Invited commentary

Abstract

This study [1Goland S. Trento A. Czer L.S.C. et al.Thoracic aortic arteriosclerosis in patients with degenerative aortic stenosis with and without coexisting coronary artery disease.Ann Thorac Surg. 2008; 85: 113-119Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar] is both timely and pertinent. Increasing numbers of elderly patients are now undergoing aortic valve surgery, many of whom have significant coronary artery disease. In this study the mean age was 75 years and 60% required both valve replacement and bypass grafting. A careful intraoperative transesophageal echocardiography study demonstrated that serious atheroma was present in nearly 2 of 3 patients with combined valve and coronary artery disease, which was much higher than that for patients with only aortic stenosis or those who were in a control cohort group. Similar findings were noted when aortic root calcification was studied.The significant finding was a stroke rate of 4.7% in the entire series; however, among 35 patients with complex arch atheroma (ie, thicker plaque with protrusion of mobile debris or ulceration, or both) the stroke rate tripled to 16%. Therefore, these findings serve as a call to action in re-evaluating our management strategy. The authors note that such strategies may include axillary cannulation, less traumatic cannula tips, balloon occlusion, soft cross clamps, circulatory arrest with aorta grafting, variations of “no touch” techniques, and recently introduced transapical valve replacement with off-pump grafting. Although these maneuvers were not used in this retrospective study, it is reasonable to assume that the stroke rate should decrease with appropriate application. This is an important article that merits careful study. Increasing numbers of elderly patients are now undergoing aortic valve surgery, and in those who required bypass grafting, severe aortic atherosclerosis is the rule not the exception. This study [1Goland S. Trento A. Czer L.S.C. et al.Thoracic aortic arteriosclerosis in patients with degenerative aortic stenosis with and without coexisting coronary artery disease.Ann Thorac Surg. 2008; 85: 113-119Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar] is both timely and pertinent. Increasing numbers of elderly patients are now undergoing aortic valve surgery, many of whom have significant coronary artery disease. In this study the mean age was 75 years and 60% required both valve replacement and bypass grafting. A careful intraoperative transesophageal echocardiography study demonstrated that serious atheroma was present in nearly 2 of 3 patients with combined valve and coronary artery disease, which was much higher than that for patients with only aortic stenosis or those who were in a control cohort group. Similar findings were noted when aortic root calcification was studied. The significant finding was a stroke rate of 4.7% in the entire series; however, among 35 patients with complex arch atheroma (ie, thicker plaque with protrusion of mobile debris or ulceration, or both) the stroke rate tripled to 16%. Therefore, these findings serve as a call to action in re-evaluating our management strategy. The authors note that such strategies may include axillary cannulation, less traumatic cannula tips, balloon occlusion, soft cross clamps, circulatory arrest with aorta grafting, variations of “no touch” techniques, and recently introduced transapical valve replacement with off-pump grafting. Although these maneuvers were not used in this retrospective study, it is reasonable to assume that the stroke rate should decrease with appropriate application. This is an important article that merits careful study. Increasing numbers of elderly patients are now undergoing aortic valve surgery, and in those who required bypass grafting, severe aortic atherosclerosis is the rule not the exception. Thoracic Aortic Arteriosclerosis in Patients With Degenerative Aortic Stenosis With and Without Coexisting Coronary Artery DiseaseThe Annals of Thoracic SurgeryVol. 85Issue 1PreviewThe association between the severity of arteriosclerosis in the thoracic aorta in patients with isolated aortic stenosis (AS) and with concomitant coronary artery disease (CAD) has been not evaluated. Therefore, the aim of our study was to compare the thoracic aortic atheroma extent and severity in patients with severe AS alone and with concomitant CAD by intraoperative transesophageal echocardiography. Full-Text PDF