Redo aortic valve replacement with ''porcelain'' aorta in an aortitis patient. A case report

We report a successful reoperation of aortic valve replacement with the severely calcified, 'porcelain' aorta due to Takayasu's disease. The patient was a 46-year-old female diagnosed with aortic prosthetic valve failure. Takayasu's aortitis had been noted at 17 years old and the patient underwent aortic valve replacement for aortic regurgitation at age 32. Chest CT scan revealed severe circumferential calcification of the whole thoracic aorta. Echocardiography revealed 100 mmHg of pressure gradient across the aortic prosthetic valve with pannus formation. Replacement of the aortic prosthetic valve was performed using the selective cerebral perfusion method under deep hypothermia. The postoperative course was uneventful without any neurological disorder. Selective cerebral perfusion was a useful method to avoid cross clamping in severely calcified ascending aortic.     

Valve surgery in octogenarians with a "porcelain" aorta and aortic insufficiency

We report the technique of balloon occlusion of the ascending aorta in two patients requiring valve operations. In the first patient, it provided a rapid solution to unexpected and potentially catastrophic severe aortic insufficiency (AI) with the initiation of cardiopulmonary bypass in a patient who required aortic valve replacement using deep hypothermic circulatory arrest due to a "porcelain" aorta. In the second patient, it allowed for a routine mitral valve repair to be performed by providing aortic occlusion in the setting of AI and avoiding the devastating consequences of cross-clamping a "porcelain" aorta.     

Valve Surgery in Octogenarians with a “Porcelain” Aorta and Aortic Insufficiency

Abstract We report the technique of balloon occlusion of the ascending aorta in two patients requiring valve operations. In the first patient, it provided a rapid solution to unexpected and potentially catastrophic severe aortic insufficiency (Al) with the initiation of cardiopulmonary bypass in a patient who required aortic valve replacement using deep hypothermic circulatory arrest due to a “porcelain” aorta. In the second patient, it allowed for a routine mitral valve repair to be performed by providing aortic occlusion in the setting of Al and avoiding the devastating consequences of cross‐clamping a “porcelain” aorta.     

Beating mitral valve replacement for a patient with porcelain aorta

Beating mitral valve replacement was performed for mitral valve stenosis in a patient with a porcelain aorta after aortic valve replacement. The 77-year-old patient had developed heart failure several times. A chest computed tomographic scan revealed severe calcification on the ascending aorta and aortic arch. A cardiopulmonary bypass was established by bicaval drainage and aortic return after epiaortic echographic evaluation of the ascending aorta. The mitral valve was successfully replaced under a beating heart.     

Radiotherapy-induced aortic valve disease associated with porcelain aorta

Mediastinal irradiation has been reported to induce cardiac disease such as pericarditis, valvular dysfunction, conduction abnormalities, accelerated arteriosclerosis of the coronary arteries, and also calcifications of the ascending aorta. We herein describe a case of radiotherapy-induced porcelain aorta and aortic valve disease and their surgical treatment. The patient was diagnosed with myasthenia gravis (MG) in 1965 (Osserman’s type II), and mediastinal irradiation was performed in 1970 for treatment of thymic tumor associated with MG. Thirty years after radiation therapy, complete atrioventricular block and aortic valve disease with severe calcification of the ascending aorta and aortic arch (porcelain aorta) were detected on echo cardiogram and cardiac catheterization. A permanent pacemaker was implanted via the left subclavian vein and aortic valve replacement was performed under extracorporeal circulation established by selective cerebral perfusion and balloon occlusion instead of aortic cross-clamping. As no risk factors of arteriosclerosis such as hypercholesterolemia, hyperglycemia and hypertension were apparent, we concluded that the aortic valve disease and porcelain aorta were primarily induced by radiotherapy.     

Cardiac surgery in patients with Gilbert's syndrome

We report the case of a 58-year-old patient with Gilbert's syndrome and multiple cardiovascular pathologies, including aortic regurgitation with a dilated aortic root, severe mitral regurgitation, and chronic atrial fibrillation. A Bentall procedure, mitral valve repair, and modified radiofrequency MAZE procedure were performed. The management of Gilbert's syndrome in patients undergoing cardiac surgery is reviewed.     

Simultaneous repair of cardiovascular disorders and pectus deformity in a patient with Sprintzen-Goldberg syndrome: A case report.

