Aortic valve bypass: experience from Denmark

In aortic valve bypass (AVB) a valve-containing conduit is connecting the apex of the left ventricle to the descending aorta. Candidates are patients with symptomatic aortic valve stenosis rejected for conventional aortic valve replacement (AVR) or transcatheter aortic valve implantation (TAVI). During the last one and a half year, 10 patients otherwise left for medical therapy have been offered this procedure. We present the Danish experiences with the AVB procedure with a focus on patient selection, operative procedure and short-term results.

AVB is performed through a left thoracotomy. A 19-mm Freestyle(®) valve (Medtronic) is anastomosed to a vascular graft and an apex conduit. The anastomosis to the descending aorta is made prior to connecting the conduit to the apex. In 1 patient, we used an automated coring and apical connector insertion device (Correx(®)). The device results in a simultaneous coring and insertion of an 18-mm left ventricle connector in the apical myocardium. AVB is routinely performed without circulatory assistance.

Ten patients have been operated on since April 2011: eight females and 2 males with a median age of 76 (65-91) years. Seven patients had a severely calcified ascending aorta. Three of these had previously had a sternotomy, but did not have an AVR because of porcelain aorta. Six patients had a very small left ventricle outflow tract (<18 mm). The median additive EuroSCORE was 12 (10-15). Seven patients were operated on without circulatory assistance. Two patients had a re-exploration for bleeding and 1 developed a ventricle septum defect 1 month postoperatively and was treated with surgical closure. The median follow-up was 7 (2-15) months and was without mortality. New York Heart Association class was reduced from 2.5 to 2 at the follow-up, but some patients were still in the recovery period. The total valve area (native plus conduit) was 2.2 (1.9-2.5) cm(2) and 1.34 (1.03-1.46) cm(2)/m(2), indexed to the body surface area. There was no AV block or stroke.

AVB can be performed with low mortality and acceptable results in selected patients. The procedure can be offered to patients rejected for conventional aortic valve replacement and TAVI and results in a larger total valve area than by insertion of standard bioprosthesis.