Apico-Aortic and Biaxillary Bypass for Severe Aortic Stenosis

Abstract

A 75-year-old man who had maintenance hemodialysis for diabetic end-stage renal disease and had a history of coronary artery bypass grafting for angina pectoris was getting out of breath. Transthoracic echocardiography showed severe aortic stenosis (aortic transvalvular peak velocity (V) : 4.1 m/s, aortic valve area : 0.57 cm², LV ejection fraction (EF) : 35%). Computed tomography images showed severe calcification of the ascending aorta, and the patent right internal thoracic artery (RITA) graft crossed just the rear of sternum. Conventional aortic valve replacement (AVR) was regarded as a difficult procedure because of the risk of injuring RITA by re-sternotomy, and the necessity for aortic cross-clamp and aortotomy. In addition, he could not have transcatheter aortic valve implantation (TAVI) because TAVI is not indicated for hemodialysis patients in Japan. Instead of AVR and TAVI, the apico-aortic bypass technique was applied. A Y-shaped artificial graft was used for the distal side of the valved conduit, and the distal portions were anastomosed to the descending aorta and axillary-axillary bypass graft which was instituted in advance for one of inflow of cardiopulmonary bypass. Finally, apico-aortic and biaxillary bypass was performed and it successfully decreased the peak V across the native aortic valve from 4.1 to 2.9 m/s and increased LVEF from 35 to 46%. In addition, a peak V across bioprosthetic valve was 1.6 m/s.