We report a 12-year-old girl with Sprintzen-Goldberg syndrome (SGS) who was complicated with annuloaortic ectasia with aortic regurgitation, mitral valve prolapse with mitral regurgitation, and a severe pectus excavatum. In this patient, aortic root replacement, mitral valve replacement, and sternal elevation were simultaneously performed, and a version of Ravitch's procedure that was technically modified to support the sternum was used for sternal elevation. This modified sternal elevation technique gave excellent operative exposure, and maintained chest wall stability after the operation.     

One-staged operation for mitral regurgitation and annuloaortic ectasia without aortic regurgitation with Marfan syndrome; report of a case

A 32-year-old man with Marfan syndrome was admitted to our hospital for detail examination of congestive heart failure. Doppler echocardiography showed severe mitral regurgitation due to prolapse of posterior mitral leaflet. Annuloaortic ectasia without aortic regurgitation was also detected by aortography. Considering the future operative need for aortic root and ascending aorta, we performed mitral valve replacement with a mechanical valve and preventive concomitant aortic root replacement with a composite valve graft. His postoperative course was uneventful. Optimal surgical treatment of mitral regurgitation and annuloaortic ectasia in Marfan syndrome is controversial because the underlying connective tissue defect theoretically might compromise repair durability. Several surgical options for mitral regurgitation and annuloaortic ectasia in Marfan syndrome are discussed.     

Aortic valvular insufficiency and postductal aortic coarctation with small aorta syndrome: one-stage surgical management using extra anatomic bypass through median sternotomy

A 30-year-old man who had undergone repair for coarctation of the thoracic aorta at age 7 and mitral valve annuloplasty at age 9 was admitted for shortness of breath and claudication of both lower legs. The preoperative angiogram showed severe aortic regurgitation, moderate coarctation of the thoracic aorta beyond the left subclavian artery, a degree of hypoplasia of the infrarenal abdominal aorta, and total occlusion of both external iliac arteries. Aortic valve replacement, ascending-to-bilateral femoral arterial bypass, and end expanded polytetra fluoro ethylene (ePTFE) graft-to-descending aorta bypass was performed via a median sternotomy. Ascending-to-descending aortic bypass via the posterior pericardium allows simultaneous intracardiac repair or an alternative approach for the patient with complex coarctation.     

Total aortic arch aneurysm repair using a stent graft without cardiac or cerebral ischemia

A 74-year-old man with an aortic arch aneurysm and a chronic type IIIb aortic dissection underwent total aortic arch repair without cerebral or cardiac ischemia. After confirming no atheromatous change in the ascending aortic wall, a custom-designed 4-limbed graft, prepared for both arterial return of cardiopulmonary bypass and reconstruction of the arch vessels, was anastomosed onto the right side of the ascending aorta. The 3 arch vessels were then bypassed sequentially during systemic cooling and monitoring cerebral perfusion with near-infrared oxymetry. After aortic cross-clamping, a stent graft was inserted into the distal arch from the distal ascending aorta, maintaining cerebral and cardiac perfusion. This procedure is indicated especially in a high-risk patient who has an aortic arch aneurysm without severe atheromatous change in the ascending aorta and the arch vessels.     

Infective endocarditis affecting both systemic and pulmonary circulations predisposed by a ventricular septal defect.

A 39-year-old woman was admitted to our hospital presenting persisting fever. An echocardiographic examination showed severe aortic and mitral valve regurgitation with moderate tricuspid regurgitation. Small left-to-right shunt through the ventricular septal defect was identified. Vegetation was also detected on the tricuspid, mitral, and aortic valves. At one month after admission, the patient showed sudden onset of headache and abdominal pain. A computed tomographic scan demonstrated cerebral and splenic infarction. A pulmonary perfusion scintigram demonstrated perfusion defects in left-S1 and right-S6 regions. At 4 months after admission, as operation was performed. The aortic valve was replaced with a #23 mm CarboMedics prosthesis and the mitral valve with a #29 mm Carbo Medics prosthesis. Tricuspid valve plasty was performed, with closure of He laceration and perforation of the anterior leaflet combined with a commissuroplasty, according to Kay's method. Ventricular septal defect was closed with a bovine pericardial patch. She was discharged at 19 days after the operation, and is leading a good life. Pervasion of the organism seemed to be initiated from the mitral valve which was conveyed by the blood stream to the aortic valve, and to the tricuspid valve through the ventricula septal defect. Left heart evaluation may be important in cases with infective endocarditis and ventricula septal defect.     

