Aortic valve bypass for the high-risk patient with aortic stenosis

Background. Interest in percutaneous therapy of heart valve disease has focused attention on the high- risk patient with aortic stenosis. Aortic valve bypass ( apicoaortic conduit) surgery is the construction of a vascular graft containing a bioprosthetic valve from the apex of the left ventricle to the descending thoracic aorta. We have undertaken a programmatic effort to perform aortic valve bypass surgery as an alternative to conventional aortic valve replacement in selected high-risk patients, and now report our recent experience. Methods. Between April 2003 and May 2005, 14 patients with aortic stenosis underwent aortic valve bypass surgery at two institutions. All patients selected for aortic valve bypass surgery were deemed to be at very high risk for conventional aortic valve replacement. These patients represented 14 ( 5.8%) of all 243 patients undergoing isolated aortic valve surgery during the same time period. Mean Society of Thoracic Surgeons predicted risk for operative mortality ( 11%) was between the 90th and 95th percentile. Results. Twelve of 14 patients had previous cardiac surgery with patent bypass grafts. Average age was 78 years. Mean aortic valve area was 0.68 cm(2). All operations were performed through a left thoracotomy on the beating heart ( cross- clamp time, 0 minutes). Cardiopulmonary bypass was used for 6 patients ( median cardiopulmonary bypass time, 15 minutes). There were 2 perioperative deaths. Median postoperative length of stay was 9 days. Two noncardiac late deaths occurred. Nine of 10 surviving patients are functional class I and are living independently. Early postoperative echocardiography confirms excellent aortic valve bypass function with preservation of ventricular ejection performance. Conclusions. Treatment of high- risk aortic stenosis patients with aortic valve bypass surgery is promising. Avoidance of sternotomy and cardiopulmonary bypass supports broader application to moderate- risk patients with aortic stenosis and as a control arm for studies of novel interventional therapies.