Aortic valve surgery for patients with severely calcified aorta

: Severe atherosclerosis of the ascending aorta frequently causes difficulties during heart operations, hindering surgical maneuvers and potentially leading to systemic embolism. There have been several methods to solve these problems but the best way to treat patients requiring aortic valve replacement (AVR) has not been established yet. Surgical techniques for AVR in these patients include AVR under deep hypothermic circulatory arrest with or without endarterectomy of the ascending aorta or replacement of the ascending aorta. Endovascular clamping using a balloon is another approach but requires manipulation of the heavily calcified aorta that may result in a certain risk for stroke. Another option to avoid the ascending aorta and cross-clamping is the apicoaortic conduit. Recently introduced trans-catheter AVR (TAVR), especially trans-apical AVR, has been shown to be feasible in such patients. Larger studies and longer follow-up will be required to scientifically prove the superiority of trans-apical AVR over conventional surgical strategies in patients with porcelain aorta requiring AVR.