Diagnosis and management of severe atherosclerosis of the ascending aorta and aortic arch during cardiac surgery: focus on aortic replacement (original) (raw)
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The atherosclerotic aorta at aortic valve replacement: Surgical strategies and results
The Journal of Thoracic and Cardiovascular Surgery, 2000
Background: Aortic valve replacement in patients with severe atherosclerosis of the ascending aorta poses technical challenges. The purpose of this study was to examine operative strategies and results of aortic valve replacement in patients with a severely atherosclerotic ascending aorta that could not be safely crossclamped. Patients and methods: From January 1990 to December 1998, 4983 patients had aortic valve surgery; of these, 62 (1.2%) patients had a severely atherosclerotic ascending aorta and required hypothermic circulatory arrest to facilitate aortic valve replacement. They form the study group. Results: All patients had hypothermic circulatory arrest, but several different strategies were used to manage the ascending aorta. These techniques included aortic valve replacement with the use of hypothermic circulatory arrest (39%), ascending aortic endarterectomy (26%), ascending aortic replacement (19%), aortic inspection and crossclamping during hypothermic circulatory arrest (10%), and balloon occlusion of the ascending aorta (6%). Duration of hypothermic circulatory arrest was substantially longer for patients having aortic valve replacement with hypothermic circulatory arrest than for all other strategies. Hospital mortality was 14%, and 10% of patients had strokes. Increasing New York Heart Association functional class and impaired left ventricular function were risk factors for hospital mortality. Choice of operative technique did not influence patient outcome; however, no patient who underwent replacement of the ascending aorta had a stroke. Conclusions: Aortic valve replacement in patients with severe atherosclerosis of the ascending aorta is associated with increased operative morbidity and mortality. Complete aortic valve replacement during hypothermic circulatory arrest, the "no-touch" technique, requires a prolonged period of circulatory arrest. Ascending aortic replacement is a preferred technique, as it requires a short period of hypothermic circulatory arrest and results in comparable mortality with a low risk of stroke. (
Replacing the atherosclerotic ascending aorta is a high-risk procedure
The Annals of Thoracic Surgery, 1998
Background. Improved techniques in cerebral and myocardial protection have made replacement of the chronically aneurysmal ascending thoracic aorta a safe and effective procedure. We hypothesized that patients with severe ascending or aortic arch atherosclerosis were at greater risk for operative complications during ascending aortic replacement because of the diffuse nature of their atherosclerotic process. Methods. We retrospectively analyzed the records of 17 patients who received ascending aortic replacement during elective coronary artery bypass grafting (CABG) because of the intraoperative finding of severe atherosclerosis. All 17 patients underwent tube graft replacement of the ascending aorta under hypothermic circulatory arrest and retrograde cerebral perfusion before coronary artery bypass grafting. The outcomes for these patients were compared with those of a control group of 89 consecutive patients who underwent replacement for ascending thoracic aortic aneurysm. Results. The hospital mortality rate for replacement of the ascending thoracic aorta for severe atherosclerosis was 23.5% (4/17) versus 2.25% (2 of 89) for the control group (p ؍ 0.006). The incidence of cerebrovascular accident in the atherosclerotic group was 17.6% (3/17) and 3.37% (3/89) for the control group (p ؍ 0.051). Nine of 17 atherosclerotic patients (52.9%) had operative morbidity. Only 20.2% (18 of 89) of the control patients had nonfatal postoperative complications. Conclusions. The severely atherosclerotic ascending aorta is a marker of diffuse atherosclerosis. Despite improved techniques of myocardial and cerebral protection, we have been unable to duplicate our success with ascending thoracic aneurysm repair. Preoperative screening of the ascending aorta by chest computed tomography may be appropriate in select high-risk patients to determine operability.
Replacement of the Ascending Aorta for Severe Atherosclerosis During Coronary Artery Bypass Surgery
Journal of Cardiac Surgery, 2012
In the present study, we investigated the benefit of ascending aorta replacement in patients with severe aortic atherosclerosis who undergo coronary artery bypass surgery (CABG). Methods: From January 2001 to April 2011, 3842 patients underwent CABG and in 36 of these patients (31 male, 5 female) the ascending aorta was replaced due to severe atherosclerosis. Total circulatory arrest was used in 22 patients (61%). The patients were followed for 69 ± 36 months (1-133 months) and compared to a control group of patients. The control group consisted of patients who underwent CABG with or without a concomitant procedure (n = 3806). Results: For the study group, the mean additive and logistic Euroscores of the patients were nine and 20, respectively. One stroke (2.8%) was observed and this patient died in the early postoperative period. There were a total of four confirmed deaths (12%) at any time point over the length of the follow-up among the patients who were discharged from the hospital. Two of them died of malignancy (lung and gastric tumors) and the other two from cardiac reasons. No patients had a stroke during follow-up. For the control group the mean age was 61 ± 1, the stroke rate was 0.6%, and the mortality rate was 0.96%, and the mean logistic and additive Euroscores were 3.7 ± 4.4, and 3.5 ± 2.5, respectively. Conclusions: Replacement of highly calcified ascending aortas during CABG can be safely performed in selected patients with good long-term outcomes.
