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. 2017 Nov;9(11):4424-4433.
doi: 10.21037/jtd.2017.10.100.

Replacement of calcified ascending aorta in patients undergoing aortic valve replacement

Hyoung Woo Chang  1 , Dong Seop Jeong  1 , Yang Hyun Cho  1 , Kiick Sung  1 , Wook-Sung Kim  1 , Young Tak Lee  1 , Pyo Won Park  1
Affiliations

Replacement of calcified ascending aorta in patients undergoing aortic valve replacement

Hyoung Woo Chang et al. J Thorac Dis. 2017 Nov.

Abstract

Background: Aortic stenosis (AS) with an extensively calcified ascending aorta is a growing indication for transcatheter aortic valve implantation (TAVI) because aortic manipulation during surgical aortic valve replacement (AVR) is unsafe in these patients. The aim of this study was to evaluate the outcomes of AVR plus ascending aorta replacement (AAR) in patients with severe AS and a heavily calcified ascending aorta.

Methods: From 2004 to 2014, a total of 32 patients with severe AS and extensive aortic calcification underwent concomitant first-time AVR and AAR (AVR + AAR). The mean patient age was 74±7 (range, 59-87) years, and 7 (22%) patients were octogenarians. The mean logistic EuroSCORE was 21.4%±19.0% (range, 3.3-68.2%). Arterial cannulae were placed at the ascending aorta (n=26, 81%), aortic arch (n=5, 16%), or axillary artery (n=1, 3%). The aorta was not clamped, and circulatory arrest was used in all patients. One-to-many (1:n) propensity score matching between the study population (AVR + AAR, n=29) and control group (isolated AVR for severe AS, n=433) was performed.

Results: There was no early mortality in the study population. Postoperative neurologic complications included a minor stroke, which resolved without sequelae at discharge, and a transient ischemic attack. The 5-year survival rate was 83%±9%. In the propensity score-matched comparison, 5-year survival was not significantly different between groups; 81%±10% in the AVR + AAR group vs. 87%±2% in the isolated AVR group (P=0.950).

Conclusions: Surgical AVR with AAR in AS patients with calcified ascending aortas led to acceptable early and late outcomes. Although the applications for TAVI are growing, a surgical approach may be an alternative option for relatively younger patients with severely calcified aorta.

Keywords: Aortic valve stenosis; deep hypothermic circulatory arrest (DHCA); thoracic aorta; vascular calcification.

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Conflict of interest statement

Conflicts of Interest: Part of this research was presented at the 29th Annual Meeting of the European Association of Cardiothoracic Surgeons, Amsterdam, Netherlands, October 3-7, 2015.

Figures

Figure 1
Figure 1
Computed tomography images of an 85-year-old male with severely displaced mediastinum due to tuberculosis. Axillary artery cannulation was performed, and he recovered without incident. He was discharged on postoperative day 8. He is currently 93 years old and in good health.
Figure 2
Figure 2
Computed tomography images taken from an 87-year-old male whose calculated EuroSCORE was 68.2%. This patient underwent emergency aortic valve replacement due to progressive orthopnea and acute renal failure. Although he did not show any neurologic complications postoperatively, he died 3 years postoperatively after a prolonged hospital stay.
Figure 3
Figure 3
Diagram showing how the propensity score matching was planned. AVR, aortic valve replacement; AAR, ascending aorta replacement.
Figure 4
Figure 4
Comparison of overall survival in total and matched patients. *, log-rank test; ?, cox regression for weighted and clustered data. AVR, aortic valve replacement; AAR, ascending aorta replacement.
See this image and copyright information in PMC

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