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horacic Aortic Arteriosclerosis in Patients Withegenerative Aortic Stenosis With and Withoutoexisting Coronary Artery Disease
orel Goland, MD, Alfredo Trento, MD, Lawrence S. C. Czer, MD,hervin Eshaghian, MD, Kirsten Tolstrup, MD, Tasneem Z. Naqvi, MD,ichele A. De Robertis, RN, James Mirocha, MS, Kiyoshi Iida, MD, and
obert J. Siegel, MDivision of Cardiology, Department of Cardiothoracic Surgery, Cedars-Sinai Medical Center, Los Angeles, California, and
epartment of Cardiology, Kaplan Medical Center, Israelrs3(ad0Aadea0
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Background. The association between the severity ofrteriosclerosis in the thoracic aorta in patients withsolated aortic stenosis (AS) and with concomitant coro-ary artery disease (CAD) has been not evaluated. There-ore, the aim of our study was to compare the thoracicortic atheroma extent and severity in patients withevere AS alone and with concomitant CAD by intraop-rative transesophageal echocardiography.Methods. We retrospectively evaluated echocardio-
rams of 105 consecutive patients with severe degenera-ive AS who underwent aortic valve replacement. Sixtyatients had concomitant CAD (AS/CAD) on coronaryngiography and 45 had no CAD (AS alone). Theseatients were compared with 54 sex- and age-matchedatients without AS or CAD. Aortic atheroma (localized
ntimal thickening of >3 mm) prevalence and morphol-gy in three segments of aorta were assessed withchocardiography.Results. There were 62 men, mean age 75.3 � 9.4 years.o difference was observed in age, sex, and risk factors for
rteriosclerosis other than hypercholesterolemia among
S/CAD, AS alone, and control groups (88%, 67%, 41%,adatcietceicn
P
Wp
edars-Sinai Medical Center, 8700 Beverly Blvd, Los Angeles, CA 90048;-mail: [email protected].
2008 by The Society of Thoracic Surgeonsublished by Elsevier Inc
espectively; p < 0.0001). The AS/CAD group had aignificantly higher rate of aortic root calcification (68%,6%, 26%, respectively; p < 0.0001) and aortic atheromaascending aorta [26%, 20%, 14%, respectively; p � 0.03];ortic arch [78%, 36%, 30%, respectively; p < 0.0001];escending aorta [72%, 42%, 29%, respectively; p <.0001]) than AS alone or control subjects. Patients withS/CAD also had more complex atheromas in the aortic
rch (48%, 20%, 7%, respectively; p < 0.0001). Significantifferences in extension of aortic arteriosclerosis (pres-nce of plaques in two or three segments) were observedmong the groups (70%, 31%, 18%, respectively; p <.0001).Conclusions. Patients with severe AS and coexisting
AD have more extensive arteriosclerotic changes in thehoracic aorta compared with those with AS alone andontrol subjects. Preoperative evaluation of the thoracicorta and more aggressive lipid therapy should be con-idered in these patients.
(Ann Thorac Surg 2008;85:113–9)
© 2008 by The Society of Thoracic Surgeonsegenerative aortic stenosis (AS) is one of the mostcommon valvular heart diseases, resulting in valve
eplacement [1, 2]. Recent studies have reported anssociation between aortic valve calcification and arterialrteriosclerosis, suggesting that the degenerativehanges of the aortic valve leading to AS may be part ofsimilar arteriosclerotic process [3, 4]. Transesophageal
chocardiography (TEE) allows accurate assessment ofhe degree of arteriosclerosis in the thoracic aorta [5–10].he severity and extent of arteriosclerosis in the thoracicorta are strong risk factors for ischemic stroke and forverall vascular risk [11–13]. The severity of aortic arte-iosclerosis has been shown to correlate with coronary
ccepted for publication Aug 13, 2007.
