2|CASE
A 61-year-old female suffering from aggravating chest distress and
shortness of breath for a year was admitted to our Department of
Cardiology. The patient with a history of chronic renal insufficiency
had undergone mechanical MVR and CABG 7 years before admission. On
physical examination, her blood pressure was 90/57 mmHg, heart rate was
84 beats/minute. Lung breaths sounded clear. Cardiac examination
revealed a grade 4/6 systolic murmur and a diastolic murmur in the
auscultation area of the aortic
valve. Transthoracic
echocardiography showed calcified aortic valve with small aortic annulus
for a diameter of 16.6 mm, as well as severe stenosis and moderate
regurgitation, accompanied by hypokinesis of the left ventricular wall,
the peak flow velocity of 4.28 m/second, peak across aortic valve
gradient of 73.4 mmHg, mean gradient of 44 mmHg, and a calculated aortic
valve area of 0.33 cm2. The left ventricular
end-diastolic diameter was 67.1 mm. The left ventricular ejection
fraction was 26%. Thoracic computed tomography (CT) showed severe and
diffuse calcifications of the coarctated ascending aorta (a porcelain
aorta) and aortic arch (Fig.1A), with an aortic root diameter of 14.6 mm
and an internal diameter of 14.0 mm. The calculated European system for
cardiac operative risk evaluation (EuroSCORE) II mortality was 72.04 %.
Under general anesthesia, the patient was placed in the right decubitus
position with hips externally rotated to allow access to the left
femoral vessels. Cardiopulmonary bypass was established between the left
femoral artery and vein. A left lateral thoracotomy
was performed through the sixth intercostal space to show both the left
ventricular apex and the descending thoracic aorta. After
systemic heparinization, the descending aorta was clamped, to which a
23-mm mechanical valved conduit was sewn in an end-to-side fashion.
Under ventricular fibrillation induced with hypothermia of 25 ℃, the
left ventricular apex was opened and the aortic valve was repaired by
through the direct apical incision. Then a 26-mm vascular tube graft was
anastomosed to the apical incision by 2-0 polypropylene sutures with
pledgets. Finally, the two grafts were anastomosed together end-to-end
with a continuous 4-0 polypropylene suture.
Postoperatively, the patient was treated with double therapy consisting
of warfarin and aspirin. The patient was extubated 21 hours after the
operation and was discharged from the hospital on day 18 after surgery
in good condition. The pre-discharge echocardiography showed a decreased
pressure gradient across the aortic valve (peak 29 mmHg, mean 11 mmHg)
and an ejection fraction of 47.82 %, with the left ventricular
end-diastolic diameter of 54.6 mm. Contrast-enhanced CT demonstrated a
valved apico-aortic conduit with fluent blood flow (Fig.1B).