A 51-year-old male with a history of lymphoma treated with mantle thoracic radiation therapy at age six presented with severe symptomatic heart failure due to a dehisced pyrolytic carbon mechanical aortic valve prosthesis (St Jude Medical, MN, USA). The patient had New York Heart Association (NYHA) Class IV symptoms, torrential paravalvular regurgitation, and concomitant severe left main coronary artery disease. Imaging revealed a true porcelain aorta—a diffusely calcified, brittle vessel with circumferential calcification extending from the aortic annulus to the distal arch—making conventional surgical re-do aortic valve replacement (SAVR) technically unfeasible and prohibitively risky. The patient’s Society of Thoracic Surgeons (STS) risk score was 21.49%, further underscoring the high procedural risk.
Given the absence of viable alternatives, a novel hybrid procedure combining open transventricular access with transcatheter techniques was devised.AK5 Antibody web The operation was performed in a hybrid operating suite. A redo midline sternotomy was performed, along with harvest of the left internal mammary artery (LITA) and left radial artery (LRA). A small left thoracotomy was made to facilitate delivery of the transcatheter heart valve (THV), but no rib spreading or formal port placement was required. Peripheral cardiopulmonary bypass (CPB) was established via the right femoral artery and vein. Instead of traditional cross-clamping, an endovascular aortic occlusion balloon was deployed in the ascending aorta via the left femoral artery, positioned just below the innominate artery, enabling controlled antegrade circulation during valve manipulation.223673-61-8 custom synthesis
Antegrade cardioplegia was delivered through a 6F EBU 3.5 guide catheter advanced into the left main coronary artery via the right radial artery, while retrograde cardioplegia was administered through a coronary sinus catheter—allowing effective myocardial protection without systemic hypothermia. A left ventriculotomy was created via the sternotomy incision, providing direct visualization for extraction of the failed mechanical prosthesis. Multidetector computed tomography had previously guided device selection, leading to implantation of a 29 mm balloon-expandable Sapien 3 THV (Edwards Lifesciences, CA, USA).PMID:35049064 The valve was deployed under direct vision, with manual trimming of the nosecone to ensure proper advancement past the aortic occlusion balloon.
After valve deployment, the ventriculotomy was repaired, and coronary artery bypass grafting (CABG) was completed using LITA to left anterior descending artery (LAD) and LRA to left circumflex artery (LCx). The patient was successfully weaned from CPB. Immediate cineangiography showed mild paravalvular leak (PVL), which remained stable at 30-day follow-up. Echocardiography confirmed optimal valve function, with resolution of heart failure symptoms. At 90 days post-procedure, the patient was classified as NYHA Class I and had returned to full-time employment.
This case demonstrates that open transventricular transcatheter aortic valve replacement (TAVR) can be a life-saving solution for patients with a failed mechanical valve in the setting of an inoperable porcelain aorta. The technique integrates open surgical access with transcatheter precision, allowing for complete revascularization and durable valve replacement. While complex and demanding, this hybrid approach offers a viable alternative when standard TAVR or surgical re-do is not possible. It also preserves the potential for future interventions, including TAVR-in-TAVR, should the implanted valve deteriorate. Success hinges on meticulous planning, a collaborative multi-disciplinary heart team, and institutional expertise in both surgical and interventional cardiology.MedChemExpress (MCE) offers a wide range of high-quality research chemicals and biochemicals (novel life-science reagents, reference compounds and natural compounds) for scientific use. We have professionally experienced and friendly staff to meet your needs. We are a competent and trustworthy partner for your research and scientific projects.Related websites: https://www.medchemexpress.com