ddress correspondence to Dr Siegel, Division of Cardiology, Room 5623,
rtery disease (CAD). More recent studies have beenemonstrated a link between arteriosclerotic changes inscending aorta and AS. However, they did not look athe subset of patients with AS alone and those withoexisting CAD [14, 15]. It is still not clear whether CADn patients with degenerative AS is associated with morextensive and severe arteriosclerosis of the thoracic aortahan patients with AS alone or patents without both theseonditions. Therefore, we compared the presence andxtent of thoracic aortic atheroma by intraoperative TEEn patients with severe degenerative AS with and withoutoexisting CAD, and matched control subjects havingeither AS nor CAD.
atients and Methods
e retrospectively evaluated TEEs of 105 consecutive
atients with severe degenerative AS (tricuspid aortic0003-4975/08/$34.00doi:10.1016/j.athoracsur.2007.08.025
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114 GOLAND ET AL Ann Thorac SurgAORTIC ARTERIOSCLEROSIS IN AORTIC STENOSIS 2008;85:113–9
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alve area �1 cm2) who underwent aortic valve replace-ent surgery (AVR). This study was approved by the
nstitutional Review Board at Cedars-Sinai Medical Cen-er with a waiver to obtain consent based on the retro-pective study nature and hiding of identification ofatient data. All patients are prospectively entered inton Institutional Review Board–certified quality assuranceatabase. Among all patients, 60 had concomitant CAD
AS/CAD) on coronary angiography (�50% coronaryrtery narrowing), and 45 had no CAD (AS/no CAD). Allatients with AS and each group according to presence ofAD were compared with 54 sex-and age-matched pa-
ients without AS (on echocardiography) or CAD (onoronary angiography or no evidence of inducible isch-mia on nuclear imaging). We defined diabetes mellituss hyperglycemia requiring pharmacologic therapy; hy-ertension as either a systolic or diastolic increase inlood pressure (�140/90 mm Hg) or use of antihyperten-ive therapy; hypercholesterolemia as a total cholesterolevel of greater than 200 mg/dL or use of lipid-loweringgents; and cigarette smoking as being an active smokerr having a history of smoking at least 10 pack-yearsithin the last 20 years. An HDI-5000 ultrasound systemith a 5-MHz TEE multiplane probe was used (Philipsedical System, Bothell, WA). Images were digitized,
nd off-line measurements were performed with theERICIS Echo Review application (Camtronics Medicalystems Inc, Hartland, WI). Transesophageal echocardi-graphy was performed in 105 patients as part of aoutine intraoperative TEE before and after AVR. Fifty-ve patients who make up the control group were re-
erred for TEE by their cardiologists as a part of thelinical work-up for different reasons such as suspectedndocarditis or atrial fibrillation, or evaluation of valvularesions other than AS. Transesophageal echocardiographymages were obtained using transgastric, midesophageal,nd basal views. All segments of the thoracic aorta,ncluding both the ascending and descending aorta andhe aortic arch, were evaluated for the presence of
able 1. Comparison of Baseline Characteristics and Arteriosc
haracteristic Control (n � 54)
ge (y) 72.3 � 10.2ales 65% (35)ypertension 62% (61)iabetes mellitus 18% (9)ypercholesterolemia 42% (22)holesterol-lowering treatment 34% (18)otal cholesterol (mg/dL) 164.4 � 33.5G (mg/dL) 119.8 � 52.3DL (mg/dL) 48.9 � 15.6DL (mg/dL) 90.9 � 32.0moking 33% (16)
p value for the comparison among the three groups.
