Strategy for Porcelain Ascending Aorta in Cardiac Surgery

Challenging clinical management of a patient with Gaucher disease type IIIC homozygous for the D409H mutation, aortic valve calcification and porcelain aorta

BACKGROUND

Gaucher disease is a rare lysosomal storage disorder caused by glucocerebrosidase enzyme deficiency resulting in the cumulative deposition of glucocerebroside in macrophages, predominantly effecting bone marrow, liver and spleen. Gaucher disease type IIIC is a rare subtype that is characterized by cardiovascular involvement, eye-movement disorders, and late-onset neurological symptoms.

CASE PRESENTATION

We present a 14-year-old adolescent boy diagnosed with Gaucher disease type IIIC at age four with a homozygous D409H mutation who developed severe aortic valve stenosis, extensive aortic calcification and a porcelain aorta despite enzyme replacement treatment since the diagnosis. Despite the challenges during the cardiac surgery, we successfully performed transcatheter aortic valve implantation (TAVI). The patient developed a complete atrioventricular block and required a pacemaker after the TAVI. He experienced further complications during the follow-up.

CONCLUSION

The case presents the challenges in the treatment of cardiovascular complications in patients with Gaucher disease and demonstrates the importance of individualized treatment approaches, as well as the potential advantages and complications of TAVI in difficult situations like this.

Off-pump Coronary Surgery Combined With Aortic Valve Replacement Under Hypothermic Circulatory Arrest Within an Unexpected Porcelain Aorta

Unexpected porcelain aorta is a real challenge to safely completing aortic valve replacement combined with coronary artery surgery. This condition often leads to an aborted sternotomy in the hope of performing transcatheter procedures, the feasibility of which may be hampered by anatomical considerations. We report the case of a 71-year old man with history of hypertension, type 2 diabetes mellitus and chronic kidney disease, which was referred for severe aortic valve stenosis and severe coronary artery disease. He benefited from an anaortic off-pump coronary surgery and clampless aortic valve replacement under hypothermic circulatory arrest to overcome an unexpected porcelain aorta.

Peripheral cannulation and endoaortic balloon occlusion for management of porcelain aorta during cardiac surgery

Porcelain aorta with extensive calcification of the ascending aorta complicates cardiac surgery and increases perioperative risk. Aortic cannulation and cross-clamping in these patients increase the risk of serious complications including perioperative embolic stroke. Although different techniques have been proposed, surgery in these patients remains a challenge. We present the clinical implications of the porcelain aorta and surgical strategies involving axillary arterial cannulation and endoaortic balloon to allow for the institution of cardiopulmonary bypass and cardioplegic arrest during surgery. The surgery included a redo sternotomy with bioprosthetic mitral valve replacement, tricuspid valve repair with an annuloplasty, and closure of the left atrial appendage. In appropriately selected patients, endoaortic balloon occlusion was a valuable tool to facilitate the safe conduct of an operation. Careful preoperative evaluation and planning by a multidisciplinary team are essential in these cases.

Surgical versus transcatheter aortic valve replacement: Impact of patient-prosthesis mismatch on outcomes

BACKGROUND

The hemodynamics of most prosthetic valves are often inferior to that of the normal native valve, and a significant proportion of patients undergoing surgical (SAVR) or transcatheter aortic valve replacement (TAVR) have high residual transaortic pressure gradients due to prosthesis-patient mismatch (PPM). As the experience with TAVR has increased and long-term outcomes are reported, a close look at the PPM literature is required in light of new evidence.

METHODS

For this review, we searched the Embase, Medline, and Cochrane databases from 2000 to 2022. Articles reporting PPM as an outcome following aortic valve replacements were identified and reviewed.

RESULTS

The impact of PPM on clinical outcomes in aortic valve replacement has not been clear as multiple studies failed to report PPM incidence. However, the PPM outcomes after SAVR vary more widely than after TAVR, ranging from 8% to 80% in SAVR and from 24% to 35% in TAVR. Incidence of severe PPM following redo SAVR ranges from 2% to 9% and following valve-in-valve TAVR is from 14% to 33%, however, while PPM is higher in valve-in-valve TAVR, patients had better survival rates.

CONCLUSIONS

The gap between valve performance and clinical outcomes in SAVR and TAVR could be reduced by carefully selecting patients for either treatment option. Understanding predictors of PPM can add to the safety, effectiveness, and increased survival benefit of both SAVR and TAVR.

Mortality Reduction After a Preincision Safety Check Before Cardiac Surgery: Is It the Aorta?

OBJECTIVES

The introduction and use of a preincision safety check were associated with lower mortality after mixed adult cardiac surgery; however, an explanatory mechanism is lacking. Stroke, one of the most severe complications after cardiac surgery, with high mortality, may be reduced by adapting the surgical handling of the ascending aorta. This study assessed the prevalence and predictors of this adaptation after a preincision safety check and the subsequent effect on outcome.

