Apicoaortic conduit insertion for elderly patients with acquired aortic stenosis and small aortic annulus

BACKGROUND: Patients with critical aortic stenosis, a heavily calcified aorta, and a small aortic annulus are at an increasing risk of complications during a conventional aortic valve replacement (AVR) procedure. Insertion of an apicoaortic conduit (AAC) can be an alternative to AVR in such situations. This study is a review of our experiences with AAC in elderly patients with acquired aortic stenosis. METHOD: From 2001 to 2005, 7 elderly patients (mean age of 81 : range 74 to 87) underwent an AAC insertion for severe symptomatic aortic stenosis with a small aortic annulus (mean annulus size 17.9 mm). Preoperatively, all were symptomatic, with 4 rated as New York Heart Association (NYHA) functional class IV, 2 as class III, and 1 as class II. In addition, 3 patients had severe congestive heart failure with mechanical ventilation and received a high dose administration of catecholamine, and 1 had undergone coronary artery bypass grafting (CABG) previously. RESULT: The AAC insertions were performed under a cardiopulmonary bypass through a left thoracotomy in 6 patients, while 1 patient underwent the procedure without a cardiopulmonary bypass. Distal anastomoses were performed in the descending thoracic aorta with a partial occluding clamp. A composite woven Dacron conduit with a stented biological valve was used in 2 cases, and a woven Dacron conduit with a stentless bioprosthesis was used in 5. Two patients underwent a concomitant CABG. There was 1 hospital death due to obstructive ileus 4 months after the operation. One patient who had been in a shock state preoperatively had hypoxic encephalopathy due to inoperative severe hypotension. Postoperative echocardiography showed relief of the left ventricle-aortic gradient in all patients. After a mean follow-up period of 22 months, there was no late death, while 3 patients were readmitted due to congestive heart failure. Further, 1 of the patients was rated as NYHA class I, 1 as class II, and 2 as class III. CONCLUSION: An AAC procedure was found to be an acceptable alternative for elderly patients who had a high-risk of complications with the standard procedure.