S � aortic stenosis; AS/CAD � patients with AS and concomitantisease; HDL � high-density lipoprotein; LDL � low-density lipo
laques between angles of 0 and 90 degrees. Plaque v
hickness was defined as the thickness of the intima andedia layers of the walls measured perpendicularly
uring systole on a frozen frame. Maximum thickness ofhe plaques in each region was recorded. The aorticntima was evaluated for changes in thickening, protru-ion, mobile components, or ulceration. Aortic atheromaas defined as localized intimal thickening of 3 mm orreater. Complex lesions were plaques extending greaterhan 5 mm, or plaques that were protruding, mobile, orlcerated. Aortic atheroma score was calculated as theum of maximum plaque thickness of three segmentsnd was used to assess the severity and extent of aorticrteriosclerosis. Atheroma prevalence and morphologyn three segments of the aorta (ascending aorta, aorticrch, and descending aorta) were assessed. All TEEsere reviewed by one echocardiographer without knowl-
dge of CAD status. In addition, 40 randomly selectedtudies were interpreted independently by the echocar-iographer with excellent agreement (98%) about theresence or absence of thoracic aortic atheroma.Data are presented as mean � standard deviation.
tatistical analysis was performed using a commerciallyvailable statistical package (SPSS 12 statistical software;PSS Inc, Chicago, IL, or SAS version 9.1; SAS Institute,ary, NC). Comparisons across several different groupsere made by analysis of variance for continuous data
nd �2 tests (with Fisher’s exact test when appropriate)or categorical data. The significant baseline predictorariables were entered into a stepwise multivariableogistic regression model to predict aortic atheroma. Arobability value of less than 0.05 was considered statis-
ically significant.
esults
linical Characteristics and Risk Factorstotal of 105 patients with severe AS who underwent
VR (62 men, 59%; mean age, 75.3 � 9.4 years; aortic
is Risk Factors Among Three Groups
/No CAD (n � 45) AS/CAD (n � 60) p Valuea
74.8 � 9.9 75.6 � 9.0 0.249% (22) 67% (40) 0.159% (26) 65% (39) 0.827% (12) 33% (20) 0.267% (30) 88% (53) 0.00762% (28) 88% (53) 0.002
175.9 � 41.7 163.5 � 43.4 0.3109.1 � 56.6 117.6 � 49.8 0.658.0 � 23.3 54.4 � 16.7 0.292.4 � 34.8 85.6 � 37.4 0.653% (24) 56% (33) 0.04
AS/no CAD � patients with AS alone; CAD � coronary arteryin; TG � triglyceride.
leros
AS
alve area, 0.71� 0.24 cm2) and 54 age- and sex-matched
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115Ann Thorac Surg GOLAND ET AL2008;85:113–9 AORTIC ARTERIOSCLEROSIS IN AORTIC STENOSIS
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atients without AS and CAD constituted this study.atients with AS had a somewhat higher incidence ofiabetes mellitus than those without AS (31% versus8%; p � 0.08). There was a significant difference inmoking (54% versus 33%; p � 0.008), hyperlipidemia83% versus 42%; p � 0.0001), and the use of cholesterol-owering agents (77% versus 35%; p � 0.0001) in patientsith AS/CAD compared with AS alone. No differenceas found in age, sex, and risk factors for arteriosclerosisther than hyperlipidemia among AS/CAD, AS alone,nd control groups (Table 1). A higher incidence of
ig 1. (A) Comparison of prevalence of aortic atheroma in any segmemong three groups: patients with degenerative aortic stenosis (AS) wB) Comparison of aortic atheroma prevalence and morphology in theithout CAD and the control group. (C) Comparison of aortic atherom
roups: patients with degenerative AS with and without CAD and theroups: patients with AS with and without CAD and the control grouegments) has been measured in patients having atheroma (83% in Aatients). Probability values are for comparisons among the three gro
able 2. Prevalence of Aortic Atheroma Among Patients Withrtery Disease and the Control Group
ariable Control (n � 54
ortic root calcification 26% (14)ortic atheroma in any segment 42% (23)ortic atheroma in the ascending aorta 7% (4)ortic atheroma in the aortic arch 30% (16)ortic atheroma in the descending aorta 28% (15)
S � aortic stenosis; AS/CAD � patients with AS and concomitantisease.
scending aorta.)
yperlipidemia was found in patients with AS/CAD88%, 67%, 41%, respectively; p � 0.0001) than in thoseith AS alone or the control subjects, and subsequentlyore patients in the combined group were treated for
yperlipidemia (88%, 62%, 34%, respectively; p � 0.0001).
