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Ann Thorac Surg 1998;65:1313-1315
© 1998 The Society of Thoracic Surgeons

Aortic Valve Operations Under Deep Hypothermic Circulatory Arrest for the Porcelain Aorta: "No-Touch" Technique

^a Division of Cardiac Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA

Accepted for publication December 17, 1997.

Address reprint requests to Dr Cohn, Division of Cardiac Surgery, Brigham and Women’s Hospital, 75 Francis St, Boston, MA 02115
e-mail: (lhcohn{at}bics.bwh.harvard.edu)

	Abstract

Top Abstract Introduction Material and methods Comment References

 
Background. Aortic valve replacement or repair becomes a high-risk procedure in patients in whom the ascending aorta cannot be clamped either because of extensive calcification and risk of cerebral embolus or because of extensive adhesions precluding safe dissection and clamping.

Methods. We report the results of aortic valve replacement or repair with deep hypothermic circulatory arrest in 3 patients. Techniques to improve results include routine use of epiaortic and transesophageal echocardiography, avoidance of manipulation of the ascending aorta until the circulation is arrested, avoidance of antegrade cardioplegia, routine use of retrograde cardioplegia and retrograde cerebral perfusion, when feasible, and minimal aortotomy (just enough to excise and replace or repair the valve).

Results. Operations were accomplished in approximately 1 hour each with minimal manipulation of the aorta, thus minimizing aortic trauma and subsequent risk of cerebral embolus. Each patient had an unremarkable recovery without neurologic complications.

Conclusions. Aortic valve replacement or repair using the "no-touch" technique and deep hypothermic circulatory arrest is the preferred method when dealing with the porcelain or unclampable aorta.

	Introduction

Top Abstract Introduction Material and methods Comment References

 
Aortic valve replacement (AVR) or repair becomes a high-risk procedure in patients in whom the ascending aorta cannot be clamped either because of extensive calcification and risk of cerebral embolus or because of extensive adhesions precluding safe dissection and clamping. Previous approaches to this problem have included the following: isolation and temporary occlusion of the innominate and carotid arteries and subsequent aortic clamping; placement of a forward occluding balloon in the ascending aorta during a brief period of circulatory arrest followed by reinstitution of circulation [1]; endarterectomy of the ascending aorta [2]; replacement of the ascending aorta; and, as presented here, AVR or repair under deep hypothermic circulatory arrest [3]. We suggest the last is to be preferred, provided it can be accomplished relatively quickly and with minimal manipulation of the aorta, because of its simplicity and because it minimizes aortic trauma and subsequent risk of cerebral embolus. We report its use in 3 patients and suggest improvements in technique to further reduce the risk of catastrophic cerebral emboli.

	Material and methods

Top Abstract Introduction Material and methods Comment References

 
Patient 1
A 51-year-old woman with severe aortic regurgitation and heart failure as well as subaortic stenosis was admitted for AVR and resection of subaortic muscular stenosis. At operation, she was found to have an eggshell, totally calcified "porcelain" aorta. After the scanning of the ascending aorta with epicardial echocardiography, cannulation or clamping of the ascending aorta was determined to carry a high risk of cerebral embolism. Therefore, the descending aorta was evaluated by transesophageal echocardiography to determine whether the femoral artery could be used for retrograde perfusion and was found to not contain marked atheromatous disease.

Cardiopulmonary bypass was established by way of the femoral artery and the right atrium, and the patient was cooled to 15°C. On circulatory arrest, the aorta was opened. Retrograde cardioplegia, a left ventricular vent, and retrograde cerebral perfusion were also used. The regurgitant valve as well as fibrotic material on the anterior leaflet of the mitral valve was excised. The middle portion of the septum was also excised. A 23-mm St. Jude Medical (St. Paul, MN) valve was placed in the standard fashion. The aorta was closed with a running suture buttressed with pericardium, the circulation was restarted, and the patient was rewarmed. Circulatory arrest time was 65 minutes. The patient was weaned from cardiopulmonary bypass without difficulty and had an unremarkable recovery without neurologic complications.