DESIGN

A prospective, single-center, observational study comparing adaptation with no-adaptation. The primary outcome measure was 30-day mortality. Multivariate analyses were performed to determine independent predictors of adaptation. To study the effect of adaptation on outcome, a propensity score-matched cohort was constructed in a 1:3 intervention:control ratio.

SETTING

At Isala Zwolle (NL), a large, nonacademic teaching hospital.

PARTICIPANTS

All consecutive cardiac surgery procedures from 2012 until 2015, including 4,752 surgeries.

INTERVENTIONS

The adaptation of surgical handling of the ascending aorta.

MEASUREMENTS AND MAIN RESULTS

In 283 cardiac surgeries (5.9%), adaptation was indicated. The most important independent predictors for adaptation were extracardiac atherosclerosis, current smoking, and increasing age. In the propensity score-matched cohort consisting of 1,069 procedures, there were no significant differences in outcome. After correction for propensity score, the hazard ratio of adaptation for 30-day mortality was 1.8 (0.85-3.79).

CONCLUSIONS

The adaptation of aortic surgical handling after a preincision safety check was necessary for 5.9% of cardiac surgeries, with extracardiac atherosclerosis as the strongest predictor. Outcome was not significantly different between patients with and without adaptation. Although promising, it remains unclear whether adaptation may fully explain mortality reduction after the use of a preincision safety check.

Choosing Between Transcatheter Aortic Valve Replacement and Surgery in the Low-Risk Transcatheter Aortic Valve Replacement Era

The landmark results of the low surgical risk pivotal transcatheter aortic valve replacement (TAVR) trials fueled speculation that the role of surgical aortic valve replacement (SAVR) would be limited in the future. Instead, the field has pivoted away from reductive surgical risk stratification toward understanding the complex interplay of anatomy, timing, and surgical risk to optimize the lifetime management of aortic stenosis. In this review, we systematically explore the subtleties that influence the choice between TAVR and surgery in the low-risk TAVR era.

Device-based prevention of neurological events in coronary artery bypass patients with calcified ascending aorta

Patients with severely calcified aorta undergoing conventional cardiac surgery are at increased risk for postoperative neurologic deficits. Implementation of cerebroprotective devices may substantially reduce or even eliminate the risk of the adverse neurologic events, thus enabling surgical therapy, especially when interventional treatment cannot be considered an alternative option.

Ascending aorta replacement with concomitant coronary and peripheral artery bypass grafting

Atherosclerosis of the aorta is a well-known risk factor for peri-operative complications in patients undergoing cardiac surgery. Coronary and peripheral artery bypass procedures can be challenging when the native aorta is not amenable to bypass grafting due to severe calcification. We describe the successful management of a patient who underwent ascending aorta replacement with concomitant three-vessel coronary artery bypass, bilateral aorto-axillary bypass and left axillary-to-carotid bypass.

Twelve-month outcomes of transapical transcatheter aortic valve implantation in patients with severe aortic valve stenosis

Introduction

Transapical access (TA) transcatheter aortic valve implantation (TAVI) (TA-TAVI) represents one of the possible routes in patients with severe aortic stenosis (AS) who are not suitable for transfemoral access.

Aim

To assess early- and mid-term clinical outcomes after TA-TAVI.

Material and methods

Patients with severe symptomatic AS undergoing TA-TAVI from November 2008 to December 2019 were enrolled. Clinical and procedural characteristics as well as clinical outcomes including all-cause mortality during 12-month follow-up were assessed.

Results

Sixty-one consecutive patients underwent TA-TAVI for native AS. Patients were elderly with median age of 80.0 (76.0-84.0) years; 55.7% were males. Median baseline EuroSCORE I and STS scores were 18.2% (11.6-27.7) and 4.8% (3.3-8.2), respectively. The procedural success rate was 96.7%. In-hospital, 30-day and 12-month mortality rates were 9.8%; 18.0% and 24.6%, respectively. The main periprocedural and in-hospital complications were bleeding complications (14.8%). The following factors were associated with 12-month mortality: previous cerebrovascular event (CVE), glomerular filtration rate (GFR), aortic valve area (AVA), right ventricular systolic pressure (RVSP) and serum level of N-terminal prohormone of brain natriuretic peptide (NT-proBNP) (RR for CVE 3.17, 95% confidence interval (CI): 1.15-8.76: p = 0.026; RR for AVA per 0.1 cm² 1.28, 95% CI: 1.03-1.55: p = 0.024; RR for GFR per 1 ml/min 0.96: 95% CI: 0.94-0.99: p = 0.007; RR for NT-proBNP per 1000 pg/ml 1.07: 95% CI: 1.01-1.17: p = 0.033; RR for RVSP per 1 mm Hg 1.07: 95% CI 1.02-1.16: p = 0.011).

Conclusions

Transapical TAVI in high-risk patients provides good hemodynamic results with acceptable outcomes.

