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Carrel T, Vogt PR. Porcelain aorta does not mean inoperability but needs special strategies. Interact Cardiovasc Thorac Surg 2022; 35:6673151. [PMID: 35993900 PMCID: PMC9473332 DOI: 10.1093/icvts/ivac222] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 08/09/2022] [Accepted: 08/19/2022] [Indexed: 11/17/2022] Open
Abstract
Porcelain aorta is not an absolute contraindication for aortic valve and/or coronary bypass grafting but it requires a special strategy and individualized approach to minimize the risk of embolic complications and technical problems during opening and/or closing the aortotomy.
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Affiliation(s)
- Thierry Carrel
- Department of Cardiac Surgery, University Hospital Zürich , Zürich, Switzerland
| | - Paul Robert Vogt
- Department of Cardiac Surgery, University Hospital Zürich , Zürich, Switzerland
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2
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Knol WG, Budde RPJ, Mahtab EAF, Bekkers JA, Bogers AJJC. Intimal aortic atherosclerosis in cardiac surgery: surgical strategies to prevent embolic stroke. Eur J Cardiothorac Surg 2021; 60:1259-1267. [PMID: 34329374 PMCID: PMC8643442 DOI: 10.1093/ejcts/ezab344] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 05/24/2021] [Accepted: 06/09/2021] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES Although the incidence of perioperative stroke after cardiac surgery gradually decreased over the last decades, there is much variation between centres. This review aimed to create a concise overview of the evidence on possible surgical strategies to prevent embolic stroke in patients with intimal aortic atherosclerosis. METHODS The PubMed and EMBASE databases were searched for studies on surgical management of aortic atherosclerosis and the association with perioperative stroke in cardiac surgery, including specific searches on the most common types of surgery. Articles were screened with emphasis on studies comparing multiple strategies and studies reporting on the patients’ severity of aortic atherosclerosis. The main findings were summarized in a figure, with a grade of the corresponding level of evidence. RESULTS Regarding embolic stroke risk, aortic atherosclerosis of the tunica intima is most relevant. Although several strategies in general cardiac surgery seem to be beneficial in severe disease, none have conclusively been proven most effective. Off-pump surgery in coronary artery bypass grafting should be preferred with severe atherosclerosis, if the required expertise is present. Although transcatheter aortic valve replacement is used as an alternative to surgery in patients with a porcelain aorta, the risk profile concerning intimal atherosclerosis remains poorly defined. CONCLUSIONS A tailored approach that uses the discussed alternative strategies in carefully selected patients is best suited to reduce the risk of perioperative stroke without compromising other outcomes. More research is needed, especially on the perioperative stroke risk in patients with moderate aortic atherosclerosis.
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Affiliation(s)
- Wiebe G Knol
- Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, Netherlands.,Radiology and Nuclear Medicine, Erasmus Medical Center, Rotterdam, Netherlands
| | - Ricardo P J Budde
- Radiology and Nuclear Medicine, Erasmus Medical Center, Rotterdam, Netherlands
| | - Edris A F Mahtab
- Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, Netherlands
| | - Jos A Bekkers
- Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, Netherlands
| | - Ad J J C Bogers
- Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, Netherlands
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3
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Aborted sternotomy in the modern era of transcatheter aortic valve replacement. COR ET VASA 2020. [DOI: 10.33678/cor.2019.080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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4
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Martinelli GL, Cotroneo A, Stelian E, Benea D, Diena M. A new approach for severe aortic regurgitation in porcelain aorta with sutureless Perceval valve: A case report. Int J Surg Case Rep 2019; 59:124-127. [PMID: 31132610 PMCID: PMC6536741 DOI: 10.1016/j.ijscr.2019.04.044] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Revised: 04/11/2019] [Accepted: 04/19/2019] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION The association of pure aortic regurgitation and porcelain aorta represents a challenging situation. In the Transcatheter Aortic Valve Implantation (TAVI) era, porcelain aorta (PA) becomes an additional risk for patient treatment and sometimes serves as the primary indication for the TAVI approach, even in low-risk patients. Devices currently on the market are not yet validated for the treatment of pure aortic regurgitation (AR) in PA and mid/long-term results are still not available. Furthermore, small calcified sinotubular junction and the association of small Valsalva sinus with low origin of coronaries ostia represent a relative contraindication of TAVI. PRESENTATION OF CASE We report a case of severe symptomatic AR associated with a PA in a patient successfully treated with a sutureless Perceval valve. DISCUSSION The sutureless Perceval valve may represent an excellent option. This valve requires less manipulation of the ascending aorta and no manipulation of the aortic annulus except for the aortic valve leaflets removal. Furthermore, it can be implanted also in a small and calcified sino-tubular junction because the valve is collapsible before the implant. CONCLUSION The present case represents a proof that self-expandable cardiac valve technology can be employed to treat, either by surgery or by catheter, selected cases of AR. We have observed an excellent mid term result with no paravalvular leak at 2 years.
