Porcelain aorta and severe aortic stenosis: is transcatheter aortic valve implantation the new standard?

Thoracic aorta calcification is associated with coronary and valvular calcification and increased risk of cardiovascular and cerebrovascular events. Porcelain aorta represents excessive calcification of the thoracic ascending aorta (Figure) and is a challenging substrate for cardiac surgeons because aortic cross-clamping and aortotomy may cause excessive aortic injury and/or release of thromboembolic material that may cause periprocedural stroke. Aortic valve replacement in patients with a porcelain aorta may mandate advanced surgical techniques including replacement of the ascending aorta under deep hypothermic circulatory arrest, endarterectomy, or balloonassisted endovascular clamping to minimize manipulation of the heavily calcified aorta. The apicoaortic conduit is a technique to bypass an excessively calcified ascending thoracic aorta, but this technique can be hampered by concomitant aortic regurgitation and more generalized calcifications that complicate the distal anastomosis of the conduit. Transcatheter aortic valve implantation (TAVI) represents a highly attractive ‘‘no-touch’’ alternative for patients with severe aortic stenosis and porcelain aorta. The emergence of TAVI has revolutionized the treatment of aortic stenosis in patients at (very) high risk for operative mortality. In truly inoperable patients, TAVI is the only life-prolonging treatment option with a stunning 25% absolute reduction in 2-year mortality compared with medical therapy and balloon valvuloplasty. Based on the favorable PARTNER (Placement of Aortic Transcatheter Valves) Cohort A and B data, the recently updated European Society of Cardiology and the European Association for Cardio-Thoracic Surgery guidelines on the management of valvular heart disease strongly recommend TAVI as the treatment option of choice in inoperable aortic stenosis patients with a reasonable life expectancy and suggest that TAVI is a reasonable alternative to surgical aortic valve replacement in aortic stenosis patients at high operative risk. With the expanding treatment armamentarium, meticulous risk stratification is clearly essential to select the best treatment modality for