ortic Plaque Prevalence and Morphologyhe prevalence of aortic root calcification (54% versus6%; p � 0.008) was significant higher in patients with ASompared with control subjects as well as the prevalencef atheroma in the ascending aorta (24% versus 7%; p �
the thoracic aorta, aortic root calcification and ascending aortad without coronary artery disease (CAD) and the control group.
c arch among three groups: patients with degenerative AS with andevalence and morphology in the descending aorta among threerol group. (D) Comparison of aortic atheroma score among threertic atheroma score (the sum of maximum plaque thickness of threeD group, 62% in AS/no CAD group, and 44% in the control groupAo � aorta; Ao root Ca � aortic root calcification; Asc Ao �
enerative Aortic Stenosis With and Without Coronary
AS/No CAD (n � 45) AS/CAD (n � 60) p Value
36% (16) 68% (41) �0.000162% (28) 83% (50) 0.0420% (9) 27% (16) 0.0336% (16) 78% (47) �0.000142% (19) 72% (43) �0.0001
; AS/no CAD � patients with AS alone; CAD � coronary artery
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116 GOLAND ET AL Ann Thorac SurgAORTIC ARTERIOSCLEROSIS IN AORTIC STENOSIS 2008;85:113–9
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.0001), arch (60% versus 30%; p � 0.0001), and descend-ng aorta (59% versus 28%; p � 0.0001). Table 2 shows theifferences in the prevalence of aortic atheroma in anynd in each of the thoracic aorta segments among pa-ients with AS alone, AS/CAD, and control subjects. OnEE, the AS/CAD group had a significantly higher rate ofortic root calcification (68%, 36%, 26%, respectively; p �.0001) and aortic atheroma in the ascending aorta (26%,0%, 14%; p � 0.03), aortic arch (78%, 36%, 30%, respec-ively; p p � 0.0001), and the descending aorta (72%, 42%,9%, respectively; p � 0.0001) compared with AS alone orontrol patients. The comparison among the three groupss presented in Figure 1. Figure 1A shows a significantlyigher prevalence of aortic atheroma in the ascendingorta in the AS groups compared with the control group.owever, aortic root calcification was found more fre-uently in AS/CAD compared with both AS/no CADatients and control subjects (p � 0.001 and p � 0.0001,espectively). Figure 1B demonstrates that there is aignificantly higher prevalence of aortic atheroma, bothimple and complex, in the aortic arch in patients havingS/CAD compared with AS/no CAD and control sub-
ects. There were no significant differences obtainedetween control subjects and patients with AS/no CAD.s shown in Figure 1C, the same trend is present for theifferences in atheroma prevalence in the descendingorta. The overall prevalence of atheroma and the prev-lence of simple atheroma were higher in the AS/CADatients than in both AS/no CAD and control subjects.he prevalence of complex atheromas in the descendingorta was overall low and significantly lower in controlubjects than in patients with AS. Examples of variousypes of atheroma in the thoracic aorta by intraoperativeEE are shown in Figure 2.Significant differences in the extent of aortic arterio-
clerosis (presence of plaques in two or three segments)as found among the three groups (70%, 31%, 18%,
espectively; p � 0.0001). Aortic atheroma score (the sumf maximum plaque thickness of three segments) haseen measured in those patients who had atheroma
ig 2. Various types of atheroma in the tho-acic aorta evaluated by intraoperative trans-sophageal echocardiography in patientsith severe aortic stenosis and coexisting
oronary artery disease. The left top imagehows a protruding complex atheroma of theortic arch (arrow). The left bottom image isn example of a simple atheroma in theunction of aortic arch and descending aortaarrow). The right top image demonstratesighly mobile sessile atheroma in the aorticrch (arrow), and the right bottom imagehows multiple protruding atheromas withery thick aortic wall (arrow).