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Affiliation(s)
- Gian Luca Martinelli
- CardioVascular Dept., Clinica San Gaudenzio - Gruppo Policlinico di Monza, 3, Via Bottini, Novara, 28100, Italy.
| | - Attilio Cotroneo
- CardioVascular Dept., Clinica San Gaudenzio - Gruppo Policlinico di Monza, 3, Via Bottini, Novara, 28100, Italy
| | - Edmond Stelian
- Cardiac Anesthesiology Dept., Clinica San Gaudenzio - Gruppo Policlinico di Monza, 3 Via Bottini, Novara, 28100, Italy
| | - Diana Benea
- Cardiology Dept., Clinica San Gaudenzio - Gruppo Policlinico di Monza, 3,Via Bottini, Novara, 28100, Italy
| | - Marco Diena
- CardioVascular Dept., Clinica San Gaudenzio - Gruppo Policlinico di Monza, 3, Via Bottini, Novara, 28100, Italy
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Carrel T. Should the porcelain aorta be revisited in the era of transcatheter aortic valve replacement? Eur J Cardiothorac Surg 2019; 55:1010-1011. [PMID: 30388207 DOI: 10.1093/ejcts/ezy366] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Thierry Carrel
- Department for Cardiovascular Surgery, University Hospital and University of Bern, Bern, Switzerland
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6
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Wanamaker KM, Hirji SA, Del Val FR, Yammine M, Lee J, McGurk S, Shekar P, Kaneko T. Proximal aortic surgery in the elderly population: Is advanced age a contraindication for surgery? J Thorac Cardiovasc Surg 2019; 157:53-63. [DOI: 10.1016/j.jtcvs.2018.04.100] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Revised: 03/29/2018] [Accepted: 04/23/2018] [Indexed: 11/29/2022]
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7
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Nakasu A, Greason KL, Nkomo VT, Eleid MF, Pochettino A, King KS, Sandhu GS, Williamson EE, Holmes DR. Transcatheter aortic valve insertion in patients with hostile ascending aorta calcification. J Thorac Cardiovasc Surg 2018; 156:1028-1034. [DOI: 10.1016/j.jtcvs.2018.03.125] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Revised: 03/15/2018] [Accepted: 03/23/2018] [Indexed: 10/17/2022]
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8
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Osaka S, Tanaka M. Strategy for Porcelain Ascending Aorta in Cardiac Surgery. Ann Thorac Cardiovasc Surg 2018; 24:57-64. [PMID: 29491196 DOI: 10.5761/atcs.ra.17-00181] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Affiliation(s)
- Shunji Osaka
- Department of Cardiovascular Surgery, Nihon University School of Medicine, Tokyo, Japan
| | - Masashi Tanaka
- Department of Cardiovascular Surgery, Nihon University School of Medicine, Tokyo, Japan
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Ramirez-Del Val F, Hirji SA, Yammine M, Ejiofor JI, McGurk S, Norman A, Shekar P, Aranki S, Bhatt DL, Shah P, Cohn LH, Kaneko T. Effectiveness and Safety of Transcatheter Aortic Valve Implantation for Aortic Stenosis in Patients With "Porcelain" Aorta. Am J Cardiol 2018; 121:62-68. [PMID: 29153772 DOI: 10.1016/j.amjcard.2017.09.024] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Revised: 09/07/2017] [Accepted: 09/11/2017] [Indexed: 11/17/2022]
Abstract
