title: Aborted sternotomy due to unexpected porcelain aorta: does transcatheter aortic valve replacement offer an alternative choice?
abstract: Surgical aortic valve replacement is challenging in patients with severe aortic calcification. Some patients undergo sternotomy and have the operation aborted because of intraoperative discovery of severe calcification. Hypothermic circulatory arrest and transcatheter aortic valve replacement offer clampless treatment options for aortic stenosis. The study objectives are to characterize patients who are referred after sternotomy was aborted for porcelain aorta and to describe the treatment outcomes.
  
  
  
  From 2001 to 2013, 19 patients presented after attempt at surgical aortic valve replacement was aborted because of porcelain aorta. Patients presented with aortic stenosis (n = 16), regurgitation (n = 1), or both (n = 2). Off-pump coronary bypass was performed in 10 patients. At the Cleveland Clinic, patients underwent surgical aortic valve replacement (n = 7) or transcatheter aortic valvve replacement (n = 12). The median interval between aborted aortic valve replacement and definitive treatment was 9.6 months. The mean age was 74 ± 11 years. The mean transvalvular gradient was 51 ± 18 mm Hg, and area was 0.6 cm(2). Axillary cannulation was used in all patients undergoing surgical aortic valve replacement, but only 4 required circulatory arrest. The transcatheter aortic valve replacement approach was transfemoral (n = 5), transapical (n = 6), or transaortic (n = 1).
  
  
  
  The mean postoperative gradient was 13 ± 4 mm Hg. There was no mortality, stroke, renal failure, or reoperation for bleeding. One patient required a second valve implantation for paravalvular leak. The median hospital length of stay was 8 days. Five late noncardiac deaths occurred at a median follow-up of 16 months.
  
  
  
  Both surgical aortic valve replacement and transcatheter aortic valve replacement are safe and effective options after aborted sternotomy in patients with porcelain aorta who are referred to a high-risk valve center. Procedure selection may be tailored to individual patients on the basis of aortic morphology and comorbidities. Patients with aortic stenosis at risk for calcific aortic disease should be screened with cross-sectional imaging preoperatively.
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Jahanzaib
authors.initials: J
authors.lastname: Idrees
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio. Electronic address: roselle@ccf.org.
authors.forename: Eric E
authors.initials: EE
authors.lastname: Roselli
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Sajjad
authors.initials: S
authors.lastname: Raza
authors.affiliation: Interventional Cardiology, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Amar
authors.initials: A
authors.lastname: Krishnaswamy
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Stephanie
authors.initials: S
authors.lastname: Mick
authors.affiliation: Interventional Cardiology, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Samir
authors.initials: S
authors.lastname: Kapadia
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Gosta B
authors.initials: GB
authors.lastname: Pettersson
authors.affiliation: Interventional Cardiology, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Murat
authors.initials: M
authors.lastname: Tuzcu
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Lars G
authors.initials: LG
authors.lastname: Svensson
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001018:Aortic Diseases / Q000150:complications* / Q000175:diagnosis / Q000503:physiopathology; D001021:Aortic Valve / Q000503:physiopathology / Q000601:surgery*; D001022:Aortic Valve Insufficiency / Q000150:complications / Q000175:diagnosis / Q000503:physiopathology / Q000601:surgery / Q000628:therapy*; D001024:Aortic Valve Stenosis / Q000150:complications / Q000175:diagnosis / Q000503:physiopathology / Q000601:surgery / Q000628:therapy*; D001027:Aortography / Q000379:methods; D006328:Cardiac Catheterization / Q000009:adverse effects; D005260:Female; D019918:Heart Valve Prosthesis Implantation / Q000009:adverse effects / Q000379:methods*; D006439:Hemodynamics; D006801:Humans; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D018579:Patient Selection; D011237:Predictive Value of Tests; D018570:Risk Assessment; D012307:Risk Factors; D012720:Severity of Illness Index; D056346:Sternotomy; D013997:Time Factors; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D061205:Vascular Calcification / Q000150:complications* / Q000175:diagnosis / Q000503:physiopathology