83.3% in AS/CAD, 62.2% in AS/no CAD groups, and4.4% in control group). Figure 1D shows significantlyigher aortic atheroma scores in patients with combinedS/CAD compared with both with AS/no CAD and
ontrol subjects. Finally, in patients with aortic athero-as significantly higher low-density lipoprotein levels
93.0 � 37.1 versus 73.1 � 29.5 mg/dL; p � 0.03) wereound compared with those without atheroma, with noignificant differences in total cholesterol (p � 0.3), tri-lycerides (p � 0.3), and high-density lipoprotein levelsp � 0.4). When the significant baseline variables werentered into a stepwise multivariable logistic regressionodel, CAD (odds ratio, 5.09; 95% confidence interval, 1.1
o 7.2; p � 0.02) was found to be the only predictor of theresence of aortic atheroma in patients with severe AS.Among 105 patients, 5 patients (4.7%) experienced a
erioperative stroke, and in 4 of them complex athero-as (3 of them protruding and mobile) in the aortic archere present on TEE. In all patients, brain computed
omography was obtained that verified cerebral infarc-ion. Three patients experienced unilateral hemiparesisuring the first 48 hours after surgery. In 1 patient a focaleficit (hemiplegia and aphasia) occurred immediatelyfter he awoke from anesthesia. One patient experiencedcute confusion state early after surgery with evidence ofnfarction on computed tomography. Among 38 patientsho had complex aortic arch atheroma on TEE, the
ncidence of postoperative stroke was 16%. The operativeortality was 0.9%.
omment
his study evaluated the association between coexistingAD and AS and the severity of atheromatous changes in
he aorta. Comparing two groups of patients with ASwith and without CAD) and the age- and sex-matchedontrol group, we were able to determine the impact ofach of these conditions on severity and extension ofrteriosclerotic changes in the thoracic aorta. Similar to arior report, we found that patients with severe AS had a
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igher prevalence of arteriosclerotic changes in all por-ions of the thoracic aorta compared with the age- andex- matched control group with neither AS nor CAD15]. However, using the aortic atheroma scores, patientsith AS/CAD had significantly higher rates of aortic
theroma in all segments and more extensive arterioscle-otic changes compared with those with AS/no CAD andontrol subjects. In addition, patients with combinedS/CAD had significantly higher prevalence of both
imple and complex atheromas in the aortic arch, com-ared with those with AS/no CAD and control subjects.lthough no significant difference was found betweenatients with AS/no CAD and the control group, CADppears to be strongly associated with thoracic aorticrteriosclerosis. Using a stepwise multivariable logisticegression model, CAD was found to be the only signif-cant predictor of the presence of aortic atheroma inatients with severe AS.It has been demonstrated that aortic plaques are re-
ated to the presence and severity of CAD [16] and of thentimal thickening in the carotid artery [17]. In addition, aecent study found a strong association between theresence of AS and severity of aortic atheromas, suggest-
ng that AS might be a manifestation of the arterioscle-otic process [15]. Although a large number of patients inhis study had concomitant coronary artery bypass graft-ng, this study did not look at patients with isolated ASeparately. The difference in aortic arteriosclerosis be-ween patients with degenerative AS and bicuspid ASas been described, suggesting that the pathogenesis of
hese two diseases might be different [18]. Transesopha-eal echocardiography is an accurate method to assessrteriosclerotic plaques in the thoracic aorta and is con-idered to be the current noninvasive clinical “goldtandard.” Magnetic resonance imaging findings inerms of aortic plaque composition, extent, and sizelosely correlate with TEE [19].