Combined aortic valve replacement and coronary artery bypass grafting with in situ arterial grafts for porcelain aorta.

Patients with porcelain aorta carry a high risk of cerebral as well as systemic embolism during cardiac surgery. Here we describe a case of severe aortic stenosis and coronary artery disease combined with the circumferentially calcified aorta. The patient was a 77-year-old man who successfully received four coronary artery bypass grafts with in situ arterial grafts without clamping the aorta and aortic valve replacement. Aortic valve replacement and two distal coronary artery anastomoses to the left circumflex artery and obtuse marginal branch were performed under cardiac arrest during hypothermic perfusion with endoaortic balloon occlusion, followed by partial endarterectomy and closure of the aorta buttressed with bovine pericardium under deep hypothermic circulatory arrest. While rewarming, the other two distal coronary anastomoses to the left anterior descending artery and diagonal branch were done on the beating heart in order to minimize cardiac arrest time. On-pump beating heart coronary artery bypass grafting (CABG) can be useful especially for combined complex cardiac surgery.     

Beating heart surgery for ischemic mitral regurgitation: report of a case

A 51-year-old man was admitted to our hospital because of dyspnea. Coronary angiography revealed triple vessel disease and echocardiography demonstrated severe mitral regurgitation with poor left ventricular function. Under a diagnosis of ischemic mitral regurgitation, on-pump beating mitral annuloplasty and coronary artery bypass grafting using the normothermic retrograde continuous coronary sinus perfusion of oxygenated blood was performed in order to prevent reperfusion injury. The patient was easily weaned from cardiopulmonary bypass and his postoperative course was uneventful. Because of the advantages of this procedure (e.g., no reperfusion injury, testing of the mitral valve repair is done in real physiologic conditions with beating tonus), on-pump beating heart surgery seems a good surgical option for ischemic mitral regurgitation with poor left ventricular function.     

Management of quadruple valves for severe infective endocarditis; report of a case

A 74-year-old man had pustulant bilateral arthritis complicated with sepsis and disseminated intravascular coagulation (DIC). Microbiologic study of blood sample showed Streptococcus and methicillin resistant Staphylococcus aureus (MRSA). He was complicated with postulant diskitis since then. Medical treatment for DIC and administration of antibiotics were performed. Preoperative echocardiography revealed massive aortic regurgitation and vegetation of aortic valve, moderate pulmonary regurgitation and vegetation of pulmonary valve, massive mitral regurgitation, massive tricuspid regurgitation. He was diagnosed as infective quadruple valve endocarditis. He received aortic valve replacement, pulmonary valve replacement, mitral valve repair and tricuspid valve repair. Postoperative echocardiography showed satisfactory function of bioprosthesis. Postoperative course was uneventful.     

Mitral valve repair in a patient with a porcelain ascending aorta

A 78-year-old patient with heavily calcified ascending aorta underwent mitral valve repair for mitral valve regurgitation. Chordal replacement with expanded polytetrafluoroethylene (ePTFE) loop technique was done under endo aortic clamp with a balloon catheter. He was discharged from the hospital on the 24th postoperative day without any major complications. Endo aortic clamp is thought to be a useful technique for a case with heavily calcified aorta.     

A successful surgical case of aortic arch aneurysm associated with aortic regurgitation

A 57-year-old male patient with aortic regurgitation and aneurysm of the ascending aorta and the aortic arch underwent aortic valve replacement and graft replacement from the ascending aorta to the aortic arch. The operation was done using cardio-pulmonary bypass and selective cerebral perfusion with deep hypothermia. Postoperative DSA revealed no dilatation of the sinus Valsalva and a good configuration of the anastomosis. It seems that selective cerebral perfusion with deep hypothermia is a safe method to prevent cerebral damage in a case of arch aneurysm.     

One-stage correction of aortic coarctation and severe mitral regurgitation via left posteriolateral thoracotomy in a 2-year-old child

We successfully treated a case of a 2-year-old male with aortic coarctation coexisting with severe mitral regurgitation via left posteriolateral thoracotomy at one stage. After a mitral valve replacement under perfused ventricular fibrillation with moderate hypothermia, we repaired the aortic coarctation with coarctation resection and end-to-end anastamosis with the aid of deep hypothermic circulatory arrest and selective low-flow cerebral perfusion. The patient had an uneventful hospital course and remains well.     

