Aortic Valve Replacement for Porcelain Aorta with Balloon Occlusion and Deep Hypothermic Circulatory Arrest

(Department of Cardiovascular Surgery, Oji General Hospital, Tomakomai, Japan)

Tatsuya Murakami Hiroki Kato Yutaka Makino
A 78-year-old woman on chronic hemodialysis was found to have severe aortic stenosis causing refractory hypotension during hemodialysis and elected to undergo aortic valve replacement. However, chest CT scan revealed a totally calcified gporcelainh ascending aorta which prevented safe aortic cross-clamping. MRA also showed stenosis of the origin of the left subclavian artery. At operation, an area free from calcification was identified in the lesser curvature of the ascending aorta where an aortic cannula was placed. Cardiopulmonary bypass was commenced. A single selective cerebral perfusion was added via the left axillary artery to maintain adequate flow to the dominant left vertebral artery. The patient was cooled to a rectal temperature of 24 when a proximal transverse aortotomy was made and an occlusion balloon was inserted into the ascending aorta during circulatory arrest for 2min. The cardiopulmonary bypass was restarted with half systemic flow. The aortic valve was excised and a 19-mm Carpentier-Edwards bovine pericardial valve was placed in the supravalvular position with simple interrupted sutures. The body was further cooled down to 19. On another circulatory arrest, the balloon was removed. Endarterectomy was performed along the edges of the aortotomy which was reinforced with equine pericardial strips. The aortotomy was then closed with a running suture. The circulation was restarted and the patient was rewarmed. Circulatory arrest time was 42min. The patient was weaned from cardiopulmonary bypass without difficulty and had an unremarkable recovery without neurologic complications. The operative technique described here for the treatment of aortic valve disease in a patient with a porcelain aorta is safer than deep hypothermic circulatory arrest alone, allowing shorter circulatory arrest period. In addition, endarterectomy of the aortotomy edges reinforced with xenopericardial strips is useful to secure the closure line against bleeding.
@Jpn. J. Cardiovasc. Surg. 36: 112-116 (2007)