The atherosclerotic aorta at aortic valve replacement: Surgical strategiesand results

Background: Aortic valve replacement in patients with severe atherosclerosi s of the ascending aorta poses technical challenges. The purpose of this st udy was to examine operative strategies and results of aortic valve replace ment in patients with a severely atherosclerotic ascending aorta that could not be safely crossclamped. Patients and methods: From January 1990 to December 1998, 4983 patients had aortic valve surgery; of these, 62 (1.2%) patients had a severely atherosc lerotic ascending aorta and required hypothermic circulatory arrest to faci litate aortic valve replacement. They form the study group. Results: All patients had hypothermic circulatory arrest, but several diffe rent strategies were used to manage the ascending aorta. These techniques i ncluded aortic valve replacement with the use of hypothermic circulatory ar rest (39%), ascending aortic endarterectomy (26%), ascending aortic replace ment (19%), aortic inspection and crossclamping during hypothermic circulat ory arrest (10%), and balloon occlusion of the ascending aorta (6%). Durati on of hypothermic circulatory arrest was substantially longer for patients having aortic valve replacement with hypothermic circulatory arrest than fo r all other strategies. Hospital mortality was 14%, and 10% of patients had strokes. Increasing New York Heart Association functional class and impair ed left ventricular function were risk factors for hospital mortality. Choi ce of operative technique did not influence patient outcome; however, no pa tient who underwent replacement of the ascending aorta had a stroke. Conclusions: Aortic valve replacement in patients with severe atheroscleros is of the ascending aorta is associated with increased operative morbidity and mortality. Complete aortic valve replacement during hypothermic circula tory arrest, the "no-touch" technique, requires a prolonged period of circu latory arrest. Ascending aortic replacement is a preferred technique, as it requires a short period of hypothermic circulatory arrest and results in c omparable mortality with a low risk of stroke.