Patient 2
A 69-year-old man had had two previous cardiac operations: triple coronary artery bypass grafting 16 years before this admission and redo double coronary artery bypass grafting, replacement of the ascending aorta with a 30-mm supracoronary tube graft, and AVR with a 25-mm Hancock (Medtronic, Minneapolis, MN) porcine valve for angina, a large aneurysm, and severe aortic regurgitation, respectively, 9 months before this admission. He was seen this time with prosthetic valve endocarditis caused by enterococcus and severe aortic regurgitation.

At operation, he was found to have massive dense adhesions precluding safe dissection of any mediastinal structures and aortic cannulation or clamping. Therefore, the femoral artery and vein were cannulated for cardiopulmonary bypass, and the patient was cooled to 15°C. The pulmonary artery was available for venting, but this was not necessary, as cooling was gradual to prevent sudden fibrillation and subsequent left ventricular distention. Retrograde cardioplegia and retrograde cerebral perfusion could not be used because the dense adhesions precluded safe dissection of appropriate structures.

On circulatory arrest, the previous supracoronary tube graft was opened below the site of the proximal vein grafts. There were two torn leaflets and old healed vegetations in the 25-mm Hancock valve, which was excised, and the pannus was debrided. A 25-mm Carpentier-Edwards (Baxter Inc, Irvine, CA) pericardial valve was inserted in the standard fashion. The patient was placed in deep Trendelenburg position during closure of the tube graft with a running suture while the circulation was restarted, and air was evacuated from the cerebral vessels. Circulatory arrest time was 61 minutes. The patient was weaned from cardiopulmonary bypass without difficulty and had an unremarkable recovery without neurologic complications.

Patient 3
An 84-year-old woman with unstable angina and moderate aortic stenosis required an intraaortic balloon pump prior to operation. At operation, she was found to have a heavily calcified aorta. After the ascending aorta was evaluated with epicardial echocardiography, a soft spot on the distal ascending aorta without disease was chosen for cannulation. Because of extensive calcification, aortic clamping was deemed to carry a high risk of cerebral embolism. Therefore, the patient was cooled to 15°C.

During cooling and in fibrillatory arrest with left ventricular venting, three distal coronary anastomoses were constructed with a sequential vein graft to the right coronary artery and the first obtuse marginal branch. A second vein graft was placed on the left anterior descending coronary artery with its proximal anastomosis to the sequential vein graft in a Y fashion so that only one proximal anastomosis to the aorta was required. After 15°C was reached, circulatory arrest was established and the aorta, opened. Retrograde cardioplegia, left ventricular vent, and retrograde cerebral perfusion were also used in this patient.

The aortic valve was moderately calcified on the left and right coronary cusps. However, to replace the valve would have required a 17-mm or 19-mm valve and a root-enlarging procedure, and this was considered unwise in this frail, elderly woman. Therefore, the calcified cusps were debrided of all calcium, and this resulted in improved leaflet motion and an enlarged valve orifice. The aorta was closed with a running suture buttressed with pericardium. The single proximal coronary anastomosis to the aorta was constructed. The circulation was restarted and the patient, rewarmed. Circulatory arrest time was 48 minutes. The patient was weaned from cardiopulmonary bypass without difficulty, and transesophageal echocardiography showed the valve area to be 1.4 cm² compared with 0.9 cm² prior to operation. The patient had an unremarkable recovery without neurologic complications.

	Comment

Top Abstract Introduction Material and methods Comment References

 
The porcelain (unclampable) aorta presents a challenging problem to the cardiac surgeon. When a totally calcified aorta is encountered, its clamping carries a high risk of cerebral embolism of either calcium or atheromatous material from the aorta. To avoid this potentially catastrophic complication, Cosgrove [1] suggested placement of a forward occluding balloon in the distal ascending aorta under circulatory arrest and, after balloon inflation, reinstitution of circulation and AVR while rewarming. We have used this technique on a few occasions but think that the balloon can still produce embolism, lacerate the fragile aortic intima, cause aortic dissection, or migrate, leading to catastrophic bleeding or fatal air embolism.