On-pump beating-heart mitral valve plasty without aortic cross-clamping

Patients with ischemic cardiomyopathy often have mitral regurgitation, which should be corrected for better long-term survival. Mitral valve surgery is usually performed during cardiopulmonary bypass under the arrested heart condition. The ascending aorta is cross-clamped and the heart is arrested using a cardioplegic solution. However, because ischemic cardiomyopathy patients often have a severely atherosclerotic ascending aorta and low cardiac function, aortic cross-clamping and cardiac arrest increase the risk of postoperative thromboemboli and low cardiac output syndrome. Under the on-pump beating-heart condition, we performed mitral valve plasty concomitant with coronary artery bypass grafting, tricuspid annuloplasty, left ventricular aneurysmectomy, and the maze procedure without aortic cross-clamping for a patient with ischemic dilated cardiomyopathy and bradycardial atrial fibrillation. The patient had no postoperative complications and recovered rapidly. Thus, to prevent serious postoperative complications, on-pump beating-heart mitral valve surgery without aortic cross-clamping may be a suitable surgical option for patients with ischemic cardiomyopathy.     

Intraoperative transesophageal echocardiography for the evaluation of mitral, aortic and tricuspid valve repair A tool to optimize surgical outcome

The present study reviews the clinical applicability and usefulness of intraoperative transesophageal echocardiography (TEE) during valve repair. Intraoperative TEE was performed in 48 consecutive patients, who were divided into three groups: 1. mitral valve repair (MVR), 2. aortic valve repair (AVR), 3. tricuspid valve repair (TVR). Residual valve regurgitation was assessed by color Doppler echocardiography on a scale from 0 to 4. The ratios of the jet area (JA) to the left- and right-atrial areas (JA/LAA and JA/RAA) were analyzed before and after cardiopulmonary bypass (CPB). In group 1, 14 patients were scheduled for MVR, of which 4 patients underwent valve replacement and 10 MVR. Post-repair TEE studies showed a significant decrease of mitral regurgitation. In 2 of the 10 patients, TEE demonstrated severe residual regurgitation requiring valve replacement during the same thoracotomy. In group 2, 11 patients underwent aortic commissurotomy. Post-repair TEE showed an increase in the systolic opening diameter and opening area of the aortic valve. One patient underwent valve substitution because of severe aortic regurgitation. In group 3, 23 patients were scheduled for TVR. In 3 of them TEE showed no significant regurgitation thus rendering tricuspid valve surgery unnecessary. Twenty patients underwent TVR of whom two showed unacceptable post-repair regurgitation requiring further surgery. Eighteen patients showed a significant reduction of valve regurgitation after TVR, and a further reduction was achieved by adjusting the tricuspid annuloplasty under TEE guidance.     

A New Modification of Debridement Valvuloplasty for Acquired Aortic Valve Disease

A high speed electric rasp was used to remove fibrous thickening from the aortic valve in conjunction with aortic valve commissurotomy in ten patients. All patients had moderate rheumatic aortic valve disease combined with severe mitral valve disease, and were treated by mitral valve replacement and aortic valve repair. All patients survived the operative procedure. There were no deaths or complications during hospitalization related to the valve repair process. The transaortic valve gradient was relieved from an average of 21.0 ± 8.6 mmHg to 5.6 ± 4.0 mmHg (catheterization), and from moderate to less-than-mild stenosis (echocardiography). Aortic valve regurgitation was reduced from an average of 2.2+ to 0.7+ on a scale of 0 to 4+ (aortography), and from an average of 2.5+ to 1.1+ on a scale of 0 to 4+ (echocardiography). During the follow-up period, no patients were reoperated on because of aortic valve dysfunction. Follow-up echocardiographic study demonstrated that the transaortic pressure gradient and valvular regurgitation had not progressed, and immediate postoperative conditions were maintained. There were two late deaths not related to the aortic valve. One patient died of prosthetic valve endocarditis in the mitral prosthesis 14 months postoperatively, and the other of a cerebrovascular accident 21 months postoperatively. Based on these data, we believe that aortic valve repair with a high speed electric rasp can effectively relieve aortic stenosis, reduce valvular regurgitation, and provide an excellent hemodynamlc result at early and mid-term follow-up. (J Card Surg 1994;9:103–108)