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Division of Cardiovascular Surgery, Toronto General Hospital, 200 Elizabeth St, 4N-480, Toronto, Ontario, Canada. M5G 2C4
(Email: gilbert.tang{at}utoronto.ca).
| Dr. Tang discloses that he has a financial relationship with Medtronic, Inc.
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Management of aortic stenosis in the presence of porcelain aorta remains a formidable challenge in cardiac surgery. Reported options in the past have included endarterectomy and replacement of the aorta under deep hypothermic circulatory arrest, or apicoaortic conduit in the absence of significant aortic insufficiency. However, both are high-risk procedures with the potential for significant mortality and morbidity, especially in elderly patients who already present with other surgical risk factors.
Transcatheter aortic valve implantation (AVI) has emerged as an important therapeutic option for patients with severe aortic stenosis not amenable to open surgical intervention. Patients with porcelain aortas would definitively fit into this category. However, because these patients often present with significant aortoiliac and peripheral vascular disease, the transfemoral approach to transcatheter AVI is not an option. Kempfert and coauthors [1] are therefore to be congratulated for presenting their early experience managing this challenging problem with transapical AVI. The group from Leipzig has already published their extensive experience with transapical AVI using the Edwards SAPIEN (Edwards Lifesciences, Irvine, CA) valve [2–4]. The risk profile in this series of 29 patients is significant, with a mean logistic European System for Cardiac Operative Risk Evaluation of 37.7% and Society of Thoracic Surgeons score of 12.8%. The 30-day mortality rate of 17.2% (5 of 29) and stroke rate of 3.5% (1 of 29) compare favorably with those in their previously reported series [2].
The group reported a higher-than-usual pacemaker implantation rate of 17.2%, compared with other published studies on the SAPIEN valve. One may hypothesize that among patients with porcelain aorta, the high degree of calcium embedded in the aortic valve and annulus may cause compression of the membranous septum after valve deployment, causing permanent heart block. In addition, despite a small contrast dose, postoperative renal failure requiring dialysis developed in 31% of patients, suggesting a significant atheroembolic risk from wire manipulation in the porcelain aorta across the arch.
The midterm to long-term outcomes of patients with aortic stenosis and porcelain aorta who receive transapical AVI remain uncertain. Kempfert and coauthors reported in this high-risk series a 1-year survival rate of 55% (18 of 29 patients), compared with their previously reported 1-year survival rate of 73% for 100 consecutive patients who received transapical AVI [2]. The difference in survival is likely attributed to the small sample size in the current series. In their previous transapical AVI study [2], patients in the highest risk category (mean logistic European System for Cardiac Operative Risk Evaluation 58% and Society of Thoracic Surgeons score of 23%) had a 1-year survival rate of 67% (6 of 9 patients among the 100 reported). Although an early learning curve in the current series may be a factor, one wonders if having porcelain aorta may itself be a negative independent predictor for survival. Retrospective analysis of a larger-sized study may provide the answer.
Finally, the economic benefits of transapical AVI in this high-risk cohort should be assessed. Compared with open aortic valve replacement with deep hypothermic circulatory arrest, transapical AVI may offer significant cost savings in both perioperative and postoperative care. However, the cost of a single transcatheter aortic valve is not insignificant, and in many centers, ongoing funding issues have become a barrier in disseminating this important emerging technology to patients who may benefit most from it. As we await the results of the Placement of Aortic Transcatheter Valve Trial (PARTNER) in the United States, the increasing adoption of transcatheter AVI may hinge on the balance between clinical efficacy and financial sustainability and will likely remain an important issue among cardiothoracic surgeons, cardiologists, hospital administrators, and government entities in the future.
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