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Published on: November 24, 2014
Cross-clamping a porcelain aorta: an alternative technique for high-risk patients
Marc Hartert1, Lars O Conzelmann2, Uwe Mehlhorn2
1Department of Cardiothoracic and Vascular Surgery, University Medical Center, Johannes Gutenberg University, Mainz, Germany - marc.hartert@unimedizin-mainz.de.
Insights
A novel "open proximal ascending aorta" technique for aortic valve replacement in porcelain aorta patients significantly reduces stroke and embolization risks, improving outcomes in this high-risk group.
Area of Science:
- Cardiovascular Surgery
- Thoracic Surgery
- Vascular Surgery
Background:
- Porcelain aorta presents significant risks during aortic cross-clamping, leading to high mortality and morbidity.
- Developing innovative surgical approaches is crucial for improving outcomes in patients with porcelain aorta.
Purpose of the Study:
- To evaluate the efficacy and safety of a new aortic cross-clamping technique in patients with porcelain aorta undergoing valve replacement.
- To reduce the incidence of stroke and systemic embolization in this high-risk population.
Main Methods:
- A cohort of 42 patients with porcelain aorta underwent aortic or mitral valve replacement between 2007 and 2012.
- A longitudinal aortotomy was performed under total cardiopulmonary bypass, allowing mobilization and flushing of atherosclerotic material.
- The aorta was slowly clamped and unclamped with the aortotomy open to release debris ('open proximal ascending aorta' technique).
Main Results:
- The "open proximal ascending aorta" technique was technically feasible with no intraoperative complications.
- Mean cardiopulmonary bypass and cardiac ischemia times were comparable for aortic and mitral valve replacement.
- The 30-day mortality rate was 6.9%, with a 7.1% rate of stroke and transient ischemic attacks.
Conclusions:
- The "open proximal ascending aorta" technique is an effective method for managing porcelain aorta during valve surgery.
- This approach demonstrates a low incidence of stroke and systemic embolization compared to existing literature.
- The technique offers a promising solution for improving surgical outcomes in high-risk patients with porcelain aorta.
Background:
Aortic cross-clamping in patients with porcelain aorta is associated with high mortality and morbidity rates. The aim is to establish a new approach to improve the outcome in this high-risk population.
Methods:
Between September 2007 and November 2012, 42 patients with an aortic (N.=33; 81.3±6.4 years) or mitral valve disease (N.=9; 80.3±5.7) combined with a porcelain aorta underwent aortic (AVR) or mitral valve replacement (MVR). After arterial cannulation via distal aortic arch or femoral artery, longitudinal aortotomy under total cardiopulmonary bypass (CPB) was performed. The aorta was slowly clamped, thus mobilized atherosclerotic material could leave the aorta through the open incision. Subsequent to the actual operation, the aorta was gradually unclamped. Again, plaques were flushed out via the still open aortotomy ("open proximal ascending aorta").
Results:
Intraoperatively, no technical no problems occurred. Mean CPB time was 92.2±27.9 min (AVR) and 92.3±36.3 min (MVR); cardiac ischemia time was 74.3±26.7 min (AVR) and 77.1±31.6 min (MVR). Surgical revision was necessary in three patients (7.1%) due to major bleedings. Two AVR-patients suffered from minor stroke and one MVR-patient from major stroke (neurological deficit rate =7.1%). Transient ischemic attacks occurred in three patients (7.1%), another three patients (7.1%) required temporary hemofiltration. Neither gastrointestinal disorders nor respiratory failure or valve-related problems were noted. 30-day mortality was 6.9%.
Conclusions:
Cross-clamping with "open proximal ascending aorta" is effective and the incidence of stroke and systemic embolization in patients with porcelain aorta is low compared to literature.
