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).