Porcelain aorta: A surgical dilemma in orthotopic heart transplantation

Background Circumferential calcification of the ascending aorta, known as porcelain aorta, in a patient candidate to a heart transplant, requires technically demanding and high-risk procedural adjustments. Aims This case report showed successful replacement of ascending aorta due to extensive calcification at time of heart transplantation. Materials and methods In the operating theatre, after median sternotomy, cardiopulmonary bypass (CPB) was achieved via the right femoral artery and vein. Due to the impossibility of replacing the ascending aorta using safe aortic cross-clamping, a moderate hypothermia was established, and circulatory arrest was realized. According to Kazui protocol for selective anterograde cerebral perfusion via anonymous trunk and left carotid artery, ascending aorta was replaced with vascular prosthesis. Results Thanks to accurate pre-surgical planning, which included hypothermic circulatory arrest, ascending aorta replacement, before orthotopic heart implantation, we were able to perform the procedure successfully and prevent neurological events. Discussion Although different reports showed the feasibility of heart transplant combined to aortic replacement for aneurysmatic pathology, few cases were described for porcelain aorta, due to technically demanding procedure and prohibitive aortic cross-clamping. To avoid vascular embolization, dissection and mural laceration, aortic cross-clamping is not recommended. We performed aortic replacement at first, to reduce allograft ischemia. Conclusion The use of hypothermic circulatory arrest technique with selective cerebral perfusion for aortic replacement, followed by vascular graft clamping to favour cardiac allograft implantation, could be considered a winning combination to guarantee procedural success and to reduce perioperative complications.