Total simultaneous repair of coarctation and intracardiac pathology in adult patients

Co-existence of severe coarctation of the aorta and aortic valve stenosis in adulthood: a case report

Aortic coarctation is a congenital heart disease that usually presents and is treated in the childhood. The aortic coarctation is often associated with concomitant cardiac pathologies, such as aortic stenosis and bicuspid aortic valve. We report the case of a 56-year-old man, admitted in our cardiologic unit, for sudden onset of chest pain, dyspnea and syncope. Aortic coarctation with aortic valve stenosis was diagnosed. The aortic valve was successfully replaced in the first stage; the coarctation had to be treated in a second time.

One stage surgical treatment of aortic valve disease and aortic coarctation with aortic bypass grafting through the diaphragm and aortic valve replacement

OBJECTIVES

To validate ascending aorta-lower abdominal aorta bypass grafting treatment for patients with descending aortic coarctation and an aortic valve disease.

METHODS

The three patients in whom a descending atypical aortic coarctation was associated with an aortic valve disease were treated with one stage surgical treatment with aortic bypass grafting through the diaphragm and aortic valve replacement in our heart center. Operative technique consisted of performing ascending aorta-lower abdominal aorta bypass grafting through diaphragm muscle and implementing aortic valve replacement. The mean time for extracorporeal circulation and occluding clamp of aorta was recorded. Blood pressure data for pre- and post-operation was measured in the limbs. Computer-enhanced transvenous angiograms of pre- and post-operation were applied for detection of aortic stenosis. The other adverse events were noticed in outpatient service during a follow-up period.

RESULTS

The mean extracorporeal circulation time was 54 ± 11 min. The mean time for occluding clamp of aorta was 34 ± 6 min. An arterial pressure gradient was totally corrected after surgical treatment. Post-operation computer-enhanced transvenous angiograms showed the grafts to be open with a fluent flow. The patients had no gastrointestinal tract complications. No adverse event was noticed during a follow-up period in outpatient service.

CONCLUSIONS

Treatment of ascending aorta-lower abdominal aorta bypass is advisable for patients with descending aortic coarctation and an aortic valve disease.

Four different strategies for repair of aortic coarctation accompanied by cardiac lesions

OBJECTIVES

Coarctation accompanied by cardiac lesions is a complex clinical situation due to the presence of two different pathologies that necessitate surgical treatment. An individual strategy, according to the severity of the disease, is important to reduce perioperative mortality and morbidity.

METHODS

We report here on 25 patients with coarctation accompanied by cardiac lesions who were treated by various surgical approaches. Coarctation and associated disease were treated in 14 patients in a single stage by an ascending-to-descending bypass (n = 11) or by a hybrid procedure (n = 3). The remaining 11 patients underwent a two-stage operation for their treatment. Six of these 11 patients who had coronary artery disease or signs of congestive heart failure were first operated for their cardiac disease, whereas in the remaining five patients, who did not have any congestive signs, coarctation repair was performed first.

RESULTS

All the patients were male, between the ages of 20 and 24 years, except for one 45-year-old woman. The mean cross-clamp times, cardiopulmonary bypass times and operation times were 52 ± 14.5, 102.3 ± 28.5 and 174 ± 24.8 min in the extra-anatomical bypass group; 29.8 ± 11.7, 55.5 ± 17.6 and 116 ± 22 min in the two-stage groups and 49 ± 19.8, 63 ± 18.7 and 159 ± 21.3 min in the hybrid patients, respectively. One patient who underwent extra-anatomical bypass died on the 14th postoperative day. There were no events during the follow-up period for the other patients. Also, there were no gradients between the extremities and no graft-related complications.

CONCLUSIONS

As a consequence of the progress in the development of endovascular techniques, hybrid treatment is becoming a more popular option for the treatment of coarctation accompanied by cardiac diseases. Two-stage procedures and extra-anatomical bypass might be alternative techniques if endovascular procedures are contraindicated or failing.

