Left Ventricle Apical Conduit to Bilateral Subclavian Artery in a Patient With Porcelain Aorta and Aortic Stenosis
Severe atherosclerosis or calcification of the ascending aorta is associated with increased morbidity and mortality rates in patients who underwent cardiac operations. Several techniques had been used to avoid the manipulation of the ascending aorta during cardiac surgery. We reported our extra-anatomic approach in a patient with coronary artery disease and severe aortic stenosis with porcelain aorta.
A 76-year-old man with chronic obstructive pulmonary disease, aortic stenosis, and coronary artery disease was scheduled to have cardiac surgery. After a standard median sternotomy, we found that the ascending aorta was severely calcified. The surgical strategy was changed to the construction of the composite conduit from the left ventricle (LV) apex to bilateral subclavian artery and coronary artery bypass grafting with saphenous vein.
The right axillary artery and right atrium were cannulated to set up the cardiopulmonary bypass. A composite graft with a 21-mm bioprosthetic valve (Hancock II, Medtronic Inc, Minneapolis, Minn) interposed into a 22–11–11 mm Y-shaped Hemashield graft (Meadox, Hemashield, Boston Scientific, Boston, Mass) was constructed. The proximal part of the composite graft was anastomosed directly to the LV apex. The distal portions of this composite graft were anastomosed end-to-side to the bilateral subclavian artery. Intraoperative transesophageal echocardiography demonstrated a wide opened connection and unlimited blood flow from the LV apex to the conduit (Figure 1). Flow in the bilateral proximal subclavian artery showed reversed flow, which highlighted the adequacy of new LV outflow tract. The postoperative plain chest film showed the unusual location of prosthetic valve (Figure 2). Magnetic resonance angiography showed the patency of this apical composite conduit (Figure 3). The patient had an uneventful recovery.
In current practice, ascending aortic calcification or atherosclerosis could be identified by epiaortic ultrasound; however, preoperative noninvasive study such as high-resolution, noncontrast computed tomography could be used for this purpose.