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Ann Thorac Surg 2006;82:381
© 2006 The Society of Thoracic Surgeons

Correspondence

Porcelain Aorta: Therapeutical Options for Aortic Valve Replacement and Concomitant Coronary Artery Bypass Grafting

Christian Schreiber, MD, Rüdiger Lange, MD, PhD

Clinic of Cardiovascular Surgery, German Heart Center, Munich Clinic of Cardiovascular Surgery at the Technical University, Lazarettstrasse 36, Munich, 80636 Germany

(Email: schreiber{at}dhm.mhn.de).

To the Editor:

We have read with interest the article on avoidance of hypothermic circulatory arrest to allow for aortic valve replacement in patients with an unclampable aorta [1]. Forty-six of seventy patients had concomitant coronary artery bypass grafting. The authors do not mention therapeutical options such as apicoaortic conduits and aortic connector systems for revascularization. We have a few comments.

First, clinical experiences with apicoaortic connections were reported in the 1950s [2]. In 1980, Nihill and colleagues [3] summarized hemodynamic observations of 25 patients of which 10 who were children. In 1986, Sweeney and colleagues [4] reported a 78% survival rate after 5 years in a series of 38 patients. Indications for interposition of a valved conduit from the apex of the left ventricle to the descending aorta were correction of left ventricular outflow tract obstructions in both the pediatric and adult populations. Today the described technique of insertion of an apicoaortic conduit provides a practical surgical alternative for patients with severe aortic stenosis in combination with porcelain aorta or multiple previous open heart operations [5, 6]. The choice of a biological versus a mechanical valved conduit depends on the usual considerations such as age of the patient and possible comorbidities.

Whereas in the complex setting described by Aranki and colleagues [1], either total arterial revascularization procedures or end-to-side anastomosis of saphenous veins into a mammary artery may be an option. We opted for a sutureless implantation of a vein into the aorta (Symmetry Bypass System [St. Jude Medical Inc, St. Paul, MN]) with a near, no-touch technique [7].


   References
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 References
 

  1. Aranki SF, Nathan M, Shekar P, Couper G, Rizzo R, Cohn LH. Hypothermic circulatory arrest enables aortic valve replacement in patients with unclampable aorta Ann Thorac Surg 2005;80:1679-1686.[Abstract/Free Full Text]
  2. Sarnoff SJ, Donovan TJ, Case RB. The surgical relief of aortic stenosis by means of apical aortic valvular anastomoses Circulation 1955;11:564-574.[Medline]
  3. Nihill MR, Cooley DA, Normann JC, Hallmann GL, McNamara DG. Hemodynamic observations in patients with left ventricle to aorta conduit Am J Cardiol 1980;45:573-582.[Medline]
  4. Sweeney MS, Walker WE, Cooley DA, Reul GJ. Apicoaortic conduits for complex left ventricular outflow tract obstructionsa 10-year experience. Ann Thorac Surg 1986;42:609-611.[Abstract]
  5. Schreiber C, Augustin N, Bauernschmitt R, Lange R. Management of coronary artery disease, aortic valve stenosis and porcelain aortamodified bypass procedure and apicoaortic conduit. Herz 2002;27:795-798.[Medline]
  6. Crestanello JA, Zehr KJ, Daly RC, Orszulak TA, Schaff HV. Is there a role for the left ventricle apical-aortic conduit for acquired aortic stenosis? J Heart Valve Dis 2004;13:57-62.[Medline]
  7. Watanabe G, Takemura H, Tomita S, Nagamine H, Kamiya H, Kanamori T. Skeletonized radial artery graft with the St. Jude Medical Symmetry Bypass System (aortic connector system) Ann Thorac Surg 2004;77:1550-1552.[Abstract/Free Full Text]



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