Not All Porcelain Is the Same: Classification of Circular Aortic Calcifications (Porcelain Aorta) According to the Impact on Therapeutic Approach

Abstract

Severe aortic calcification, also known as “porcelain aorta,” has a major impact on patient outcome. Its presence also influences the choice of procedure depending on where it is located. However, to date there is no clear definition on how this term should be employed, being often used as an exclusion criteria for conventional surgery where aortic clamping and/or cannulation is required.

We here suggest a classification of the “porcelain aorta” regarding its location and how it influences particular therapeutic options. Therefore, making more clear what procedures would represent an increased risk for the patient and which are more suitable when discussed in a “Heart Team.”

Type I implies localization of a circumferential calcification in the ascending aorta. Type IA represents the calcified aorta with no possibility of clamping and Type IB represents the calcified aorta with possible clamping. Type II addresses the calcification of the descending aorta including or not the aortic arch.

Keywords

aorta/aortic - cardiac - cardiology/cardiologist - heart valve surgery - heart valve - transapical - percutaneous (TAVI) minimally invasive surgery (includes port access minithoracotomy)

• References

• 1 Hiratzka LF, Bakris GL, Beckman JA , et al; American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines; American Association for Thoracic Surgery; American College of Radiology; American Stroke Association; Society of Cardiovascular Anesthesiologists; Society for Cardiovascular Angiography and Interventions; Society of Interventional Radiology; Society of Thoracic Surgeons; Society for Vascular Medicine. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with Thoracic Aortic Disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine. Circulation 2010; 121 (13) e266-e369
• 2 Girardi LN, Krieger KH, Mack CA, Isom OW. No-clamp technique for valve repair or replacement in patients with a porcelain aorta. Ann Thorac Surg 2005; 80 (5) 1688-1692
• 3 Lockowandt U. Apicoaortic valved conduit: potential for progress?. J Thorac Cardiovasc Surg 2006; 132 (4) 796-801
• 4 Aranki SF, Nathan M, Shekar P, Couper G, Rizzo R, Cohn LH. Hypothermic circulatory arrest enables aortic valve replacement in patients with unclampable aorta. Ann Thorac Surg 2005; 80 (5) 1679-1686 , discussion 1686–1687
• 5 Zingone B, Gatti G, Rauber E, Pappalardo A, Benussi B, Dreas L. Surgical management of the atherosclerotic ascending aorta: is endoaortic balloon occlusion safe?. Ann Thorac Surg 2006; 82 (5) 1709-1714
• 6 Schenk S, Fritzsche D, Atoui R, Koertke H, Koerfer R, Eitz T. EuroSCORE-predicted mortality and surgical judgment for interventional aortic valve replacement. J Heart Valve Dis 2010; 19 (1) 5-15
• 7 Kempfert J, Van Linden A, Linke A , et al. Transapical aortic valve implantation: therapy of choice for patients with aortic stenosis and porcelain aorta?. Ann Thorac Surg 2010; 90 (5) 1457-1461
• 8 Nishi H, Mitsuno M, Ryomoto M, Miyamoto Y. Comprehensive approach for clamping severely calcified ascending aorta using computed tomography. Interact Cardiovasc Thorac Surg 2010; 10 (1) 18-20
• 9 Price DL, Harris J. Cholesterol emboli in cerebral arteries as a complication of retrograde aortic perfusion during cardiac surgery. Neurology 1970; 20 (12) 1209-1214
• 10 Martin WR, Hashimoto SA. Stroke in coronary bypass surgery. Can J Neurol Sci 1982; 9 (1) 21-26
• 11 Gaudino M, Glieca F, Alessandrini F , et al. The unclampable ascending aorta in coronary artery bypass patients: A surgical challenge of increasing frequency. Circulation 2000; 102 (13) 1497-1502
• 12 Al-Attar N, Himbert D, Descoutures F , et al. Transcatheter aortic valve implantation: selection strategy is crucial for outcome. Ann Thorac Surg 2009; 87 (6) 1757-1762 , discussion 1762–1763
• 13 Takami Y, Tajima K, Terazawa S, Okada N, Fujii K, Sakai Y. Safer aortic crossclamping during short-term moderate hypothermic circulatory arrest for cardiac surgery in patients with a bad ascending aorta. J Thorac Cardiovasc Surg 2009; 137 (4) 875-880
• 14 Nishi H, Mitsuno M, Tanaka H, Ryomoto M, Fukui S, Miyamoto Y. Who needs preoperative routine chest computed tomography for prevention of stroke in cardiac surgery?. Interact Cardiovasc Thorac Surg 2010; 11 (1) 30-33
• 15 Bergman P, van der Linden J, Forsberg K, Ohman M. Preoperative computed tomography or intraoperative epiaortic ultrasound for the diagnosis of atherosclerosis of the ascending aorta?. Heart Surg Forum 2004; 7 (3) E245-E249 , discussion E249