Trans-apical aortic valve implantation in patients with severe calcification of the ascending aorta.

OBJECTIVE In patients with calcification of the ascending aorta, postoperative stroke and mortality rates remain high after conventional aortic valve replacement, but the results of trans-apical aortic valve implantation in these patients are not known. We evaluate the outcome of trans-apical aortic valve implantation in patients with severely calcified ascending aorta in a single center with expanded procedural experience. METHODS Between April 2008 and July 2010, 258 patients underwent trans-apical aortic valve implantation using Edwards Sapien valve. By computed tomography (CT) scan, we identified 46 (18%) patients with severe calcification of the ascending aorta (16 with porcelain aorta and 30 with severe, but not complete, calcification). RESULTS Of 46 patients (mean age 77 ± 10 years, range 63-90 years; EuroSCORE (European System for Cardiac Operative Risk Evaluation) 45 ± 22%; STS (Society of Thoracic Surgeons) score 23 ± 13) with calcified aorta, 15 received 23-mm valves and 31 patients 26-mm valves. Primary valve implantation was successful in 44 patients and a second valve was implanted (valve-in-valve) in two. Six patients underwent concomitant interventions (three elective percutaneous coronary intervention (PCI), one off-pump coronary artery bypass (OPCAB), one tricuspid valve reconstruction, and one left-ventricular (LV) aneurysmectomy). The final procedural results showed valve incompetence (trace or grade 1) in 17 (37%) patients and paravalvular leak in 15 (32.6%) (trace in 10 and grade 1 in five). There was no 30-day mortality. Postoperatively, cranial CT showed new cerebral ischemia areas in three patients (6.2%), but only one patient (2.1%) experienced postoperative neurological deficit (temporary aphasia). Survival at 6 and 12 months was 88% and 85.2%, respectively. CONCLUSIONS Trans-apical aortic valve implantation can be performed safely in patients with aortic valve stenosis and severe calcification of the ascending aorta.