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OBJECTIVE: Aortic valve replacement(AVR) is challenging in patients with porcelain aorta, but transcatheter aortic valve replacement(TAVR) offers a clampless option. With the advent of TAVR, more patients have been referred after sternotomy and aborted procedure due to intraoperative discovery of severe aortic calcification. Objectives are to characterize these patients and describe outcomes
METHODS: From 2001 to 2012, 17 patients were referred after a prior aborted attempt at an outside facility for surgical AVR due to unexpected intraoperative findings of porcelain aorta. Procedures performed at the time of aborted AVR included off pump coronary bypass in 9 and isolated exploratory sternotomy in 8. These patients were then treated with open AVR(n=6) or TAVR(n=11) for severe aortic stenosis(n=14), regurgitation(n=1) or both(n=2) at our institution. Median interval between prior aborted AVR and definitive AVR was 9.6 months. Mean age was 74±11 years, preoperative gradients were 53±18mm Hg, and valve area was 0.6cm2. In surgical AVR group the approach was via redo sternotomy in 5 and mini sternotomy in 1. Hypothermic circulatory arrest was used in 4 and axillary artery cannulation was used in 2. Additional procedures included ascending repair(n= 4), coronary bypass(n= 3) other valve repair(n=1). In TAVR group, the approach was transfemoral(n=6), or transapical(n=5)
RESULTS: Proximal aorta was severely calcified in all patients. Mean postoperative gradient was 13±4 mmHg. Patients in surgical AVR group had multiple cardiac co-morbidities, whereas in TAVR group patients were older(mean age 79±3 years) and high risk(STS score 8-13).There was no operative mortality, stroke, renal or respiratory failure, but in TAVR group, one patient required valve-in-valve implantation for paravalvular leak, another required intra-aortic balloon pump for hemodynamic instability. Median hospital length of stay was 8 days. Three late deaths occurred at median follow-up of 2.5 years
CONCLUSIONS: Open and transcatheter AVR at a tertiary care center are safe and effective. TAVR expands options in high risk patients with aortic stenosis and porcelain aorta. Open approach may be preferred when multiple cardiac co-morbidities are present