Surgical aortic valve replacement (SAVR) in patients with porcelain aorta is considered a high-risk procedure. Hence, transcatheter aortic valve implantation (TAVI) is emerging as the intervention of choice. However, there is a paucity of data directly comparing TAVI with SAVR in patients with porcelain aorta. We compared outcomes of TAVI versus SAVR in high-risk patients with porcelain between March 2012 and June 2015. The TAVI group included 54 patients, whereas 130 SAVR patients with porcelain aorta were identified (operated on between 2004 and 2015). Both groups were matched 1:1 based on the Society of Thoracic Surgeons Predicted Risk of Mortality (STS-PROM) score with a 0.5% a priori caliper, resulting in 52 matched pairs. The mean STS-PROM was 7.3 ± 3.9 for both groups (p = 0.98), whereas mean age was 77.5 years for TAVI and 78.8 years for SAVR (p = 0.46). Compared with SAVR, TAVI patients had lower operative mortality (3.8% vs 17.3%; p = 0.052), significantly shorter median intensive care unit (40 vs 107 hours; p < 0.001) and hospital (5 vs. 7 days; p < 0.001) length of stay (LOS), but similar postoperative stroke rates (7.7% vs 11.5%; p = 0.74). One-year unadjusted survival was 81.7% (95% confidence interval [CI]: 69.8% to 93.5%) in the TAVI group versus 71.2% (95% CI: 61.0% to 85.1%) in the SAVR group, p = 0.093. Cox proportional hazard modeling identified preoperative chronic kidney disease (hazard ratio: 2.63 [95% CI: 1.03 to 6.70]; p = 0.043) and SAVR (hazard ratio: 2.641 [95% CI: 1.07 to 6.51]; p = 0.035) as significant predictors for decreased survival. Overall, TAVI was associated with reduced operative mortality, increased survival, and shorter intensive care unit and hospital length of stay compared with SAVR in patients with porcelain aorta. This study demonstrates that TAVI is a safe intervention in this high-risk population.
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Affiliation(s)
- Fernando Ramirez-Del Val
- Division of Cardiac Surgery, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts
| | - Sameer A Hirji
- Division of Cardiac Surgery, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts
| | - Maroun Yammine
- Division of Cardiac Surgery, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts
| | - Julius I Ejiofor
- Division of Cardiac Surgery, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts
| | - Siobhan McGurk
- Division of Cardiac Surgery, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts
| | - Anthony Norman
- Division of Cardiac Surgery, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts
| | - Prem Shekar
- Division of Cardiac Surgery, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts
| | - Sary Aranki
- Division of Cardiac Surgery, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts
| | - Deepak L Bhatt
- Division of Cardiovascular Medicine, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts
| | - Pinak Shah
- Division of Cardiovascular Medicine, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts
| | - Lawrence H Cohn
- Division of Cardiac Surgery, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts
| | - Tsuyoshi Kaneko
- Division of Cardiac Surgery, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts.