One of the first AVRs performed under total circulatory arrest was reported by Jacobowitz and co-workers [3]. Their technique was similar to that presented here but included the use of snares around the innominate and carotid arteries to further prevent cerebral emboli. We believe this is unnecessary and may damage these vessels, thus causing dissection or thrombosis. Jacobowitz and associates also used antegrade cardioplegia administered through the coronary ostia. We suggest this should be avoided in the heavily diseased aorta because of the risk of emboli or dissection of the coronary arteries. We use retrograde cardioplegia on arresting the circulation and then redirect retrograde cardioplegia catheter into the superior vena cava to administer retrograde cerebral perfusion after snaring the superior vena cava. Retrograde cerebral perfusion helps protect the brain and "wash out" particulate or gaseous emboli.

Coselli and Crawford [4] presented the cases of 2 patients having operation with techniques similar to those of Jacobowitz and colleagues. In addition, Coselli and Crawford placed gauze in the distal ascending aorta and left ventricle to catch debris. In a recent report, Svensson and co-workers [2] presented the use of ascending aorta endarterectomy in 6 patients but did not state whether the aorta was clamped or whether circulatory arrest was employed. Another option for treating these patients is to replace the entire ascending aorta, but we think this is excessive and should not be necessary if the techniques we suggest are used.

Our patient 2 illustrates a unique situation in which the ascending aorta could not safely be clamped because of massive dense adhesions resulting from two prior cardiac operations and graft replacement. The following principles of the "no-touch" technique were applied, as in patients 1 and 3, with a satisfactory outcome:

1. Routine use of epiaortic echocardiography to evaluate the ascending aorta for disease without manipulation; if the ascending aorta cannot be cannulated safely, then peripheral cannulation (femoral or axillary) should be used.
   
2. Routine use of transesophageal echocardiography to evaluate the descending aorta for disease (if femoral cannulation is considered) and for evacuation of air; if femoral cannulation is precluded because of descending aorta disease and subsequent risk of retrograde cerebral emboli, axillary cannulation should be performed.
   
3. Avoidance of manipulation of the ascending aorta until the circulation is arrested.
   
4. Avoidance of antegrade cardioplegia and subsequent risk of coronary emboli or dissection.
   
5. Routine use of retrograde cardioplegia, when feasible.
   
6. Routine use of retrograde cerebral perfusion, when feasible.
   
7. Minimal aortotomy, that is, just enough to excise and replace or repair the valve.
   

Because retrograde cerebral perfusion could not be used, careful attention to deairing with the patient in deep Trendelenburg position was necessary. Another option for this situation is use of a Heartport (Redwood City, CA) Port-Access Endoaortic Clamp balloon occluder passed transfemorally to occlude the ascending supracoronary tube graft. We believe this technique could be safe in a nondiseased aorta or a tube graft, but we do not recommend it for a heavily diseased ascending aorta, as in patients 1 and 3.

If the femoral arteries are not suitable for cannulation because of severe peripheral vascular disease or major disease in the descending thoracic aorta precluding safe retrograde perfusion, then axillary cannulation should be carried out. In our experience, the axillary artery is free from substantial disease and is easily approached through a subclavian incision [5].

	References

Top Abstract Introduction Material and methods Comment References

 

1. Cosgrove D.M. Management of the calcified aorta: an alternative method of occlusion. Ann Thorac Surg 1983;36:718-719.[Abstract]
2. Svensson L.G., Sun J., Cruz H.A., Shahian D.M. Endarterectomy for calcified porcelain aorta associated with aortic valve stenosis. Ann Thorac Surg 1996;61:149-152.[Abstract/Free Full Text]
3. Jacobowitz I.J., Rose D.M., Shevede K., Cunningham J.N. Use of profound hypothermia and circulatory arrest for the calcified aorta. Chest 1984;85:288-289.[Abstract/Free Full Text]
4. Coselli J.S., Crawford S.E. Aortic valve replacement in the patient with extensive calcification of the ascending aorta (the porcelain aorta). J Thorac Cardiovasc Surg 1986;91:184-187.[Abstract]
5. Bichell D.P., Balaguer J.M., Aranki S.F., et al. Axilloaxillary cardiopulmonary bypass: a practical alternative to femorofemoral bypass. Ann Thorac Surg 1997;64:702-705.[Abstract/Free Full Text]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): John G. Byrne Sary F. Aranki Lawrence H. Cohn Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Byrne, J. G. Articles by Cohn, L. H. Search for Related Content PubMed PubMed Citation Articles by Byrne, J. G. Articles by Cohn, L. H.