Is there a role for the left ventricle apical-aortic conduit for acquired aortic stenosis?

Background and aim of the study: Aortic valve replacement (AVR) in patients with a heavily calci-fied ascending aorta and aortic root, or with condi-tions that preclude a median sternotomy, poses a formidable challenge. A left ventricle apical-aortic conduit (AAC) is an alternative in these situations. Herein, the authors' experience with AAC in adult patients with acquired aortic stenosis is reported. Methods: Between 1995 and 2003, 13 patients (mean age 71 years) underwent AAC for severe sympto-matic aortic stenosis (mean valve area 0.65 ± 0.02 cm²). Indications for AAC were heavily calcified ascending aorta and aortic root (n = 5), patent ret-rosternal mammary grafts (n = 4), calcified ascending aorta and aortic root plus patent retrosternal mam-mary graft (n = 1), retrosternal colonic interposition (n = 1) and multiple previous sternotomies (n = 2). Seven patients had previous coronary artery bypass grafting (CABG). The mean preoperative left ventric-ular ejection fraction was 50 ± 4%. Results: AAC were performed under cardiopul-monary bypass through a left thoracotomy (n = 10), median sternotomy (n = 2) or bilateral thoracotomy (n = 1). Hearts were kept beating (n = 5) or fibrillated (n = 7). Circulatory arrest was used in one patient. Composite Dacron conduits with biological (n = 6), mechanical (n = 4) or homograft (n = 2) valves were used. Distal anastomoses were performed in the descending thoracic aorta (n = 12) or in the left iliac artery (n = 1). Two patients underwent simultaneous CABG. Three patients died in-hospital from ventric-ular failure (n = 1), intravascular thrombosis (n = 1) and multi-organ failure (n = 1). The mean hospital stay was 26 days. Complications included respiratory failure requiring tracheostomy (n = 2), stroke (n = 1) and re-exploration for bleeding (n = 2). At a mean fo1-low up of 2.1 years, there have been four late deaths; causes of death were congestive heart failure (n = 2), ischemic cardiomyopathy (n = 1) and cancer (n = 1). Conclusion: AAC provides an acceptable alternative to AVR in selected patients who are at exceedingly high risk for the standard procedure.