Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
J Thorac Cardiovasc Surg. 2015 Jan;149(1):131-4. doi: 10.1016/j.jtcvs.2014.09.035. Epub 2014 Sep 18.
Surgical aortic valve replacement is challenging in patients with severe aortic calcification. Some patients undergo sternotomy and have the operation aborted because of intraoperative discovery of severe calcification. Hypothermic circulatory arrest and transcatheter aortic valve replacement offer clampless treatment options for aortic stenosis. The study objectives are to characterize patients who are referred after sternotomy was aborted for porcelain aorta and to describe the treatment outcomes.
From 2001 to 2013, 19 patients presented after attempt at surgical aortic valve replacement was aborted because of porcelain aorta. Patients presented with aortic stenosis (n = 16), regurgitation (n = 1), or both (n = 2). Off-pump coronary bypass was performed in 10 patients. At the Cleveland Clinic, patients underwent surgical aortic valve replacement (n = 7) or transcatheter aortic valvve replacement (n = 12). The median interval between aborted aortic valve replacement and definitive treatment was 9.6 months. The mean age was 74 ± 11 years. The mean transvalvular gradient was 51 ± 18 mm Hg, and area was 0.6 cm(2). Axillary cannulation was used in all patients undergoing surgical aortic valve replacement, but only 4 required circulatory arrest. The transcatheter aortic valve replacement approach was transfemoral (n = 5), transapical (n = 6), or transaortic (n = 1).
The mean postoperative gradient was 13 ± 4 mm Hg. There was no mortality, stroke, renal failure, or reoperation for bleeding. One patient required a second valve implantation for paravalvular leak. The median hospital length of stay was 8 days. Five late noncardiac deaths occurred at a median follow-up of 16 months.
Both surgical aortic valve replacement and transcatheter aortic valve replacement are safe and effective options after aborted sternotomy in patients with porcelain aorta who are referred to a high-risk valve center. Procedure selection may be tailored to individual patients on the basis of aortic morphology and comorbidities. Patients with aortic stenosis at risk for calcific aortic disease should be screened with cross-sectional imaging preoperatively.
在严重主动脉钙化的患者中，主动脉瓣置换术极具挑战性。一些患者接受了胸骨切开术，但由于术中发现严重钙化而手术被中止。低温体外循环和经导管主动脉瓣置换术为主动脉瓣狭窄提供了无夹闭的治疗选择。本研究的目的是描述因瓷主动脉而中止胸骨切开术的患者，并描述其治疗结果。
2001 年至 2013 年，19 例患者因瓷主动脉而中止主动脉瓣置换术，随后转诊。患者表现为主动脉瓣狭窄（n=16）、反流（n=1）或两者兼有（n=2）。10 例患者行非体外循环冠状动脉旁路移植术。在克利夫兰诊所，7 例患者行主动脉瓣置换术，12 例患者行经导管主动脉瓣置换术。中止主动脉瓣置换术和明确治疗之间的中位间隔时间为 9.6 个月。患者平均年龄为 74±11 岁。平均跨瓣压差为 51±18mmHg，瓣口面积为 0.6cm2。所有行主动脉瓣置换术的患者均采用腋动脉插管，但只有 4 例需要体外循环。经导管主动脉瓣置换术途径为经股动脉（n=5）、经心尖（n=6）或经主动脉（n=1）。
术后平均压差为 13±4mmHg，无死亡、卒中和肾衰竭，也无因出血而再次手术。1 例患者因瓣周漏需再次植入瓣膜。中位住院时间为 8 天。中位随访 16 个月时，5 例患者发生晚期非心源性死亡。
对于转诊至高危瓣膜中心的因瓷主动脉而中止胸骨切开术的患者，行主动脉瓣置换术和经导管主动脉瓣置换术均安全有效。可根据主动脉形态和合并症选择个体化治疗方案。有发生钙化性主动脉疾病风险的主动脉瓣狭窄患者应在术前进行影像学筛查。