AORTIC VALVE REPLACEMENT AND ASSCENDING AORTIC ANGIOPLASTY – CASE REPORT (Atena Editora)
AORTIC VALVE REPLACEMENT AND ASSCENDING AORTIC ANGIOPLASTY – CASE REPORT (Atena Editora), 2024
INTRODUCTION: Aortic stenosis (AS) is a serious cardiovascular condition characterized by narrowing of the aortic valve, resulting in an obstruction to blood flow from the left ventricle to the aorta. This can lead to symptoms such as angina, syncope and dyspnea, especially during physical exertion. The treatment of severe AS generally involves aortic valve replacement, a surgical intervention that replaces the diseased aortic valve with a valve prosthesis, with the choice between biological or mechanical prosthesis depending on several factors. DESIGN AND METHODS: This case report details the diagnosis, treatment and evolution of a 56-year-old male patient with severe aortic stenosis. Data collection involved a comprehensive review of medical records, laboratory tests, and imaging. Furthermore, a bibliographical review was carried out to support the case with current and relevant information about aortic stenosis and its therapeutic interventions. CASE REPORT: The patient initially presented with complaints of myalgia and chronic fatigue, along with a systolic murmur during physical examination. Examinations revealed severe aortic stenosis, left ventricular diastolic dysfunction and aortic ectasia. He underwent aortic valve replacement surgery with a number 23 metal prosthesis and ascending aorta plasty. Postoperative follow-up included drug treatment and monitoring of INR levels to adjust anticoagulation. DISCUSSION: Aortic stenosis can have several causes, including senile calcification, rheumatic fever, and congenital malformations. Your symptoms may vary depending on the severity of the valve obstruction. Treatment involves aortic valve replacement, which can be performed by conventional surgery or minimally invasive procedures, such as transcatheter aortic valve replacement (TAVR). CONCLUSION: This case illustrates the importance of a multidisciplinary approach in the management of severe aortic stenosis, highlighting the effectiveness of surgical interventions to improve the patient's symptoms and cardiac function. Long-term follow-up is essential to ensure satisfactory clinical results and the patient's quality of life. Ler mais
Contemporary Trends in Aortic Valve Surgery:. A Single Centre 10-Year Clinical Experience*
Journal of Cardiac Surgery, 2004
The purpose of this study is to present a comprehensive profile of the trends in aortic valve replacement at a single institution over the past decade. Prospectively collected data concerning 873 patients undergoing aortic valve replacement (AVR), with and without coronary artery bypass grafting (CABG), were analysed. The patients were divided into three time periods: period I, (1990 to 1993); period II, (1994 to 1996); and period III, (1997 to 2000). Actuarial survival of AVR patients with and without CABG at 7 years was 82.9 ± 2.4% and 79.1 ± 3.3% (p = 0.17), respectively. Actuarial survival at 7 years for stentless, mechanical, and stented valve patients were 89.5 ± 2.7%, 85.5 ± 2.8%, and 76.0 ± 3.2%, respectively. There was a significant difference in survival between the stentless and stented valve groups (p = 0.014). Age (63.8 ± 12.9 yrs, 66.2 ± 11.0 yrs, 67.9 ± 10.3 yrs; p = 0.01), the incidence of peripheral vascular disease (5.1%, 10.8%, 16.6%; p = 0.001), and the extent of coronary artery disease necessitating CABG (34.0%, 38.8%, 41.0%; p = 0.05) have increased significantly in the later time period. However, operative mortality has remained constant (4.7%, 4.8%, 4.5%; p = 0.9). Moreover, perioperative complications have decreased significantly (27.4%, 18.0, 16.0%; p = 0.001). Multivariate analysis identified more recent time period as independent protective factor for early mortality and morbidity (period I, RR 1.00; period II, RR 0.47; period III, RR 0.40from the analysis. Clinical, operative, and outcome data were collected in a computerized database.
Aortic Valve Replacement: A 9-Year Experience
The Annals of Thoracic Surgery, 1980
Experience with aortic valve replacement over a 9-year period is reviewed. Hospital mortality was 5.0°/0, with an additional late mortality of 15.0% during a mean follow-up period of 4.3 years. There was a 7.5% mortality among the 93 patients who were operated on using direct coronary perfusion. There were no early deaths among the 48 patients operated on using cold cardioplegic arrest. Paravalvular leaks developed in 20 patients, and 9 had reoperation. There were no early deaths following elective reoperations for prosthetic valve dysfunction, but urgent reoperation was associated with a 40% mortality. Eighty percent of all patients are still alive at a maximum follow-up of 9 years. Eighty-six percent of the survivors who were in New York Heart Association Functional Class 111 or IV before operation are now in Class I or 11. Hypothermic cardioplegic arrest was found to be preferable to coronary perfusion as a method of myocardial protection during aortic valve replacement. Patients with paravalvular leaks who have a history of left ventricular failure prior to aortic valve replacement should be considered candidates for early elective reoperation, owing to the significantly greater mortality associated with urgent reoperation.
