Title: Apico-Biaxillary Bypass for an Aortic Stenosis Patient With Severe Calcification of the Entire Aorta
Abstract: HomeCirculationVol. 121, No. 24Apico-Biaxillary Bypass for an Aortic Stenosis Patient With Severe Calcification of the Entire Aorta Free AccessReview ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplemental MaterialFree AccessReview ArticlePDF/EPUBApico-Biaxillary Bypass for an Aortic Stenosis Patient With Severe Calcification of the Entire Aorta Koji Hattori, Toshihiko Shibata, Yasuyuki Kato, Yasuyuki Bito, Shinsuke Kotani and Daisuke Kaku Koji HattoriKoji Hattori From the Department of Cardiovascular Surgery, Osaka City General Hospital, Osaka, Japan. , Toshihiko ShibataToshihiko Shibata From the Department of Cardiovascular Surgery, Osaka City General Hospital, Osaka, Japan. , Yasuyuki KatoYasuyuki Kato From the Department of Cardiovascular Surgery, Osaka City General Hospital, Osaka, Japan. , Yasuyuki BitoYasuyuki Bito From the Department of Cardiovascular Surgery, Osaka City General Hospital, Osaka, Japan. , Shinsuke KotaniShinsuke Kotani From the Department of Cardiovascular Surgery, Osaka City General Hospital, Osaka, Japan. and Daisuke KakuDaisuke Kaku From the Department of Cardiovascular Surgery, Osaka City General Hospital, Osaka, Japan. Originally published22 Jun 2010https://doi.org/10.1161/CIRCULATIONAHA.109.935833Circulation. 2010;121:e447–e449A 70-year-old man with severe aortic stenosis was referred with repeated hospitalization for congestive heart failure for 1 year and a 1-month history of serious hypotension during every hemodialysis. He had been treated for diabetes mellitus for 28 years and had been undergoing hemodialysis for 5 years. Medical history included iliac and femoral arterial atherosclerosis treated with catheter and surgical interventions. Transthoracic echocardiography showed elevation of the systolic aortic transvalvular gradient (peak gradient, 67 mm Hg; mean gradient, 42 mm Hg), aortic valve area of 0.8 cm2 measured by the continuity equation, and mild aortic regurgitation (Figure 1, Movie I in the online-only Data Supplement). Coronary angiography demonstrated 75% stenosis of the left anterior descending artery. Computed tomography revealed severe calcification of arterial system, particularly of the entire aorta, except for the bilateral axillary arteries (Figure 2). Conventional aortic valve replacement was regarded as a difficult procedure because of the necessity for aortic cannulation, aortic cross-clamp, and aortotomy. Download figureDownload PowerPointFigure 1. A, Transthoracic echocardiography showing a thick calcified aortic valve with reduced opening (arrow; see Movie I in the online-only Data Supplement). B, Continuous wave Doppler recording of aortic velocity from the apex with a peak systolic aortic transvalvular gradient of 67 mm Hg and a peak velocity of 4.1 m/s. LV denotes left ventricle; LA denotes left atrium.Download figureDownload PowerPointFigure 2. Preoperative computed tomography images. A, Maximum intensity projection image on a coronal projection showing severe calcification of the entire aorta and the bilateral ilio-femoral artery. B, Eccentric encircled calcification of the ascending aorta. C, Heavy encircled calcification of the descending aorta.We considered a modification of apico-aortic bypass (AAB) as a surgical treatment. AAB connects the apex of the left ventricle (LV) to the descending aorta with an artificial graft containing a bioprosthetic valve through a left thoracotomy. In our AAB procedure, the apico-aortic conduit had been divided into 3 pieces: the first piece of the conduit for the apical anastomosis, the second piece as the composite graft containing a bioprosthetic valve, and the third piece for the distal anastomosis to the descending aorta. We decided to change the third piece of the conduit into a Y-shaped artificial graft and to perform an "apico-biaxillary" bypass through a median sternotomy without any manipulation of the aorta. After a standard median sternotomy, the pericardium and bilateral pleural cavity were opened to provide for the conduit of the apico-biaxillary bypass. A 10 mm ring-reinforced artificial graft (Gelsoft ERS; Vascutek, Renfrewshire, Scotland) was anastomosed end to side to the bilateral axillary arteries. This artificial graft was connected to the arterial lines of the cardiopulmonary bypass. A 22 mm artificial graft (Gelseal; Vascutek, Renfrewshire, Scotland) as the first conduit was anastomosed directly to the apex of the LV under mild hypothermia of 28°C and ventricular fibrillation. After defibrillation, a 22 mm artificial graft containing a 19 mm bioprosthetic valve (Perimount Magna; Edwards Lifesciences, Irvine, Calif.) as the second conduit was anastomosed to the first graft. The proximal portion of a Y-shaped artificial graft (Hemashield; Maquet Cardiovascular LLC, Wayne, N.J.) as the third conduit was anastomosed to the second graft. The 10 mm ring-reinforced artificial graft that was anastomosed to the left axillary artery was disconnected from the arterial line and led into the left pleural cavity through the second intercostal space. This graft was anastomosed to a distal portion of the Y-shaped graft. Concomitant coronary artery