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Ann Thorac Surg 1998;66:2158-2159
© 1998 The Society of Thoracic Surgeons
a Department of Cardiothoracic Surgery, Shaare Zedek Medical Center, PO Box 3235, Jerusalem 91031, Israel
To the Editor
In the May 1998 issue of The Annals, Byrne and associates [1] reported three patients undergoing aortic valve operation using deep hypothermic circulatory arrest because of a calcified aorta. This approach certainly offers a solution to a group of patients having a relative contraindication to operative procedures. In addition to the measures recommended by these authors, we perform computed tomography of the chest in all patients suspected of having a calcified aorta, and in all patients more than 80 years old. This enables us to find a so-called window through which the aorta may be entered in cases where the ascending aorta is indeed calcified. We would like to share our experience in three patients undergoing aortic valve replacement using circulatory arrest.
The first patient was a 75-year-old man found to have severe aortic stenosis after evaluation for angina pectoris and a syncopal attack. At operation, an unexpected calcified ascending aorta was discovered, with a circumferential plaque at the proximal portion and a posterior plaque at the distal ascending aorta extending into the arch. This enabled cannulation of the distal ascending aorta, but precluded clamping of the aorta. The aortic valve was replaced with a Hancock II 23-mm bioprosthesis (Medtronic Inc, Minneapolis, MN), using deep hypothermic circulatory arrest, insertion of a left ventricular vent, and retrograde cerebral perfusion. Circulatory arrest time was 31 minutes. The patient was weaned from cardiopulmonary bypass without any difficulty and had an uneventful recovery with no neurologic damage.
The second patient was a 58-year-old woman who had undergone a coronary bypass operation 4 years previously. At that time she was found to have mild aortic insufficiency, with no evidence at all of aortic stenosis. She was admitted to the Orthopedic Surgery Department after she fainted and broke her hip. Evaluation disclosed severe aortic stenosis, with functioning coronary grafts. In addition to her heart disease, she suffered from severe peripheral vascular disease, having undergone left femoropopliteal bypass 2 years previously. The patient was bedridden in the orthopedic department for about a month before her transfer to our department. Because of the severity of the aortic stenosis, it was decided to replace her valve before repairing her hip. The patient was connected to partial cardiopulmonary bypass through right femoral artery-femoral vein cannulation before sternotomy. After sternotomy the right atrium was cannulated to achieve full bypass, and dense adhesions were dissected to expose the ascending aorta, which was thickened and had proximal calcification. Deep hypothermic circulatory arrest with left ventricular venting, retrograde cardioplegia, and retrograde cerebral perfusion were used, and the aortic valve was replaced by a St Jude 19-mm HP mechanical prosthesis (St Jude Medical Inc, St Paul, MN). Circulatory arrest time was 39 minutes, and the patient was disconnected from cardiopulmonary bypass without any difficulty. The initial postoperative course was satisfactory; the patient awakened from the operation with no neurologic deficits and underwent early extubation. After hip surgery, she suffered recurring episodes of sepsis and died 2 months after her heart operation.
The third patient was a 67-year-old man who developed severe aortic stenosis 5 years after a coronary artery bypass operation. His bypass grafts, including a left internal mammary to the left anterior descending coronary artery, were patent. The combination of patent grafts in the presence of severe adhesions posed a high risk for aortic clamping, therefore the operation was performed using deep hypothermic circulatory arrest with venting of the left ventricle. The aortic valve was replaced with a Sorin Bicarbon 23-mm mechanical prosthesis (Sorin Biomedica Cardio, Saluggia, Italy). Circulatory arrest time was 49 minutes, and the patient was disconnected from bypass without any difficulty. He made an uneventful recovery with no neurologic damage.
The 3 patients described survived the heart operation with no cardiac or neurologic sequelae. Unfortunately, the second patient, having complex and severe comorbidity, died of causes unrelated to her heart operation. The third patient, although not having a calcified aorta, and who could not have his aorta clamped for the reasons noted, underwent circulatory arrest with no adverse effects. Our experience and that of Byrne and associates shows that the technique of deep hypothermia with circulatory arrest is feasible, and that patients with a calcified ascending aorta can undergo an operation of the aortic valve with an acceptable degree of safety.
References
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