Aortic root aneurysm in an adult patient with aortic coarctation: a single-stage approach

Coarctation of the aorta is a common congenital defect that may be undiagnosed until adulthood. Moreover, coarctation is associated with congenital and acquired cardiac pathology that may require surgical intervention. The management of an adult patient with aortic coarctation and an associated cardiac defect poses a great technical challenge since there are no standard guidelines for the therapy of such a complex pathology. Several extra-anatomic bypass grafting techniques have been described, including methods in which distal anastomosis is performed on the descending thoracic aorta, allowing simultaneous intracardiac repair. We report here a 37-year old man who was diagnosed with an aortic root aneurysm and aortic coarctation. The patient was treated electively with a single-stage approach through a median sternotomy that consisted of valve-sparing replacement of the aortic root and ascending-to-descending extra-anatomic aortic bypass, using a 18-mm Dacron graft. Firstly, the aortic root was replaced with the Yacoub remodelling procedure, and then the distal anastomosis was performed to the descending aorta, behind the heart, with the posterior pericardial approach. The extra-anatomic bypass graft was brought laterally from the right atrium and implanted in the ascending graft. Postoperative recovery was uneventful and a control computed tomographic angiogram 1 month after complete repair showed good results.

Severe aortic coarctation in a 75-year-old woman: total simultaneous repair of aortic coarctation and severe aortic stenosis

Aortic coarctation is usually diagnosed and repaired in childhood and early adulthood. Survival of a patient with an uncorrected coarctation to more than 70 years of age is extremely unusual, and management strategies for these cases remain controversial. We present a case of a 75-year-old woman who was first diagnosed with aortic coarctation and severe aortic valve stenosis 5 years ago and who underwent a successful one-stage repair involving valve replacement and insertion of an extra-anatomical bypass graft from the ascending to the descending aorta.

Single stage repair of a complex pathology: end stage ischaemic cardiomyopathy, ascending aortic aneurysm and thoracic coarctation

The not uncommon combination of ascending aortic pathology with late presenting coarctation is a difficult surgical challenge. The two stage approach is usually adopted. The necessity for cardiac transplantation adds to the complexity: a trans-sternal approach and single stage repair become mandatory.

Internal mammary artery dilatation in a patient with aortic coarctation, aortic stenosis, and coronary disease. Case report

The ideal surgical approach is unclear in adult patients with coarctation of the aorta that is associated with other cardiovascular pathologies that require intervention. Standard median sternotomy allows simultaneous, coronary revascularization surgery, valve replacement and repair of aortic coarctation. However the collateral circulation and the anatomy of the mammary arteries must be determined, to avoid possible complications. We report a case of a 69 year-old man with aortic coarctation, aortic stenosis, coronary artery disease and internal mammary artery dilatation who underwent concomitant surgical procedures through a median sternotomy.

Ascending-to-Descending Aortic Bypass and Aortic Valve Replacement for Concomitant Severe Aortic Coarctation and Aortic Stenosis

We present a 33-year-old male with severe, symptomatic aortic coarctation and aortic stenosis assessed on a humanitarian medical mission to a developing country. Contemplating limited time and available resources, we performed a simultaneous single-stage approach with ascending-to-descending aortic bypass with a reinforced gortex graft and concomitant aortic valve replacement through a median sternotomy. The patient had an uneventful postoperative convalescence and was discharged on postoperative day 5. At 1-year follow-up, he was asymptomatic and doing well with good blood pressure control and complete equalization of upper and lower limb blood pressure measurements. Computed tomography and transthoracic echocardiography demonstrated a widely patent ascending-to-descending aortic bypass graft and a normally functioning prosthetic aortic valve, respectively. In developing countries where health care resources are limited, a combined approach with an extra-anatomic, thoracic aortic bypass, and aortic valve replacement resulted in good early and 1-year outcomes. This procedure may represent the most effective surgical option for patients with concomitant aortic coarctation and aortic stenosis.

