Technical Modifications for Patients with Aortic Stenosis and Calcified Ascending Aorta During Aortic Valve Replacement

Aortic stenosis (AS) is the most prevalent valvular heart disease in developed countries1). Aortic valves deteriorate due to degenerative processes, and calcification is the most frequent cause of AS. Clinical factors related to aortic valve calcification are similar to those for atherosclerosis, and the prevalence of calcified aortic valves increases with age2). As a consequence, AS is associated with a high risk of cardiovascular morbidity and mortality in the elderly3). To achieve longer life expectancy, aortic valve replacement (AVR) is recommended as a definitive treatment for calcified aortic valves4,5). Although the operative mortality of isolated AVR is low, the surgical risk is increased in elderly patients due to concomitant procedures and/or comorbidities associated with advanced age6). Thus, it is very important to plan a careful strategy for co-existing atherosclerotic lesions, especially in the ascending aorta. Atherosclerotic change in the ascending aorta is one of the potential causes of postoperative stroke, which results in higher morbidity and mortality7,8). Most embolic events are associated with manipulation of the ascending aorta such as the clamping of the ascending aorta or the release of aortic crossclamping9). To reduce embolic complications, surgical treatments have changed, and there are several techniques, including AVR during hypothermic circulatory arrest (HCA)10-12), complete thromboendarterectomy during HCA13), endarterectomy or ascending aorta replacement during HCA14), endoaortic balloon occlusion15), and apicoaortic conduit16). Despite aggressive attempts to deal with the calcified ascending aorta, surgical outcomes such as the stroke rate, morbidity, and mortality have remained unsatisfactory. This paper describes our surgical strategy for patients with AS associated with a diseased calcified ascending aorta. Furthermore, meticulous techniques for atherosclerotic lesions designed to avoid perioperative morbidity are described in detail.