A high incidence of perioperative stroke (25%) inatients with protruding atheromas has been reportedompared with those with less severe aortic arch athero-as (2%) [20]. In that study the intraoperative diagnosis
hanged the surgical approach in 8%, including changingf the site of cannulation or debridement of atheromauring circulatory arrest. The presence of complex aorticrch atheromas has been shown to increase the strokeate by sixfold after heart surgery [21]. In our study, 16%f patients with complex aortic arch experienced periop-rative stroke. The overall incidence of perioperativetroke in our study is 4.7% and was similar to previouslyublished data [15]. Of note, 4 of 5 of our patients witherioperative stroke had complex aortic arch atheromas.erioperative stroke has been mostly attributed to ma-ipulations of the ascending aorta during graft anasto-osis, cross-clamping, or cannulation with the “sand-
lasting effect” from the high-flow jet [22]. Therefore,atients with severe aortic arch arteriosclerosis representhigh risk for heart surgery with cannulation of the
ortic arch. The detection of complex aortic atheromasnd choice of the surgical approach can reduce the
ncidence of this debilitating complication. Intraoperative palpation of the aorta has been found to be insensitive foretecting and assessing the severity of the lesions [23].ransesophageal echocardiography has been demon-trated to be much more sensitive than palpation toetect ascending aorta atheromas [20]. During surgerypiaortic ultrasound has also been shown to predicttroke [22]. However, this technique is used only intra-peratively, whereas TEE is a safe and sensitive tool forreoperative assessment of thoracic aortic arteriosclero-is, identifying high-risk patients for stroke and helpingn the decision making and planning of different surgicalpproaches in this patient population. Moreover, it haseen shown that TEE-guided cannulation reduces mor-
ality and stroke [24]. Unlike patients with severe arterio-clerosis of the aorta who undergo coronary artery by-ass grafting, in whom off-pump techniques can be usedithout any manipulation of the aorta, in those who
equire AVR either aortic clamping or hypothermic cir-ulatory arrest is currently needed. In patients with ailder degree of aortic arch arteriosclerosis the uses of a
hort aortic cannula or a soft-flow cannula have beenntroduced with no perioperative stroke [25]. Severaleports on a small number of patients described differentechniques for managing aortic valve disease in patientsith severe aortic arch arteriosclerosis including a “no-
ouch” technique in which an alternative site for arterialannulation is chosen and AVR is performed underypothermic circulatory arrest [26, 27]. However, theuration of hypothermic circulatory arrest was long;
herefore, an alternative strategy such as aortic endarter-ctomy in patients with aortic arteriosclerosis has beenntroduced. This technique, however, has been nothown to prevent embolization [21]. Another methodsing balloon occlusion of the ascending aorta aftererforming an aortotomy with the use of hypothermicirculatory arrest for a brief time has been suggested, butemonstrated an increased risk for embolizations [28]. Inrecent study of 62 patients with severely arterioscleroticscending aortas who underwent AVR, five differenttrategies were used to manage the ascending aorta [29].hese techniques included AVR with the use of hypo-
hermic circulatory arrest (39%), ascending aortic endar-erectomy (26%), ascending aortic replacement (19%),ortic inspection and cross-clamping during hypother-ic circulatory arrest (10%), and balloon occlusion of the
scending aorta (6%). The postoperative death was 14%,nd 10 % experienced stroke. Although strokes wereimited to those with AVR with hypothermic circulatoryrrest and aortic endarterectomy, the choice of the oper-tive technique did not influence the risk of stroke.omplete AVR during hypothermic circulatory arrest
the “no-touch” technique) had required a prolongederiod of circulatory arrest. In this study authors con-luded that ascending aortic replacement is a preferredechnique, as it required a short period of hypothermicirculatory arrest and showed comparable mortality withlow risk of stroke.Degenerative AS has many similarities in the arterio-
clerotic plaque histology as well as many of the same
redisposing risk factors. Despite the similarities in clin-
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cal risk factors such as hypercholesterolemia or hyper-ension, others such as sex, diabetes, and endothelialysfunction have not been as strongly linked to AS [30].ome of the histopathologic findings associated withegenerative aortic valve disease and arteriosclerosis areifferent. For example, calcific changes, which can be alsoeen in arteriosclerotic plaques, occur earlier and areore prominent in calcific aortic valve disease [3]. More-
ver, in contrast to the gradual progression of degener-tive AS, acute plaque rupture can occur in CAD. Theseiscrepancies may help to explain the limited response totatin therapy in altering of aortic valve disease progres-ion compared with well-established efficacy on coronaryrtery plaque regression and reversal of carotid intimal-edial thickening by statins [31]. At present, based on
he available data there are no indications for statinherapy solely on the basis of AS alone if conventionaluidelines for statin therapy are not met [32–34]. Despitehe fact that both patient populations with AS and withAD were found to have strong association with aorticrteriosclerosis, it still remains unclear why some pa-ients with severe AS have normal coronary arteries andhether both CAD and AS are linked to aortic atheroma.he present study clearly demonstrates that coexistingAD in patients with AS appears to have an extremely
trong association with advanced thoracic aortic arterio-clerosis, whereas those without CAD had only a trendor higher prevalence of atheroma in the thoracic aortaompared with control subjects.
