Thinking beyond the aortic valve: implications of a diseased aorta.

摘要

THE CASE presented by Bottiger et al is an excellent example of a well-laid management plan that was derailed by an unexpected finding of severe atherosclerotic disease in the aorta, especially in its ascending portion. There were 2 important issues raised by the rinding of a "porcelain" aorta and the surgical limitations it posed. The first decision was whether the aortic valve needed to be replaced under these conditions. Although the American Heart Association guidelines on the management of patients with valvular disease recommend aortic valve replacement for moderate aortic stenosis (AS) if the patient is undergoing coronary artery bypass graft (CABG) surgery (class IIa, level of evidence B), they do not account for the confounding presence of aortic atherosclerotic disease. If the decision is made not to replace the aortic valve, the implications of leaving a moderately ste-nosed aortic valve alone arise. Given the patient's age (77 years) and concurrent coronary disease, the rate of progression of AS would be accelerated, and the patient would be at high risk of developing severe AS within the next 3 years, assuming an average increase of 7 mmHg/year. At this point, the expected mortality risk increases dramatically. However, this longer-term risk must be counterbalanced by the absolute increase in short-term risk incurred by manipulating a porcelain aorta. The additional concern was the minimal decrease in gradient that would be enabled with a prosthetic valve in the aortic position.