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Objective: Aortic cross-clamping in patients with aortic valve disease and porcelain aorta is associated with high mortality and morbidity rates. Despite optimised standard operative techniques - including deep hypothermia and cardiocirculatory arrest - the results in these patients are unsatisfying. Therefore, a new approach was established to improve the neurological outcome in this high-risk population.
Methods: Between September 2007 and November 2011, 35 patients with aortic valve stenosis (81.3 ± 6.4 years; EuroSCORE [European System for Cardiac Operative Risk Evaluation] 29.2 ± 16.5 %; STS-Score [Society of Thoracic Surgeons] 11.6 ± 3.4) combined with porcelain aortas underwent aortic valve replacement (AVR). After arterial cannulation via distal aortic arch or femoral artery, a dual-stage cannula was inserted through the right appendage. Following a longitudinal aortotomy under total cardiopulmonary bypass (CPB), the aorta was slowly clamped. Atherosclerotic material, mobilised by the clamping procedure, could leave the aorta through the open incision. Subsequent to the actual operation, the aorta was deaired and gradually unclamped. Again, plaques were flushed out via the still open aortotomy, the so-called "open aortic root". Finally, the aortic sutures were closed.
Results: The procedure was technically successful in all patients. A shift to alternative operation techniques was not necessary. Following intraoperative data were obtained: mean CPB time 92.2 ± 27.9 min; cardiac ischaemia 74.3 ± 26.7 min; total operative time 168 ± 42min. Mean ICU stay was 2.4 ± 1.9 days with a mean ventilation-time of 19 ± 9h. Three patients (8.6 %) had to be reoperated due to major bleedings. Three patients developed temporary motoric deficits (neurological deficit rate = 8.6 %), seven patients temporary mental disorders. Three patients had to undergo temporary postoperative dialysis due to renal insufficiency. Neither gastrointestinal disorders nor respiratory failure or valve-related problems were noted. The 30-day mortality for the entire group was 5.7 %.
Conclusions: Cross-clamping with "open aortic root" can optimise the neurological outcome for patients with porcelain aorta undergoing minimally invasive AVR. It has the potential to become a viable standard procedure in high-risk patients as the prevalence of stroke and systemic embolisation are reduced.