Ann Thorac Surg 1997;64:1179-1181
© 1997 The Society of Thoracic Surgeons
Case Report
Mitral Valve Repair in a Patient With Severe Porcelain Aorta
Hitoshi Ogino, MD,
Yuichi Ueda, MD,
Koichi Morioka, MD,
Keiji Matsubayashi, MD,
Takuya Nomoto, MD
Department of Cardiovascular Surgery, Tenri Hospital, Tenri, Japan
Accepted for publication May 29, 1997.
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Abstract
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We repaired the mitral valve in a patient with severe porcelain aorta. Significant mitral regurgitation developed in a 66-year-old woman with heavy calcification throughout the whole aorta. At operation, cardiopulmonary bypass was properly established by combined axillary and femoral arterial cannulations for sufficient systemic flow. Likewise, the combination of a superior mitral approach and profound hypothermic fibrillatory arrest in conjunction with low-flow cardiopulmonary bypass allowed us to repair the mitral valve successfully.
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Introduction
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In cardiac operations, both standard aortic cannulation for cardiopulmonary bypass (CPB) and aortic cross-clamping create some risk of distal embolism of aortic plaque, particularly in cases of heavily calcified aorta (porcelain aorta). The "aortic nontouch technique" has reportedly been applied in such cases [1–5]. We successfully repaired the mitral valve in a patient with porcelain aorta through a superior mitral approach [6] using combined axillary and femoral cannulations and profound hypothermic fibrillatory arrest [7] with low-flow CPB.
A 66-year-old woman was referred because of significant mitral regurgitation. At admission, the chest roentgenogram showed moderate cardiomegaly (cardiothoracic ratio = 0.65) and pulmonary congestion. Severe mitral regurgitation due to prolapse of the anterior mitral leaflet was demonstrated by transthoracic and transesophageal echocardiography. The following cardiac catheterization also showed moderate to severe mitral regurgitation with moderate pulmonary hypertension (pulmonary arterial pressure of 50/11 [29] mm Hg). Therefore, mitral valve repair was scheduled. However, severe calcification on the ascending to descending aorta was found on the preoperative chest roentgenogram. Subsequent chest and abdominal computed tomographic scans also revealed extremely heavy calcification throughout the whole aorta (Fig 1
). Based on these findings, we estimated that aortic cannulation for CPB and aortic cross-clamping would be difficult and the risk of aortic damage and embolism due to dislodged calcified fragment was high.
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Fig 1. . Chest and abdominal computed tomographic scans demonstrating the heavily calcified whole aorta, particularly the abdominal part, which appeared to be too narrow to bring sufficient cerebral and systemic flow with only femoral retrograde perfusion during cardiopulmonary bypass.
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At operation on March 3, 1996, the ascending aorta was found to be totally calcified and rigid by palpation and epiaortic echocardiography. The femoral artery was first cannulated with an 18F straight cannula (Bardic, Inc) for CPB instead of routine aortic cannulation. Axillary cannulation with a 14F straight cannula (Bardic, Inc) was added because the heavily calcified abdominal aorta seemed to be too narrow, less than 1 cm in diameter, to produce sufficient systemic perfusion of CPB. Consequently, an adequate CPB flow of 3.8 L/min and a flow index of 2.4 L • min-1 • m-2 were obtained. The patient was then cooled to a rectal temperature of 25°C to induce fibrillatory arrest for myocardial protection without aortic cross-clamping. A standard right lateral incision of the left atrial wall was made after ventricular fibrillation occurred spontaneously. However, sufficient visualization of the mitral valve was disturbed by aortic regurgitation, which was caused by retraction of the heart to the left. Therefore, profound hypothermia at 20°C and low-flow CPB at 1 L/min were employed. A superior mitral approach in conjunction with temporary division of the superior vena cava [6] was also added for satisfactory exposure of the mitral valve (Fig 2). During low-flow CPB for 45 minutes, successful mitral valve repair was performed by reconstructing the mitral chordae with artificial chordae of expanded polytetrafluoroethylene (Gore-Tex suture, CV4; W. L. Gore & Associates, Flagstaff, AZ) on the anterior mitral leaflet along the anterolateral commissure side, and additional annuloplasty on both commissures was applied. With this procedure, mitral regurgitation disappeared, and this was confirmed by intraoperative transesophageal echocardiography and postoperative echocardiography. The duration of ventricular fibrillation and total CPB was 91 minutes and 173 minutes, respectively. There were no remarkable neurologic signs of distal embolism postoperatively.
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Fig 2. . Superior mitral approach with temporary division of the superior vena cava in conjunction with profound hypothermic fibrillatory arrest and low-flow cardiopulmonary bypass.