Ascending-descending posterior pericardial bypass of complex coarctation of the aorta

Recurrent coarctation or complex aortic arch obstruction can present a surgical challenge. The ascending-descending posterior pericardial aortic bypass offers a safe, reproducible solution for the surgical treatment of complex or recurrent coarctation of the aorta and facilitates concomitant cardiac surgery.

Posterior pericardial ascending-to-descending aortic bypass through median sternotomy

BACKGROUND AND AIM

Adult patients with complex forms of descending aortic disease remain a surgical challenge and have a high risk of postoperative mortality and morbidity. Surgical management may be complicated when there is an associated cardiac defect, necessitating repair, or a hostile anatomy exists. We present our experience with extra-anatomic bypass through posterior pericardial route at the same stage with intracardiac/ascending aortic aneurysm repair.

METHODS

Patients that underwent one-stage surgery with posterior pericardial bypass between ascending and descending aorta during 2003-2007 were reviewed. Data from early and mid-term follow-up, including mortality, perioperative blood loss, graft-related complications, patency, and persistent hypertension, were noted.

RESULTS

Six male patients with a mean age of 20.8 +/- 0.7 years were operated for coarctation of the aorta associated with additional pathologies (three cases of ascending aortic aneurysm-one with associated aortic valve insufficiency, one case of isolated aortic valve regurgitation, two cases of mitral valve regurgitation). No early or mid-term mortality was observed during follow-up of a mean of 21.6 +/- 10.0 months. No late graft-related complications or reoperations were observed with patent grafts. Systolic blood pressure decreased after surgery by an average of 43 mmHg.

CONCLUSIONS

Coarctation of the aorta with concomitant cardiac lesions can be repaired simultaneously through sternotomy and posterior pericardial approach, when patients present in adulthood, to minimize morbidity and mortality.

Cardiac transplantation and aortic coarctation repair in severe heart failure

A 37-year-old man presented with severe dilated cardiomyopathy secondary to occult aortic coarctation. He was successfully managed with combined orthotopic heart transplantation and aortic coarctation repair.

Extraanatomic Aortic Bypass for Repair of Aortic Coarctation

We describe two adult patients who underwent extraanatomic ascending aorta-to-descending thoracic aorta bypass grafting for repair of aortic coarctation through a median sternotomy and posterior pericardial approach. Of the two patients, one presented with coarctation and concurrent cardiovascular disorders, and the other, with residual coarctation. Cardiopulmonary bypass was established with double arterial cannulation in the aorta or axillary artery and the femoral artery ensure adequate perfusion proximal and distal to coarctation and bicaval cannulation. The heart was retracted cephalic and superiorly, and the descending thoracic aorta was exposed through the posterior pericardium. After achieving distal anastomosis, the graft was directed anterior to the inferior vena cava and lateral to the right atrium, and anastomosed to the right lateral aspect of the ascending aorta. A 14-mm graft was used. In one patient receiving concomitant procedures, mitral valve repair and replacement of the ascending aorta was performed after the distal anastomosis.

Aortic valvular insufficiency and postductal aortic coarctation with small aorta syndrome: one-stage surgical management using extra anatomic bypass through median sternotomy

A 30-year-old man who had undergone repair for coarctation of the thoracic aorta at age 7 and mitral valve annuloplasty at age 9 was admitted for shortness of breath and claudication of both lower legs. The pre-operative angiogram showed severe aortic regurgitation, moderate coarctation of the thoracic aorta beyond the left subclavian artery, a degree of hypoplasia of the infrarenal abdominal aorta, and total occlusion of both external iliac arteries. Aortic valve replacement, ascending-to-bilateral femoral arterial bypass, and end expanded polytetra fluoro ethylene (ePTFE) graft-to-descending aorta bypass was performed via a median sternotomy. Ascending-to-descending aortic bypass via the posterior pericardium allows simultaneous intracardiac repair or an alternative approach for the patient with complex coarctation.

