Asian Cardiovasc Thorac Ann 2000;8:258-261
© 2000 Asia Publishing EXchange Pte Ltd
One-Stage Operations for Adult Cardiac Disease With Aortic Coarctation
Kaya Süzer, MD,
Tevfik Tezcaner, MD,
Ali Cem Yorgancio
lu, MD,
Zeki Çatav, MD,
Hilmi Tokmakolu, MD,
lhan Günay, MD1,
Thoracic and Cardiovascular Surgery Clinic
Bayindir Medical Center
Ankara, Turkey
1
Cumhuriyet University
Sivas, Turkey
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For reprint information contact: Tevfik Tezcaner, MD Tel: 90 312 438 1709 Fax: 90 352 437 5285 Re at Nuri Sokak 86/16, Yukari Ayranci, Ankara 06540, Turkey.
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Abstract
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Three patients with aortic coarctation and additional cardiac disease underwent a one-stage operation through a median sternotomy. Ascending-to-descending aortic bypass was carried out with a prosthetic graft in all 3 cases. One patient also had triple coronary bypass grafting with internal thoracic artery. Another patient underwent single coronary bypass grafting and aortic valve replacement. Aortic remodeling and mitral valve ring annuloplasty were performed in the third patient. There were no postoperative complications and all patients became symptom-free.
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Introduction
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Coarctation of the aorta constitutes 6% to 8% of cases of congenital heart disease.
1
If not surgically corrected, 50% of patients survive until 10 years of age. The optimal age recommended for correction of aortic coarctation is 2 to 9 years. Therefore, uncorrected aortic coarctation is seldom seen in adulthood; the frequency is even lower for coarctation associated with cardiac disease. This report describes one-stage operations in 3 patients with aortic coarctation who had additional cardiac diseases.
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Case Reports
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Case 1
Coronary arteriography and aortography in a 54-year-old woman revealed aortic coarctation with a systolic gradient of 70 mm Hg (
Figure
1
), left main and 3-vessel coronary disease, and mild left ventricular dysfunction. After a median sternotomy, the internal thoracic artery (ITA) was prepared in the usual way. The graft was divided proximally and distally after systemic heparinization and a free ITA graft of 25 cm in length with an 8-mm diameter tapered tip was obtained. Cardiopulmonary bypass (CPB) was instituted with ascending aortic and two-stage venous cannulation. The heart was retracted medially and the descending thoracic aorta was exposed after dissecting the posterior pericardium. Using a partial-occlusion clamp, a 16-mm Dacron graft was placed on the descending aorta by end-to-side anastomosis. After completing the distal aortic anastomosis, the ascending aorta was clamped and cold crystalloid cardioplegia was delivered. The left anterior descending, diagonal, and right posterior de-scending arteries were grafted sequentially with the free ITA graft. The aorta was declamped and proximal anastomoses of the ITA and the prosthetic vascular graft were made on the ascending aorta with a partial-occlusion clamp (
Figure
2
). The aortic crossclamp time was 28 minutes and the total perfusion time was 180 minutes. Before decannulation of the radial artery, a simultaneous femoral artery pressure measurement revealed an 8 mm Hg systolic gradient. The postoperative period was un-eventful. Magnetic resonance imaging showed patency in both grafts 2 months after the operation (
Figure
3
). During a 4-year follow-up, the patient has been asymptomatic, normotensive, and taking only antiplatelet medication.
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Figure 2.
Operative photograph of the prosthetic graft bypassing the aortic coarctation and the internal thoracic artery as a coronary bypass graft in case 1.
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Case 2
A 46-year-old man with a diagnosis of coarctation of the aorta associated with aortic valve stenosis and coronary artery disease, underwent coronary arteriography, aortog-raphy, and cardiac catheterization. These revealed aortic coarctation with a systolic gradient of 100 mm Hg, aortic valve stenosis with a systolic gradient of 85 mm Hg, significant aortic valve insufficiency, and right posterior descending coronary artery stenosis. After a median sternotomy and institution of CPB, the heart was retracted medially and the descending thoracic aorta was exposed through the dissected posterior pericardium. By applying two crossclamps far from the coarctated segment of descending aorta, an end-to-side anastomosis was made on the descending aorta with a 14-mm Dacron graft. The ascending aorta was clamped, cold crystalloid cardioplegia was delivered, and the right posterior descending artery was bypassed with a saphenous vein graft. The bicuspid and severely calcified aortic valve was replaced with a prosthesis. The aortotomy was closed with running sutures and declamped, proximal anastomosis of the prosthetic vascular graft was made to the ascending aorta using a partial-occlusion clamp. A saphenous vein graft was attached to the vascular graft. Aortic crossclamp and total perfusion times were 104 and 164 minutes, respectively. Moderate inotropic support with dopamine was administered for 40 hours. During a 3-year follow-up, the patient has been asymptomatic and normotensive with angiotensin-converting enzyme inhibitors.