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Comment
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We successfully carried out mitral valve repair in a patient with severe porcelain aorta. In this report, we focus on our operative strategies including establishment of CPB, myocardial protection, and visualization of the mitral valve. There have been several reports on the proper management of porcelain aorta [1–5]. However, most reports were in conjunction with aortic valve or coronary operations. For cases of porcelain aorta, the "aortic nontouch technique" [1–5] abandoning aortic cannulation and aortic cross-clamping has been principally recommended to prevent fragmentation of the calcified plaque, which could cause cerebral or systemic embolism, aortic dissection, mural laceration, and hemorrhage. Initially, CPB should be established with femoral cannulation or, if possible, arch cannulation depending on the extent of aortic disease. In this patient we also employed femoral cannulation because of the severe calcified ascending aorta and arch. In addition, the right axillary artery [4] was cannulated at the bifurcated arterial line because the patient had a too heavily calcified and narrowed abdominal aorta to provide sufficient systemic CPB flow. The sufficient CPB flow was consequently obtained by these combined arterial cannulations. Furthermore, antegrade flow via this additional axillary cannulation might prevent cerebral embolism of calcified plaque generated by retrograde perfusion through femoral cannulation.
Proper myocardial protection is also an important issue in patients with porcelain aorta in whom aortic cross-clamping must be abandoned. Either a normothermic beating-heart technique with or without CPB [5] or hypothermic fibrillatory arrest [7] should instead be applied. We chose profound hypothermic fibrillatory arrest in conjunction with low-flow CPB, which allowed a good surgical field. The myocardium was consequently well protected. Despite the long duration of VF (91 minutes), the heart smoothly recovered to sinus rhythm and postoperative hemodynamics were stable with a low level of creatine kinase.
The final issue involves sufficient visualization of the mitral valve to facilitate repair. There have been several reports on patients with coronary artery disease and calcified aorta [2–5], but this is a rare report involving a mitral valve operation. It is somewhat difficult to obtain sufficient visualization of the intracardiac structures without aortic cross-clamping and cardiac arrest. Because we employed profound hypothermic fibrillatory arrest for myocardial protection, we could opt for low-flow CPB to obtain an acceptable surgical field. The duration of low-flow CPB at 1 L/min was 45 minutes, which should be within safe limits at 20°C. With regard to this subject, many similar experiences with aortic arch operations indicate that circulatory arrest with retrograde cerebral perfusion (200 to 300 mL/min via the superior vena cava at 18°C) for 60 to 80 minutes should be safe. A superior mitral approach with temporary division of the superior vena cava [6] was also useful for good visualization of the mitral valve. In addition, because retraction of the left atrial wall to the left by atrial retractors produced some amount of aortic regurgitation resulting in poor visualization of the mitral valve, both the superior mitral approach and low-flow CPB were essential in this case.
Initial mitral valve replacement may be more beneficial than mitral valve repair for such a complex case. If the repair were inadequate, the patient should be recooled. However, at operation, the mitral lesion was estimated to be repaired without difficulty, so we chose the repair promptly. Consequently, an intraoperative competency test injecting solution into the left ventricle did not show any residual mitral regurgitation. Intraoperative transesophageal echocardiography and postoperative routine echocardiography also demonstrated the absence of mitral regurgitation.
In conclusion, the conjunction of CPB with combined arterial cannulation and low-flow, profound hypothermic fibrillatory arrest, and superior mitral approach was beneficial for mitral valve repair in a complex case involving severe porcelain aorta.
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Footnotes
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Address reprint requests to Dr Ogino, Cardiovascular Surgery, Tenri Hospital, 200 Mishima-cho, Tenri, Nara 632, Japan.
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References
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- Coselli JS, Crawford S. Aortic valve replacement in the patient with extensive calcification of the ascending aorta (the porcelain aorta). J Thorac Cardiovasc Surg 1986;91:184–7.[Abstract]
- Culliford AT, Colvin SB, Rohrer K, Baumann FG, Spencer FC. The atherosclerotic ascending aorta and transverse arch: a new technique to prevent cerebral injury during bypass: experience with 13 patients. Ann Thorac Surg 1986;41:27–35.[Abstract]
- Wareing TH, Davila-Roman VG, Barzilai B, Murphy SF, Kouchoukos NT. Management of the severely atherosclerotic ascending aorta during cardiac operations. J Thorac Cardiovasc Surg 1992;103:453–62.[Abstract]
- Sabik JF, Lytle BW, McCarthy PM, Cosgrove DM. Axillary artery: an alternative site of arterial cannulation for patients with extensive aortic and peripheral vascular disease. J Thorac Cardiovasc Surg 1995;109:890–1.
- Buffolo E, Silva de Andrade JC, Rodrigues Branco JN, Teles CA, Aguiar LF, Gomes WJ. Coronary artery bypass grafting without cardiopulmonary bypass. Ann Thorac Surg 1996;61:63–6.[Abstract/Free Full Text]
- Selle JG. Temporary division of the superior vena cava for exceptional mitral valve exposure. J Thorac Cardiovasc Surg 1984;88:302–6.[Abstract]
- Akins CW. Noncardioplegic myocardial preservation for coronary revascularization. J Thorac Cardiovasc Surg 1984;88:174–81.[Abstract]
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Abstract
Introduction
