title: No-clamp technique for valve repair or replacement in patients with a porcelain aorta.
abstract: BACKGROUND
  Patients requiring valvular heart surgery may have circumferential calcification of the ascending aorta. A variety of creative procedures have been described for managing this "porcelain aorta." We describe a technique based on replacement of the ascending aorta and proximal arch under profound hypothermic circulatory arrest, followed by the valve procedure.
  
  
  METHODS
  Twenty-five consecutive patients with a porcelain aorta were referred for heart valve surgery. In every case the aorta was replaced under circulatory arrest before the valve procedure. Postoperative morbidity, mortality, and univariate risk factors for death were calculated. Fisher's exact test defined significant perioperative variables with a p value less than 0.05.
  
  
  RESULTS
  Of 25 patients, 23 (92%) survived the surgery to hospital discharge. One patient had a stroke (4%) and 2 patients (8%) required reexploration for bleeding. Risk factors for perioperative death by univariate analysis included age more than 78 years (p < 0.009), cardiopulmonary bypass time longer than 200 minutes (p < 0.0001), reexploration for bleeding (p < 0.02), need for intra-aortic balloon pump support (p < 0.001), and postoperative gastrointestinal complications (p < 0.001).
  
  
  CONCLUSIONS
  Valve replacement or repair in the patient with a porcelain aorta can be safely accomplished with a technique based on aortic replacement under circulatory arrest. Elderly patients requiring extensive procedures and prolonged periods on bypass have a substantially increased risk for postoperative complications and death.
authors.affiliation: Department of Cardiothoracic Surgery, Weill Medical College of Cornell University, New York, New York 10021, USA. lngirard@med.cornell.edu
authors.forename: Leonard N
authors.initials: LN
authors.lastname: Girardi
authors.forename: Karl H
authors.initials: KH
authors.lastname: Krieger
authors.forename: Charles A
authors.initials: CA
authors.lastname: Mack
authors.forename: O Wayne
authors.initials: OW
authors.lastname: Isom
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001011:Aorta / Q000601:surgery; D001018:Aortic Diseases / Q000145:classification / Q000150:complications / Q000601:surgery*; D002315:Cardiopulmonary Bypass; D005260:Female; D006349:Heart Valve Diseases / Q000473:pathology / Q000601:surgery*; D019918:Heart Valve Prosthesis Implantation / Q000379:methods*; D017052:Hospital Mortality; D006801:Humans; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications; D012189:Retrospective Studies