Outcomes of Aortic Arch Replacement Performed Without Circulatory Arrest or Deep Hypothermia
AORTA, 2013
Background: Aortic arch replacement using standard techniques, including deep hypothermic circulatory arrest and selective antegrade cerebral perfusion, is still associated with significant mortality and cerebral morbidity. We have previously described the "branch-first" technique that avoids circulatory arrest or profound hypothermia with excellent outcomes. We now describe our clinical experience with a larger cohort of patients as well as follow-up of our earlier results. We also describe a further technical simplification to this technique. Methods: From 2005 to 2010, 43 patients underwent a "branch-first continuous perfusion" technique for aortic arch replacement. In this technique, arterial perfusion is peripheral, usually by femoral inflow. Disconnection of each arch branch and anastomosis to a perfused trifurcation graft proceeds sequentially from the innominate to the left subclavian artery, with uninterrupted perfusion of the heart and viscera by the peripheral cannula. In the first cohort perfusion to the trifurcation graft was by right axillary cannulation. Since 2009, a modification was introduced such that perfusion is supplied directly by a sidearm on the trifurcation graft. This was used in the last 18 patients of this series. After reconstruction of the debranched arch and ascending aorta, the common stem of the trifurcation graft is anastomosed to the arch graft. In this series, there were 27 males, and mean age was 63 ؎ 13 years. Fifteen cases (35%) were performed with urgent/emergent priority. Nineteen patients (44%) were operated for aortic dis-section, and the remainder for aneurysms. Seven patients (16%) had previously undergone a cardiac surgical procedure. Results: There were two (4.7%) early mortalities while one patient (2.3%) experienced a permanent stroke. One patient (2%) required mechanical support while three (7%) required hemofiltration for renal support. Extubation was achieved within 24 hours in 21 patients (49%) while 19 (42%) were discharged from the Intensive Care Unit (ICU) within two days. Eight patients (19%) did not require any transfusion of red cells or platelets. Mean follow-up duration was 21 ؎ 19 months and was 100% complete. At three years, survival was 95 ؎ 3.2%. No patients required subsequent aortic reoperation during this early follow-up period. Conclusions: This modified branch-first continuous perfusion technique brings us closer to the goal of arch surgery without cerebral or visceral circulatory arrest and the morbidity of deep hypothermia. Our early experience is encouraging although greater numbers and longer follow-up will reveal the full potential of this approach.
Aortic Valve Replacement Under Deep Hypothermic Circulatory Arrest
Journal of Cardiac Surgery, 2002
Background: Aortic valve replacement (AVR) in the presence of a calcified aorta or patent grafts may preclude clamping of the ascending aorta. We employed deep hypothermic circulatory arrest in order t o circumvent this problem. Methods: Between January 1993 and December 2000,415 patients underwent AVR in our department. Eight of these were operated using deep hypothermic circulatory arrest. There were 5 males, and mean age was 72 years (range 56-81). Indications for using circulatory arrest were reoperation with patent grafts and/or severe calcification of t h e ascending aorta. In six patients, cardiopulmonary bypass was achieved via femoro-femoral bypass, and i n t w o via aortic-right atrial cannulation. Retrograde cerebral perfusion was employed in five. Mean bypass time was 155 minutes (range 122-1871, and mean circulatory arrest t i m e was 38 minutes (range 31-49). Results: There was no operative mortality, and no patient suffered any neurologic sequelae. Echocardiography showed all valves t o be functioning well. Conclusions: AVR under deep hypothermic circulatory arrest can be accomplished with an acceptable degree of safety. It should be considered as an alternative in patients i n w h o m aortic clamping is prohibitive, and might otherwise be considered inoperable. The ability t o connect the patient t o bypass and the presence of a "window" t o allow aortotomy are prerequisites for employing this
Interactive cardiovascular and thoracic surgery, 2015
Aortic valve replacement (AVR) in patients with severely atherosclerotic aortas (porcelain aorta) presents a significant technical challenge. Two strategies are deep hypothermic circulatory arrest (DHCA) during conventional surgery and transcatheter aortic valve replacement (TAVR). The aim of this study was to examine the outcomes in patients who underwent DHCA for AVR with a porcelain aorta to identify whether older patients are more suitable for TAVR. Between October 2004 and December 2012, 122 patients underwent AVR using DHCA for atherosclerotic aorta. Patients with concomitant valve surgery were excluded. Overall, 63.9% (78/122) were of age <80 (non-octogenarian group, NOG) and 36.1% (44/122) were >80 (octogenarian group, OG). Of the total cohort, 62.3% (76/122) had concomitant coronary artery bypass graft surgery. The mean age for the whole cohort was 75.7 ± 8.5 years; 70.2 ± 8.1 years for the NOG and 83.4 ± 2.6 years for the OG (P = 0.001). The OG had a higher rate of p...