Asian Cardiovasc Thorac Ann 1998;6:221-223
© 1998 Asia Publishing EXchange Pte Ltd
One-Stage Repair of Aortic Coarctation, Aneurysm, and Calcified Stenosis
Taro Yokoyama, MD, PhD,
Eli R Capouya, MD,
Ali Gheissari, MD,
Ilana Platin, PA-C
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Thoracic and Cardiovascular Surgery St. Vincent Medical Center Los Angeles, CA, USA
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For reprint information contact: Taro Yokoyama, MD, PhD Pacific Cardiothoracic Surgery Group St. Vincent Medical Center 2200 W Third Street, Suite 300 Los Angeles, CA 90057-1904, USA Tel: 1 213 368 7766 Fax: 1 213 368 7739
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ABSTRACT
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A 74-year-old female presented with severe proximal hypertension. She was found to have coarctation of the aorta, calcified aortic stenosis, and an ascending aortic aneurysm. Surgery was performed through a median sternotomy to insert a 25-mm aortic valve composite graft and a 20-mm woven Dacron graft. A Bentall procedure was carried out on the 25-mm aortic valve graft. The proximal portion of the 20-mm graft was anastomosed to the lateral portion of the replaced ascending aorta and the distal portion was anastomosed to an aortotomy in the descending thoracic aorta through the pericardial space. After 2 years of follow-up, the patient is well.
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INTRODUCTION
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It is rare to see a patient with an undiagnosed coarctation of the aorta in old age, especially when it is combined with a calcified aortic valve and an ascending aortic aneurysm. We recently encountered these conditions in a 74-year-old Armenian immigrant. We are not aware of any previously reported cases of this medley of pathology.
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CASE REPORT
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A 74-year-old female who had been treated for severe hypertension, atrial fibrillation, and congestive heart failure was admitted for further evaluation. On admission, the systolic blood pressure in her right arm was 180/90 mm Hg and electrocardiography demonstrated atrial fibrillation with a controlled ventricular response. Chest radiograph revealed moderate cardiomegaly with evidence of pulmonary congestion. Heart catheterization showed a preductal coarctation of the aorta with multiple collaterals and a pressure gradient of 60 mm Hg across this area. There was a gradient of 50 mm Hg across the heavily calcified aortic valve and the ascending aorta was markedly dilated. Left ventricular function was within normal limits and the coronary arteries had no significant stenosis. A computed tomography scan of the chest demonstrated an ascending aortic aneurysm measuring 5.5 cm in the transverse diameter with a slightly hypoplastic arch proximal to the coarctation (Figure 1
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Figure 1. Diagram depicting the pathological disease state of this patient with a coarctation of the aorta, a 5.5-cm ascending aortic aneurysm, and a stenotic aortic valve.
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The aortic arch and ascending aortic aneurysm were isolated through a median sternotomy. The left posterior aspect of the pericardium was opened and the descending thoracic aorta was exposed. An arterial cannula was placed at the junction of the innominate artery and the aortic arch and a venous line was inserted into the right atrium. Using moderate hypothermia (25°C), the ascending aorta was cross-clamped, and cold intermittent antegrade-retrograde blood cardioplegia was administered. An aortotomy was made in the partially occluded descending thoracic aorta. An end-to-side anastomosis between a 20-mm Dacron graft and the descending thoracic aorta was performed using nonabsorbable monofilament sutures. A Y-connector was attached to the arterial perfusion line to perfuse the distal descending thoracic aorta through the proximal end of the 20-mm graft (Figure 2).
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Figure 2. The 20-mm Dacron graft was anastomosed to the descending aorta and a branch from the arterial perfusion line supplied blood to the distal organs. The cross-clamp above the aneurysm protected the vital organs. Arrows show the direction of blood flow.