Intrapulmonary channel for one-stage correction of aortic arch obstruction

There are several methods of surgical repair of aortic coarctation or interruption; the optimal technique is still controversial. The purpose of this study was to assess a new surgical method: intrapulmonary channel for one-stage repair of aortic coarctation or interruption associated with intracardiac anomalies. Between 1993 and 1995, 4 patients with aortic coarctation or interruption and intracardiac anomalies received one-stage surgical correction. Their ages ranged from 5 to 26 years (mean, 16 years). The aortic arch lesions were preductal coarctation in 2, and type B interruption in 2. Coexisting anomalies consisted of patent ductus arteriosus in 4, ventricular septal defect in 3, and aortopulmonary window in 1. An intrapulmonary channel was constructed in all patients, and co-existing anomalies were corrected simultaneously. There was no hospital death or late mortality. A cerebral complication occurred in one patient because of air embolism. Mean follow-up was 9.5 years (range, 8.5-11.5 years). There was no evidence of recoarctation or late aneurysm formation. For selected patients with aortic coarctation or interruption and intracardiac anomalies, an intrapulmonary channel might be an option for one-stage correction.

Single-stage repair of adult aortic coarctation and concomitant cardiovascular pathologies: a new alternative surgical approach

BACKGROUND

Coarctation of the aorta in the adulthood is sometimes associated with additional cardiovascular pathologies that require intervention. Ideal approach in such patients is uncertain. Anatomic left-sided short aortic bypass from the arcus aorta to descending aorta via median sternotomy allows simultaneous repair of both complex aortic coarctation and concomitant cardiac operation.

MATERIALS

Four adult patients were underwent Anatomic left-sided short aortic bypass operation for complex aortic coarctation through median sternotomy using deep hypothermic circulatory arrest. Concomitant cardiac operations were Bentall procedure for annuloaortic ectasia in one patient, coronary artery bypass grafting for three vessel disease in two patient, and patch closure of ventricular septal defect in one patient.

RESULTS

All patients survived the operation and were alive with patent bypass at a mean follow-up of 36 months. No graft-related complications occurred, and there were no instances of stroke or paraplegia.

CONCLUSION

We conclude that single-stage repair of adult aortic coarctation with concomitant cardiovascular lesions can be performed safely using this newest technique.

Extraanatomic Bypass for Recurrent Aortic Coarctation Involving the Arch and Replacement of the Ascending Aorta via Sternotomy

A suction device, currently used to lift the heart in off-pump coronary surgery, was used to facilitate an extraanatomic bypass grafting procedure in a patient with recoarctation of the aorta, hypoplasia of the aortic arch, and dilatation of the ascending aorta.

Surgery for complex coarctation of the aorta

The application of improved surgical techniques to correct coarctation in the neonate and infant may in the longterm reduce the incidence of recoarctation in the adult. In addition, in many cases, catheter-based intervention offers an alternative to reoperation and the role of catheter-based intervention is likely to be extended with the introduction of improved technology. However, surgery is likely to be required in coarctation and recoarctation in the adult in some cases, particularly those with hypoplasia of the aortic arch, aneurysms of the ascending aorta and those with intracardiac pathology. Operation for primary coarctation in the adult can be performed through a left thoracotomy without significant postoperative morbidity. However, this is not the case with recoarctation where reoperation through a left thoracotomy has resulted in a high incidence of postoperative complications including residual coarctation, false aneurysm and recurrent laryngeal nerve palsy. Repair through a median sternotomy offers an alternative surgical approach to recoarctation which avoids these complications and allows concomitant procedures for problems associated with arteriopathy, aortic valve disease and other associated intracardiac anomalies. The approach to coarctation and recoarctation in the adult should be tailored to individual patients and made after careful discussion with interventional cardiologists.

