The calcified ascending aorta in aortic valve replacement: surgical strategies and results

Calcification in the ascending aorta may constitute a major problem during aortic valve replacement (AVR). We examined the distributions of calcification and the associated operative strategies.

Between 1999 and 2012, 207 consecutive, elderly patients underwent isolated AVR at our center. Computed tomographic scan data were available for all patients, and 105 were found to have at least one segment of calcification. Aortic calcifications were based on the section of the aorta that was calcified: distal, middle, and proximal of the ascending aorta.

Forty-six patients had calcification in the distal zone. In these patients, conventional cannulation was performed in 26 patients, with an associated in-hospital mortality of 7.7%. Arterial cannulation site was changed from the ascending aorta to somewhere in 20 patients (including other aortic sites in 9 patients, femoral artery in 7 patients, and both femoral and innominate arteries in 4 patients), without any patient deaths. Middle zone calcifications were observed in 70 patients: 63 underwent conventional cross-clamping with particular care (7.9% mortality), 5 underwent cross-clamping under direct vision during hypothermic circulatory arrest, and 2 underwent balloon occlusion. None of the patients undergoing substitute cross-clamping died. Proximal calcifications were observed in 66 patients; 47 patients underwent conventional transverse aortotomy, with an associated mortality of 8.5%.

Although the 8.3% mortality rate in patients undergoing conventional procedures was not negligible, it was lower than the expected 25.9% estimated by the patient EuroSCOREs. The conventional procedure results are reasonable, but may require a substitute procedure in some cases.