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After excising the ascending aortic aneurysm, the calcified bicuspid aortic valve was replaced with a 25-mm aortic valve conduit sutured to the aortic annulus. The right and left coronary artery orifices were individually attached to the lateral wall of the Dacron graft using 4/0 monofilament nonabsorbable sutures. The distal end of the composite valve conduit was then anastomosed to the distal ascending aorta using nonabsorbable sutures reinforced with a pericardial strip. With the cross-clamp in placed, the proximal end of the 20-mm Dacron graft was brought up through the diaphragmatic aspect of the pericardial space to the right side of the pericardium and anastomosed to the side of the ascending aortic graft using nonabsorbable running sutures (Figure 3). The venting process was continued through a vent in the ascending aortic graft and the aortic cross-clamp was released. At a temperature of 37.5°C, cardiopulmonary bypass was terminated and excellent blood pressure and normal sinus rhythm were obtained.
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Figure 3. A 25-mm aortic valve conduit replaced the aortic aneurysm and stenotic aortic valve. The right and left coronary artery orifice buttons were reanastomosed. The 20-mm Dacron graft connected the ascending and descending aorta providing adequate blood flow around the coarctation.
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Pathology of the ascending aorta revealed marked degenerative changes of the aortic wall. The postoperative course was complicated by transient renal insufficiency without the need for dialysis. The patient was transferred from the intensive care unit on the 3rd postoperative day and she was discharged from the hospital on the 13th postoperative day in normal sinus rhythm and on maintenance doses of warfarin, digoxin, and bronchodilators. After 2 years of follow-up, she has continued to do well.
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DISCUSSION
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Management of this case required careful planning of the sequence of surgical procedures in order to correct the condition safely. Placement of an extra-anatomic bypass graft to the descending thoracic aorta through a pericardial incision into the left chest allowed optimal arterial perfusion of the kidneys and lower extremities until completion of the Bentall procedure. Consequently, only a brief cessation of perfusion to the lower extremities was necessary while the tube graft was anastomosed to the ascending aortic graft.
Adult patients with a complex form of aortic coarctation remain a technical challenge and represent a high-risk group for postoperative mortality and morbidity.1–3 Extra-anatomic bypass for recurrent complex coarctation of the aorta was reported by Edie and colleagues4 in 1975. Of their 23 patients, 4 underwent ascending aorta-to-descending thoracic aortic bypass using median sternotomy and left thoracotomy incisions. In our case, we found that the median sternotomy provided excellent exposure to perform the surgery without the need for a second incision.
Recently, Pethig and colleagues5 described successful combined aortic valve replacement and extra-anatomic ascending aorta-to-descending aortic bypass in 2 patients. We did not incur any perioperative complications and we attribute this to the use of moderate hypothermia and the timely perfusion of the descending thoracic aorta through the tube graft, which protected the visceral organs both during and after the surgical procedure. Excellent preservation of myocardial function was achieved with cold retrograde intermittent blood cardioplegia through the coronary sinus and cerebral perfusion was well maintained with an arterial perfusion cannula placed close to the aortic arch.
The incidence of this type of pathology in a 74-year-old patient is less likely to occur in our patient population as healthcare throughout the world becomes more standardized. However, we found that the approach described in this report was safe and appropriate to deal with this complex cardiac abnormality.
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REFERENCES
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Liberthson RR, Pennington DC, Jacobs ML, Daggett WM. Coarctation of the aorta: review of 234 patients and clarification of management problems. Am J Cardiol
1979;43:835–40.[Medline]
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Schuster SR, Gross RE. Surgery for coarctation of the aorta. A review of 500 cases. J Thorac Cardiovasc Surg
1962;43:54–70.
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Pennington DG, Liberthson RR, Jacobs M, Scully H, Goldblatt A, Daggett WM. Critical review of experience with surgical repair of coarctation of the aorta. J Thorac Cardiovasc Surg
1979;77:217–29.[Medline]
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Edie RN, Janani J, Attai LA, Malm JR, Robinson G. Bypass grafts for recurrent or complex coarctations of the aorta. Ann Thorac Surg
1975;20:358–66.
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Pethig C, Wahlers T, Tager S, Borst H. Perioperative complications in combined aortic valve replacement and extraanatomic ascending-descending bypass. Ann Thorac Surg
1996;61:1724–7.[Abstract/Free Full Text]
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ABSTRACT
INTRODUCTION