Case 3
A 32-year-old man with coarctation of the aorta associated with an ascending aortic aneurysm and aortic and mitral valve insufficiency, was in New York Heart Association functional class II on admission. Aortography showed aortic coarctation with a systolic gradient of 55 mm Hg and an ascending aortic aneurysm of 100 mm in diameter. Echocardiography revealed significant aortic and mitral insufficiency and pulmonary hypertension. After a median sternotomy, CPB was instituted with femoral artery and bicaval cannulation. The ascending aorta was clamped just before the innominate artery. An ascending aortotomy was carried out and cardioplegia was delivered directly via the coronary ostia. The mitral valve was repaired by ring annuloplasty. The ascending aorta including the sinuses of Valsalva was replaced with a 28-mm Dacron graft, with protection of the aortic valve. During this pro-cedure, the main coronary arteries were liberated and anastomosed to the Dacron graft in button fashion. The crossclamp was removed and an ascending aorta-to-descending aorta bypass was performed with a 20-mm Dacron graft during total circulatory arrest. The proximal anastomosis was made to the proximal arcus aorta with distal anastomosis to the descending aorta distal to the coarctation. Aortic crossclamp, total perfusion, and total circulatory arrest times were 241, 314, and 45 minutes, respectively. The postoperative period was uneventful. During follow-up of 3 years, the patient was asymptomatic and his blood pressure was within normal limits.
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Discussion
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Few cases of uncorrected aortic coarctation associated with cardiac pathology in adults have been reported. The associated pathologies have included coronary artery disease, aortic dissection, ascending aortic aneurysm, annu-loaortic ectasia, aortic valve stenosis and insufficiency.
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As these associated lesions necessitated an operation with CPB, the common tendency was to perform a one-stage operation in such cases. Several bypass techniques have been reported. Heinemann and colleagues
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described 17 patients with complex aortic coarctation who had under-gone ascending aorta-descending aorta, ascending aortaabdominal aorta, descending aorta-abdominal aorta, des-cending aorta-descending aorta, or left subclavian arterydescending aorta bypass. In this study, choice of technique depended on the complexity of the lesions (recoarctation, complex coarctation, or associated cardiac anomalies).
Uncorrected coarctation of the aorta associated with coronary heart disease is very unusual. Ascending aorta and aortic valve diseases are more frequently associated with uncorrected aortic coarctation. In such combined lesions, the method of choice is ascending aortadescending aorta or ascending aorta-abdominal aorta bypass with cardiac repair in a one-stage operation through a median sternotomy. Some prefer abdominal aortic exposure for distal anastomosis, proposing that CPB is not required at that stage and sudden hemodynamic variations do not occur during the procedure.
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However, we think that abdominal aortic exposure carries the disadvantages of laparotomy, a long sternotomy skin incision that extends to the umbilicus, and intraabdominal hemorrhage due to heparinization. If the associated cardiac lesion necessitates an operation with the aid of CPB, transpericardial descending aortic exposure by retracting the heart medially with the pump running is a logical alternative.
There may be no enthusiasm for the use of ITA for coronary artery bypass grafting in patients with aortic coarctation. Besides being a hypertrophied graft, its preparation is difficult, but this can be overcome by a no-touch technique and meticulous hemostasis. We think that if there is no atheromatous plaque or calcification, it may be used as a coronary bypass graft. This hypertrophied graft for coronary bypass in a patient with aortic coarctation was found to be patent in a magnetic resonance study 10 months after the operation.
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A similar finding of patency on magnetic resonance imaging 2 months post-operatively was noted in case 1 in this study. It was concluded that aortic coarctation and additional cardiac lesions may be repaired simultaneously through a median sternotomy if the cardiac pathology necessitates the use of cardiopulmonary bypass.
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References
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Abstract
Introduction