linical Implicationsrom our findings, several clinical implications can berawn. The presence of complex aortic arch atheromasn TEE appears be associated with an increased risk oferioperative stroke. A preoperative and intraoperativevaluation of the thoracic aorta should be considered,specially in patients having combined aortic and coro-ary disease. In selected patients with severe arterioscle-osis of the ascending aorta and aortic arch, coronaryrtery bypass grafting can be done without cardiopulmo-ary bypass, and alternative surgical approaches includ-
ng ascending aortic replacement or “no-touch” proce-ures without aortic clamping must be considered.ecently developed transapical surgical approach of im-lantation of a catheter-mounted valve combined withff-pump coronary artery bypass grafting is being pur-ued to reduce the risk of stroke in this high-risk popu-ation. Finally, it is not surprising that in patients with ASaving thoracic aorta atheromas, significant higher low-ensity lipoprotein levels were found compared with
hose who had no arteriosclerotic changes. However,ven in patients with atheroma the mean low-densityipoprotein level was less than 100 mg/dL, suggesting theeed for more aggressive treatment in this population.
onclusionsmong patients with severe AS, coexisting CAD is
trongly associated with the presence and severity ofrteriosclerotic changes in the thoracic aorta. Careful
resurgical evaluation and alternative approaches in1
atients with combined AS and CAD, who represent aigh-risk population in terms of severe arteriosclerosisnd calcification of the ascending aorta, should be con-idered.
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his study [1] is both timely and pertinent. Increasingumbers of elderly patients are now undergoing aorticalve surgery, many of whom have significant coronaryrtery disease. In this study the mean age was 75 yearsnd 60% required both valve replacement and bypassrafting. A careful intraoperative transesophagealchocardiography study demonstrated that serioustheroma was present in nearly 2 of 3 patients withombined valve and coronary artery disease, whichas much higher than that for patients with only aortic
tenosis or those who were in a control cohort group.imilar findings were noted when aortic root calcifica-
ion was studied.The significant finding was a stroke rate of 4.7% in the
ntire series; however, among 35 patients with complexrch atheroma (ie, thicker plaque with protrusion ofobile debris or ulceration, or both) the stroke rate
ripled to 16%. Therefore, these findings serve as a call toction in re-evaluating our management strategy. Theuthors note that such strategies may include axillaryannulation, less traumatic cannula tips, balloon occlu-ion, soft cross clamps, circulatory arrest with aorta
ently introduced transapical valve replacement withff-pump grafting. Although these maneuvers were notsed in this retrospective study, it is reasonable tossume that the stroke rate should decrease with appro-riate application. This is an important article that meritsareful study. Increasing numbers of elderly patients areow undergoing aortic valve surgery, and in those whoequired bypass grafting, severe aortic atherosclerosis ishe rule not the exception.
lfred Culliford, MD
ardiothoracic SurgeryYU Medical Center
30 First Ave, Suite 9-Vew York, NY 10016
-mail: [email protected]
eference
. Goland S, Trento A, Czer LSC, et al. Thoracic aortic arterio-sclerosis in patients with degenerative aortic stenosis withand without coexisting coronary artery disease. Ann Thorac
Surg 2008;85:113–9.0003-4975/08/$34.00doi:10.1016/j.athoracsur.2007.09.042