Plaster pipes and crystalized graphite: Open transventricular transcatheter aortic valve replacement for failed mechanical aortic valve prostheses in the porcelain aorta

Patients with a true porcelain aorta and a failed mechanical aortic valve prosthesis have limited treatment options. Using a hybrid of an open trans-ventricular approach with peripheral cardiopulmonary bypass and integration of transcatheter techniques this challenge can be overcome. Trans-ventricular mechanical valve extraction (with transcatheter endovascular occlusion and cardioplegia) followed by direct ante-grade transcatheter heart valve implantation offers a potential solution to this conundrum. The procedure described is a novel technique that allows for the effective treatment of patients with failed mechanical surgical aortic valve prostheses in the setting of an inoperable porcelain aorta. In addition, a collaborative integrated multi-disciplinary heart team environment is required for the management of these complex patients.

Direct Abdominal Aortic Access for Thoracic Endovascular Aortic Repair in a Patient with Severe Aortic and Arterial Calcification

Aortic and arterial calcification is a complication of advanced atherosclerosis and is a critical intraoperative issue that can reduce the ability to achieve safe and adequate access for stent graft introduction. Different vascular access sites are used to deliver stent grafts when a standard transfemoral or iliac access is not feasible. We report a challenging case of a direct transabdominal aortic thoracic endovascular aortic repair for a thoracic aortic aneurysm complicated with severe aortic and arterial calcification, in which the noncalcified area of the infrarenal abdominal aorta was extremely limited. This may be a reasonable access site, especially for patients with severe aortic and arterial calcification.

A hybrid clampless technique for aortic anastomoses

Background and Purpose

In various circumstances of aortic repairs (heavy circumferential calcifications or shaggy aorta with extensive thrombus), open and endovascular techniques are at high risk. In addition to a likelihood of emboli, aortic clamping can be complicated by rupture and endovascular techniques may not be successful. We here describe a simple and reproducible hybrid technique that allows performing an aortic anastomosis without clamping in these situations.

Methods

After a limited exposure of the anterior aortic wall in a healthy segment, a prosthetic graft is sutured without any arteriotomy or clamping (adventitial suture), mimicking the final aspect of an end-to-side anastomosis. The graft and the anastomosis site are punctured using a long needle, allowing a guidewire to be positioned in the aorta under fluoroscopic guidance. Protected covered stenting of the anastomosis site opens the anastomosis without aortic clamping. After tunneling the graft to the target artery, the distal anastomosis is performed in a usual fashion.

Results

This technique was successfully used in 10 challenging consecutive cases with a sustained patency.

Conclusions

This hybrid clampless technique for aortic anastomosis represents a useful alternative for challenging lesions unsuitable for a simple open or endovascular treatment.

Aortic endarterectomy: a useful technique to utilize for aortic valve replacements in hostile aorta

Calcified aorta poses a significant technical challenge in the performance of surgical aortic valve replacement (AVR). Aortic endarterectomy is a less utilized approach and is suitable in select cases for aortic decalcification during AVR. Here, we report a case of calcified ascending aorta who underwent ascending aortic endarterectomy and AVR with the technical details of the procedure.

Aortic calcifications on routine preoperative chest X-ray and perioperative stroke during cardiac surgery: a nested matched case-control study

OBJECTIVES

Perioperative stroke in cardiac surgery is most often embolic in origin. Preoperative chest X-ray (CXR) is routinely used amongst others to screen for relevant aortic calcification, a potential source of embolic stroke. We performed a nested matched case-control study to examine the relationship between aortic calcifications on CXR and the occurrence of embolic stroke.

METHODS

Among all consecutive patients undergoing cardiac surgery in our hospital between January 2014 and July 2017, we selected all patients with perioperative embolic stroke (cases). Controls, all patients without perioperative stroke, were matched on age, sex and type of surgery. All preoperative CXRs were scored for aortic calcifications (none, mild, severe) in the ascending aorta, arch, aortic knob and descending aorta.

RESULTS

Out of the 3038 eligible patients, 27 cases were detected and 78 controls were selected. In the stroke group, mild-to-severe calcifications were found least often in the ascending aorta [9% of patients, 95% confidence interval (CI) 1-29%] and most frequently in the aortic knob (63% of patients, 95% CI 44-78%). The distribution of aortic calcification was comparable in cases versus controls.

CONCLUSIONS

Calcification burden was comparable between the cases and their matched controls. In our study population, CXR findings on aortic calcification were not related to the risk of embolic stroke. In these patients, the correlation between findings on the preoperative CXR and the risk of stroke might, therefore, be too weak to use the CXR directly for the assessment of the safety of manipulating the ascending aorta during surgery.

Aortic valve replacement in porcelain aorta-a novel technique for endoaortic occlusion

Aortic valve surgery invariably becomes a high-risk, challenging procedure when there is extensive calcification of the ascending aorta which precludes safe cross-clamping. Very few case reports of performing aortic valve surgery in this condition with a non-cross-clamping technique of using endoaortic occlusion have been reported. We describe and recommend a non-cross-clamping technique of using a semi-compliant polyurethane balloon catheter (CODA balloon, Cook Incorporated, Bloomington, IN) and report its successful outcome in a patient, with porcelain aorta, who underwent aortic valve replacement.