Cross-clamping a porcelain aorta: an alternative technique for high-risk patients

BACKGROUND: Aortic cross-clamping in patients with porcelain aorta is associated with high mortality and morbidity rates. The aim is to establish a new approach to improve the outcome in this high-risk population. METHODS: Between September 2007 and November 2012, 42 patients with an aortic (N.=33; 81.3 +/- 6.4 years) or mitral valve disease (N.=9; 80.3 +/- 5.7) combined with a porcelain aorta underwent aortic (AVR) or mitral valve replacement (MVR). After arterial cannulation via distal aortic arch or femoral artery, longitudinal aortotomy under total cardiopulmonary bypass (CPB) was performed. The aorta was slowly clamped. thus mobilized atherosclerotic material could leave the aorta through the open incision. Subsequent to the actual operation. the aorta was gradually undamped. Again, plaques were flushed out via the still open aortotomy ("open proximal ascending aorta"). RESULTS: Intraoperatively, no technical no problems occurred. Mean CPB time was 92.2 +/- 27.9 min (AVR) and 92.3 +/- 36.3 min (MVR); cardiac ischemia time was 74.3 +/- 26.7 min (AVR) and 77.1 +/- 31.6 min (MVR). Surgical revision was necessary in three patients (7.1%) due to major bleedings. Two AVR-patients suffered from minor stroke and one MVR-patient from major stroke (neurological deficit rate =7.1%). Transient ischemic attacks occurred in three patients (7.1%). another three patients (7.1%) required temporary hemofiltration. Neither gastrointestinal disorders nor respiratory failure or valve-related problems were noted. 30-day mortality was 6.9%. CONCLUSIONS: Cross-clamping with "open proximal ascending aorta" is effective and the incidence of stroke and systemic embolization in patients with porcelain aorta is low compared to literature.