bypass grafting was done with the anastomosis of the left internal mammary artery to the left anterior descending coronary artery under on-pump beating fashion. After termination of the cardiopulmonary bypass, the right-side 10 mm graft was anastomosed to the other distal portion of the Y-shaped graft with the same procedure as the left side for completion of the apico-biaxillary bypass. The patient's hemodynamic conditions were improved dramatically, and he recovered uneventfully. Postoperative 3-dimensional reconstructed computed tomography showed the valved conduit connecting the apex of the LV to the bilateral axillary artery without angulations (Figure 3). Magnetic resonance imaging showed bidirectional ejection from the LV to the ascending aorta and the conduit (Figure 4, Movie II in the online-only Data Supplement). Magnetic resonance phase-contrast flow measurement (Achieva 1.5T magnetic resonance scanner; Philips Medical Systems, Best, the Netherlands) revealed a 2.12 L/min (56%) forward flow at the ascending aorta and a 1.66 L/min (44%) forward flow at the straight portion of the composite graft (Figure 5). Download figureDownload PowerPointFigure 3. Three-dimensional reconstructed computed tomography image showing a valved conduit connecting the apex of the left ventricle to the bilateral axillary artery. The left internal mammary artery was anastomosed to the left anterior descending coronary artery.Download figureDownload PowerPointFigure 4. Magnetic resonance imaging showing the long axis view of the ascending aorta (Ao), the left ventricle (LV), and the conduit (*) containing the bioprosthetic valve (arrow). Diastolic phase (A) and systolic phase (B) magnetic resonance images present well-preserved left ventricular function and bidirectional ejection flow from the LV to the ascending aorta and the conduit (see Movie II in the online-only Data Supplement). RV denotes right ventricle.Download figureDownload PowerPointFigure 5. A, The 2.12 L/min forward flow at the ascending aorta was obtained by velocity curve of phase-contrast magnetic resonance imaging. Backward flow with aortic regurgitation was observed. B, The 1.66 L/min forward flow at the straight portion of the composite graft.There is only 1 case report on apico-biaxillary bypass,1 in which a patient with aortic stenosis was operated through a median sternotomy with a plan to perform conventional aortic valve replacement. However, severe calcification of the ascending aorta was observed during the operation, and an apico-biaxillary bypass instead of AAB was performed because the anastomosis of the distal graft to the descending aorta is difficult through a median sternotomy, not because of the calcified descending aorta. Because AAB requires the distal anastomosis to the descending aorta, a patient with a calcified descending aorta is excluded due to the indication of AAB.2 Thus, apico-biaxillary bypass is a feasible option for patients with severe aortic stenosis with severe calcification of the entire aorta.The online-only Data Supplement is available with this article at http://circ.ahajournals.org/cgi/content/full/121/24/e447/DC1.DisclosuresNone.FootnotesCorrespondence to Koji Hattori, Department of Cardiovascular Surgery, Osaka City General Hospital, 2-13-22 Miyakojima-hondori, Miyakojima-ku, Osaka 534-0021, Japan. E-mail [email protected]References1 Chiu KM, Lin TY, Chen JS, Li SJ, Chan CY, Chu SH. Left ventricle apical conduit to bilateral subclavian artery in a patient with porcelain aorta and aortic stenosis. Circulation. 2006; 113: e388–e389.LinkGoogle Scholar2 Gammie JS, Krowsoski LS, Brown JM, Odonkor PN, Young CA, Santos MJ, Gottdiener JS, Griffith BP. Aortic valve bypass surgery: midterm clinical outcomes in a high-risk aortic stenosis population. Circulation. 2008; 118: 1460–1466.LinkGoogle Scholar eLetters(0)eLetters should relate to an article recently published in the journal and are not a forum for providing unpublished data. Comments are reviewed for appropriate use of tone and language. Comments are not peer-reviewed. Acceptable comments are posted to the journal website only. Comments are not published in an issue and are not indexed in PubMed. Comments should be no longer than 500 words and will only be posted online. References are limited to 10. Authors of the article cited in the comment will be invited to reply, as appropriate.Comments and feedback on AHA/ASA Scientific Statements and Guidelines should be directed to the AHA/ASA Manuscript Oversight Committee via its Correspondence page.Sign In to Submit a Response to This Article Previous Back to top Next FiguresReferencesRelatedDetailsCited By Yoshida K, Yoshida H, Kishi Y, Narumiya Y, Yokoyama S, Saiki M, Tateishi A, Ohshima Y, Yunoki K and Hisamochi K (2021) Apico-Aortic and Biaxillary Bypass for Severe Aortic Stenosis重症大動脈弁狭窄症に対する心尖部-下行大動脈および両側腋窩動脈バイパス(apico-aortic and biaxillary bypass)の1例, Japanese Journal of Cardiovascular Surgery, 10.4326/jjcvs.50.78, 50:2, (78-81), Online publication date: 15-Mar-2021. June 22, 2010Vol 121, Issue 24 Advertisement Article InformationMetrics https://doi.org/10.1161/CIRCULATIONAHA.109.935833PMID: 20566961 Originally publishedJune 22, 2010 PDF download Advertisement SubjectsCardiovascular Surgery