Conventional aortic valve replacement in patients with severely calcified ascending aorta in the era of transcatheter aortic valve implantation

Objective: With the recent development of transcatheter aortic valve implantation (TAVI), patients with severely calcified ascending aorta awaiting an aortic valve replacement tend to be considered for TAVI independent of their general operative risk profile. Here we present our surgical experiences on a cohort of these patients, in whom we have performed conventional surgery.

Methods: From 08/2009 until 08/2011, a conventional aortic valve replacement was performed in 5 male patients with severely calcified ascending aorta (Table 1). The arterial cannulation site was at the distal aortic arch in all patients. In patients with porcelain aorta, the body temperature was cooled down without any manipulation on the ascending aorta, the head was packed with ice before circulatory arrest was induced. Without any adjunctive measure of cerebral protection, such as antegrade cerebral perfusion, the ascending aorta was rapidly replaced. During this phase, heart arrest was obtained with a retrograde cardioplegia. Thereafter, the vascular prosthesis was clamped and cardiopulmonary bypass was restored. In patients with a partial calcification of the ascending aorta, the procedure up to the induction of circulatory arrest, was similar to that in patients with porcelain aorta. Under circulatory arrest, the ascending aorta was opened and calcification was removed under direct vision, then the aorta was clamped softly and cardioplegic solution was given directly into the coronary ostia.

Table 1

Patient no.	Age (years)	Aortic valve pathology	Ascending aorta pathology	Procedure on the ascending aorta	Body temperature at circulatory arrest (°C)	Duration of circulatory arrest (min)	Concomitant procedures
1	73	Stenosis	Porcelain Aorta	Replacement	26	6	CABG
2	69	Stenosis	Porcelain Aorta	Replacement	28	7	None
3	71	Regurgitation due to an endocarditis	Porcelain Aorta	Replacement	27	12	Mitral valve repair
4	72	Stenosis	Partial calcification	Removal of calcification	30	2	CABG, mitral valve repair, tricuspid valve repair
5	65	Stenosis	Partial calcification	Removal of calcification	28	3	CABG, Bentall-operation

Results: All of the patients were extubated on the 1^st postoperative day and there was no neurological deficit. One patient (no. 4) died on 53^rd postoperative day due to lever failure, but all other patients are doing well (mean follow up 5.3±4.4 days).

Conclusions: Using moderate hypothermic circulatory arrest with or without a replacement of the ascending aorta, an aortic clamping could be performed safely in patients with severe calcification of the ascending aorta. Our results suggests that severe calcification of the ascending aorta in patients with severe aortic valve stenosis is not a contraindication for conventional surgery.