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      Aortic Valve Replacement Using Balloon Catheter for Thoracic Endovascular Aortic Repair to Patient with Calcified Aorta

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          Abstract

          A 79-year-old man was admitted to Samsung Changwon Hospital due to chest pain and dyspnea. The ejection fraction was 31% and mean pressure gradient between the left ventricle and aorta was 69.4 mmHg on echocardiography. Chest computed tomography showed severe calcification of the ascending aorta. Aortic valve replacement was successfully performed using a thoracic endovascular aortic repair balloon catheter without classic aortic cross clamping. The patient was discharged on the eleventh postoperative day.

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          Most cited references 7

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          The atherosclerotic aorta at aortic valve replacement: surgical strategies and results.

          Aortic valve replacement in patients with severe atherosclerosis of the ascending aorta poses technical challenges. The purpose of this study was to examine operative strategies and results of aortic valve replacement in patients with a severely atherosclerotic ascending aorta that could not be safely crossclamped. From January 1990 to December 1998, 4983 patients had aortic valve surgery; of these, 62 (1.2%) patients had a severely atherosclerotic ascending aorta and required hypothermic circulatory arrest to facilitate aortic valve replacement. They form the study group. All patients had hypothermic circulatory arrest, but several different strategies were used to manage the ascending aorta. These techniques included aortic valve replacement with the use of hypothermic circulatory arrest (39%), ascending aortic endarterectomy (26%), ascending aortic replacement (19%), aortic inspection and crossclamping during hypothermic circulatory arrest (10%), and balloon occlusion of the ascending aorta (6%). Duration of hypothermic circulatory arrest was substantially longer for patients having aortic valve replacement with hypothermic circulatory arrest than for all other strategies. Hospital mortality was 14%, and 10% of patients had strokes. Increasing New York Heart Association functional class and impaired left ventricular function were risk factors for hospital mortality. Choice of operative technique did not influence patient outcome; however, no patient who underwent replacement of the ascending aorta had a stroke. Aortic valve replacement in patients with severe atherosclerosis of the ascending aorta is associated with increased operative morbidity and mortality. Complete aortic valve replacement during hypothermic circulatory arrest, the "no-touch" technique, requires a prolonged period of circulatory arrest. Ascending aortic replacement is a preferred technique, as it requires a short period of hypothermic circulatory arrest and results in comparable mortality with a low risk of stroke.
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            Atherosclerosis of the ascending aorta and coronary artery bypass. Pathology, clinical correlates, and operative management.

             C Everson,  N Mills (1991)
            Analysis of 1735 patients who underwent coronary artery bypass grafting from January 1981 through December 1988 revealed 152 (8.8%) patients with mild (4.5%), moderate (2.2%), or severe (2.0%) atherosclerosis of the ascending aorta. Three distinct pathologic patterns were found. The prevalence of stroke in patients with the severe type of aortic disease prompted development of a new operative technique that has been used in 16 patients. It involves a "no-touch" technique of the ascending aorta whereupon the proximal saphenous vein anastomoses are performed end to side to internal mammary artery grafts. Ages ranged from 49 to 80 years (mean 68.9). The 16 patients had 62 distal artery and vein anastomoses and 26 proximal saphenous vein-internal mammary end-to-side anastomoses. Internal mammary artery free flows ranged from 130 to 420 ml/min. Two hospital deaths were unrelated to the technique. There have been no strokes or recurrences of angina. An inordinately high incidence of main left coronary disease (50%), significant carotid disease (79%), and abdominal aortic occlusive or aneurysm disease (93%) was discovered. Ascending aortic atherosclerosis must be suspected in all coronary bypass patients with associated significant carotid, abdominal aortic, and main left coronary artery disease, aortic wall irregularity on ascending aortic angiography, adhesions between the ascending aorta and its adventitia, pale appearance of the ascending aorta, and minimal bleeding of an aortic cannulation stab wound. A "no-touch" technique that avoids any manipulation of the ascending aorta and that uses the internal mammary arteries as the sole source of blood supply for coronary bypass is an effective method to prevent aortic clamp injury, "trash heart," or stroke from severe ascending aortic disease. Preoperative angiographic visualization of the ascending aorta of all patients undergoing coronary artery bypass is mandatory.
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              Endarterectomy for calcified porcelain aorta associated with aortic valve stenosis.

              A calcified porcelain aorta may complicate aortic valve insertion and require an alternative, more complex method for valve replacement. The reason for this is that sutures cannot be inserted through the calcific plates in the annulus and ascending aorta. In 6 patients with an average age of 73.8 years (range, 65 to 81 years), we performed the simpler procedure of aortic endarterectomy of the calcific plates with the aortic valve replacement. We realized that there may be an increased risk of postoperative complications, particularly stroke. The calcific plates were fractured to allow debridement of the calcium. In addition, an end-arterectomy was performed of the left main coronary ostium in 2 patients, and 5 patients also had coronary artery bypass grafting performed. All 6 patients underwent successful operations without major complications. On follow-up, echocardiography or computed tomographic scans in 3 patients have not shown dilation of the ascending aorta. Endarterectomy of the aorta may be an option in the management of patients with calcification of the aorta.
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                Author and article information

                Journal
                Korean J Thorac Cardiovasc Surg
                Korean J Thorac Cardiovasc Surg
                KJTCS
                The Korean Journal of Thoracic and Cardiovascular Surgery
                Korean Society for Thoracic and Cardiovascular Surgery
                2233-601X
                2093-6516
                June 2013
                05 June 2013
                : 46
                : 3
                : 212-215
                Affiliations
                [1 ]Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Korea.
                [2 ]Department of Thoracic and Cardiovascular Surgery, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Korea.
                [3 ]Department of Radiology, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Korea.
                Author notes
                Corresponding author: Joung Hun Byun, Department of Thoracic and Cardiovascular Surgery, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, 158 Paryong-ro, Masanhoewon-gu, Changwon 630-723, Korea. (Tel) 82-55-290-6019, (Fax) 82-55-290-6785, jhunikr@ 123456naver.com
                Article
                10.5090/kjtcs.2013.46.3.212
                3680608
                23772410
                © The Korean Society for Thoracic and Cardiovascular Surgery. 2013. All right reserved.

                This is an open access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

                Categories
                Case Report

                Surgery

                aortic valve, aorta, calcification

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