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10
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Chang HW, Jeong DS, Cho YH, Sung K, Kim WS, Lee YT, Park PW. Replacement of calcified ascending aorta in patients undergoing aortic valve replacement. J Thorac Dis 2017; 9:4424-4433. [PMID: 29268511 DOI: 10.21037/jtd.2017.10.100] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Aortic stenosis (AS) with an extensively calcified ascending aorta is a growing indication for transcatheter aortic valve implantation (TAVI) because aortic manipulation during surgical aortic valve replacement (AVR) is unsafe in these patients. The aim of this study was to evaluate the outcomes of AVR plus ascending aorta replacement (AAR) in patients with severe AS and a heavily calcified ascending aorta. Methods From 2004 to 2014, a total of 32 patients with severe AS and extensive aortic calcification underwent concomitant first-time AVR and AAR (AVR + AAR). The mean patient age was 74±7 (range, 59-87) years, and 7 (22%) patients were octogenarians. The mean logistic EuroSCORE was 21.4%±19.0% (range, 3.3-68.2%). Arterial cannulae were placed at the ascending aorta (n=26, 81%), aortic arch (n=5, 16%), or axillary artery (n=1, 3%). The aorta was not clamped, and circulatory arrest was used in all patients. One-to-many (1:n) propensity score matching between the study population (AVR + AAR, n=29) and control group (isolated AVR for severe AS, n=433) was performed. Results There was no early mortality in the study population. Postoperative neurologic complications included a minor stroke, which resolved without sequelae at discharge, and a transient ischemic attack. The 5-year survival rate was 83%±9%. In the propensity score-matched comparison, 5-year survival was not significantly different between groups; 81%±10% in the AVR + AAR group vs. 87%±2% in the isolated AVR group (P=0.950). Conclusions Surgical AVR with AAR in AS patients with calcified ascending aortas led to acceptable early and late outcomes. Although the applications for TAVI are growing, a surgical approach may be an alternative option for relatively younger patients with severely calcified aorta.
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Affiliation(s)
- Hyoung Woo Chang
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Dong Seop Jeong
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Yang Hyun Cho
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Kiick Sung
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Wook-Sung Kim
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Young Tak Lee
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Pyo Won Park
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
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11
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Boultadakis V, Baikoussis NG, Panagiotakopoulos V, Papakonstantinou NA, Xelidoni P, Anagnostou S, Charitos C. Sutureless aortic valve implantation in patient with porcelain aorta via unclamped aorta and deep hypothermic circulatory arrest. Ann Card Anaesth 2017; 20:447-449. [PMID: 28994683 PMCID: PMC5661317 DOI: 10.4103/aca.aca_70_17] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Severe atherosclerotic calcification of the ascending aorta, the so-called porcelain aorta, precludes cardiac surgeons from placing an aortic cross-clamp and direct aortic cannulation due to the increased risk of systemic embolism and stroke. In the present report, we support the option of sutureless valve implantation in a case of a porcelain ascending aorta, with deep hypothermic circulatory arrest and also without aortic cross-clamp.
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Affiliation(s)
- Vagelis Boultadakis
- Department of Cardiac Surgery, Extracorporeal Circulation Unit, Evangelismos General Hospital of Athens, Athens, Greece
| | - Nikolaos G Baikoussis
- Department of Cardiac Surgery, Extracorporeal Circulation Unit, Evangelismos General Hospital of Athens, Athens, Greece
| | - Victoras Panagiotakopoulos
- Department of Cardiac Surgery, Extracorporeal Circulation Unit, Evangelismos General Hospital of Athens, Athens, Greece
| | - Nikolaos A Papakonstantinou
- Department of Cardiac Surgery, Extracorporeal Circulation Unit, Evangelismos General Hospital of Athens, Athens, Greece
| | - Polyxeni Xelidoni
- Anaesthesiology Department, Extracorporeal Circulation Unit, Evangelismos General Hospital of Athens, Athens, Greece
| | - Stratos Anagnostou
