, Kochi, Japan
| | - Masaki Yamamoto
- Department of Surgery II, School of Medicine, Kochi University, Nankoku, Kochi, Japan
| | - Kazumasa Orihashi
- Department of Surgery II, School of Medicine, Kochi University, Nankoku, Kochi, Japan
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