Clampless Aortic Valve Replacement in a Partial Porcelain Aorta With Aortic Root Enlargement and CABG With Two Grafts

A 66-year-old 75 KG female presented with New York Heart Association functional classification II/III (NYHA2/3) due to moderate calcific aortic stenosis, estimated to be 60-70 percent. She had lesions in the right coronary artery (RCA) and left anterior descending artery (LAD). A computed tomography (CT) scan of the thorax showed a calcified arch and a calcified ascending aorta posteriorly, allowing for some space for aortotomy, but no space for cross-clamping. The innominate artery was free of disease. 

After meticulous planning, aortic valve replacement (AVR) and coronary artery bypass grafting (CABG) was performed without cross-clamping, with modified nicks and aortic root enlargement. 

The patient was extubated the following morning without any neurological deficits and was discharged on day five.  

Operative Steps 

The procedure began with a median sternotomy. A saphenous vein graft (SVG) was prepared to the RCA and LAD off-pump. The innominate artery was then isolated and cannulated using an 18 French cannula. The right atrium (RA) was cannulated, and the coronary sinus cannulation was accessed for retrograde cardioplegia, along with a left ventricular (LV) vent placed through the right superior pulmonary vein (RSPV). The patient was cooled to 28 degrees Celsius. The aortic site was marked for the proximal anastomosis, and an oblique hockey stick aortotomy was performed once the desired temperature was achieved. The innominate artery and left carotid were clamped with soft clamps. Lower body circulation was started using a 16 French suprapubic (SPC) catheter, while antegrade cerebral circulation was established through the innominate artery, monitored by noninvasive cerebral oximetry.

Retrograde cardioplegia and antegrade cardioplegia were administered through the superior vena cava (SVC) for the RCA. A sump sucker was placed at the upper end of the aortotomy to maintain a clear operative field. The aortic valve, which was tricuspic and calcified, was excised. The 19 sizer was not accepted due to a small annulus and calcified aortic root. Since a Bo Yang procedure was not possible due to posterior calcification, a modified Nick's repair was performed. The aortotomy was extended into the middle of the noncoronary sinus, reaching the aortic annulus, and further extended into the aortomitral curtain on both sides for approximately 1.5-2 cm to accommodate a rectangular patch, rather than a tear-shaped one, to achieve a more spacious aorta. 

A 21 mm Flomero pericardial valve was implanted using 2-0 Prolene continuous sutures at the left and right coronary annulus, while 4-0 Prolene pledgeted sutures were used on the patch side. After valve implantation, the top ends of the vein graft were done at the marked site before closing the aortotomy, ensuring that the length of the SVG graft was kept slightly longer to prevent it from interfering during aortic closure. The aortotomy was repaired in the routine way with 5-0 Prolene sutures, and at the end of the repair, the SPC was removed. Both carotid arteries were declamped, and an aortic root deairing catheter was placed to fill the aorta and facilitate deairing. Rewarming started, and the patient regained spontaneous sinus rhythm, allowing for successfully weaning from cardiopulmonary bypass (CPB) on the first attempt. Both pericardial and mediastinal drains were placed, followed by routine sternal closure. 

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