- Anaesthesiology Department, Extracorporeal Circulation Unit, Evangelismos General Hospital of Athens, Athens, Greece
| | - Christos Charitos
- Department of Cardiac Surgery, Extracorporeal Circulation Unit, Evangelismos General Hospital of Athens, Athens, Greece
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Fernando R, Gutsche JT, Augoustides JGT, Kukafka JD, Spitz W, Frogel J, Fabbro M, Patel PA. Transcatheter Aortic Valve Replacement After Intraoperative Discovery of Porcelain Aorta in a Patient With Aortic Stenosis. J Cardiothorac Vasc Anesth 2016; 31:738-747. [PMID: 27543996 DOI: 10.1053/j.jvca.2016.04.031] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2016] [Indexed: 11/11/2022]
Affiliation(s)
- Rohesh Fernando
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jacob T Gutsche
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - John G T Augoustides
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
| | - Jeremy D Kukafka
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Warren Spitz
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jonathan Frogel
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Michael Fabbro
- Cardiothoracic Anesthesiology, Department of Anesthesiology, Perioperative Medicine and Pain Management, Miller School of Medicine, University of Miami, Miami, FL
| | - Prakash A Patel
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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13
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Affiliation(s)
- Yigal Abramowitz
- From Cedars-Sinai Heart Institute, Los Angeles, California (Y.A., H.J., T.C., R.R.M.); and Department of Cardiovascular Surgery, Heart Hospital Baylor Plano, Baylor Health Care System, Plano, TX (M.J.M.)
| | - Hasan Jilaihawi
- From Cedars-Sinai Heart Institute, Los Angeles, California (Y.A., H.J., T.C., R.R.M.); and Department of Cardiovascular Surgery, Heart Hospital Baylor Plano, Baylor Health Care System, Plano, TX (M.J.M.)
| | - Tarun Chakravarty
- From Cedars-Sinai Heart Institute, Los Angeles, California (Y.A., H.J., T.C., R.R.M.); and Department of Cardiovascular Surgery, Heart Hospital Baylor Plano, Baylor Health Care System, Plano, TX (M.J.M.)
| | - Michael J Mack
- From Cedars-Sinai Heart Institute, Los Angeles, California (Y.A., H.J., T.C., R.R.M.); and Department of Cardiovascular Surgery, Heart Hospital Baylor Plano, Baylor Health Care System, Plano, TX (M.J.M.)
| | - Raj R Makkar
- From Cedars-Sinai Heart Institute, Los Angeles, California (Y.A., H.J., T.C., R.R.M.); and Department of Cardiovascular Surgery, Heart Hospital Baylor Plano, Baylor Health Care System, Plano, TX (M.J.M.).
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14
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Maldonado Y, Singh S, Augoustides JG, MacKnight B, Zhou E, Gutsche JT, Ramakrishna H. Moderate Aortic Stenosis and Coronary Artery Bypass Grafting: Clinical Update for the Perioperative Echocardiographer. J Cardiothorac Vasc Anesth 2015; 29:1384-90. [PMID: 26275517 DOI: 10.1053/j.jvca.2015.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2015] [Indexed: 11/11/2022]
Abstract
Incidental aortic stenosis in the setting of coronary artery bypass surgery may be a perioperative challenge. The accurate assessment of the degree of aortic stenosis remains an important determinant. Although severe aortic stenosis is an indication for valve replacement, current guidelines advise a balanced approach to the management of moderate aortic stenosis in this setting. Multiple factors should be considered in a team discussion to balance risks versus benefits for the various management options in the given patient. The rapid progress in aortic valve technologies also offer alternatives for definitive management of moderate aortic stenosis in this setting that will likely become even safer in the near future.
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Affiliation(s)
- Yasdet Maldonado
- Department of Anesthesiology, Allegheny Health Network, Temple University School of Medicine, Pittsburgh, PA
| | - Saket Singh
- Department of Anesthesiology, Allegheny Health Network, Temple University School of Medicine, Pittsburgh, PA
| | - John G Augoustides
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
| | - Brenda MacKnight
- Department of Anesthesiology, Allegheny Health Network, Temple University School of Medicine, Pittsburgh, PA
| | - Elizabeth Zhou
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jacob T Gutsche
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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