Surgical Treatment of Interrupted Aortic Arch with Extraanatomical Bypass Simultaneous to Coronary Artery Bypass Grafting and Aortic Valve Replacement

An interrupted aortic arch accompanied by further surgically reparable cardiac lesions is a rare combination in adult patients. We describe treatment of an interrupted aortic arch, coronary artery bypass grafting (CABG), and aortic valve replacement (AVR) performed simultaneously through median sternotomy in a 64-year-old man. The patient underwent surgery performed using standard cardiopulmonary bypass with cannulation of the ascending aorta and the right atrium, hypothermia (24.6degreesC), and blood cardioplegic arrest. Four aortocoronary vein grafts and pericardial aortic valve replacement were carried out. Finally, the posterior pericardium was opened, and a 16-mm prosthesis was anastomosed to the descending aorta during side clamping using a 4-0 monofilament continuous suture. Optimal placement of the prosthesis was obtained by guiding it to the ascending aorta laterally to the right atrium and passing it between the inferior vena cava and right inferior lung vein. The operation was carried out without complications, and the postoperative course was uneventful. Magnetic resonance imaging showed competent aortic valve prosthesis and highly decreased collateral flow via the internal mammary arteries. Postoperatively both inguinal pulses were present, and the patient was free of angina. In the presence of an interrupted aortic arch, extraanatomical bypass via the posterior pericardium between the ascending and descending aorta can safely be performed at the same time as CABG and AVR through a median sternotomy.

Single-stage treatment of aortic coarctation and aortic valve disease

Surgical management of thoracic aortic coarctation associated with severe aortic valve disease is difficult in most cases. As staged procedures are associated with a higher rate of morbidity and mortality, simultaneous operative management of both lesions is desirable. From 1997 to 2001, 9 patients (8 males and 1 female with a mean age of 30.1 +/- 10.4 years) with this condition underwent simultaneous ascending aorta-infrarenal abdominal aorta bypass graft and aortic valve replacement. One patient died from failure of the extracorporeal circulation during the operation. Another patient suffered from partial intestinal obstruction in the early postoperative period but was successfully treated. The underlying pathology was successfully corrected in the 8 surviving patients, whose blood pressure in the upper limbs was reduced while that in the lower limbs rose. Being easier to manage, the single-stage approach with extraanatomic bypass is safe and effective for managing this aortic complication.

Transpericardial extra-anatomic intrathoracic aortic bypass conduits in the management of coarctation of the aorta

Two varied cases of coarctation of the aorta are described, in which transpericardial ascending to descending thoracic aortic conduits were routed around the right atrium, utilizing deep hypothermic circulatory arrest. The approach was through a median sternotomy in two patients. The first case is a 52-year-old female who underwent combined aortic valve replacement for aortic stenosis and repair of aortic coarctation distal to the left subclavian artery. The second case was a fifth time reoperation in a 12-year-old girl with recurrent coarctating. Both patients remain well and asymptomatic.

Spectrum of reoperations after repair of aortic coarctation: importance of an individualized approach because of coexistent cardiovascular disease

OBJECTIVE

To determine the indications for and spectrum of late reoperations in adults who had previously undergone coarctation repair.

PATIENTS AND METHODS

We reviewed clinical, cardiac catheterization, and echocardiographic data and criteria for reoperation, surgical procedures, and outcome in 43 patients who underwent 54 reoperations between 1972 and 1996.

RESULTS

Of the reoperations for recoarctation or associated cardiovascular disease (or both), 20% were performed in asymptomatic patients and 80% in symptomatic patients. Associated cardiovascular disease included bicuspid aortic valve in 36 patients (84%), aortic arch hypoplasia in 12 (28%), true or false aortic aneurysm in 6 (14%), mitral valve disease in 6 (14%), and subvalvular aortic stenosis in 5 (12%). Surgical procedures included 22 recoarctation repairs and 32 other cardiovascular interventions. Simultaneous repair of recoarctation and associated cardiovascular disease was performed as a single-stage repair in 5 reoperations through a median sternotomy using an extra-anatomic, ascending-to-descending aortic bypass, with no complications. One patient died (surgical mortality, 1.9%) of preexisting severe pulmonary vascular obstructive disease.

CONCLUSIONS

After coarctation repair, associated cardiovascular diseases are the most common cause for reoperation. An individualized surgical approach is important and may range from valve replacement or recoarctation surgery to extra-anatomic bypass combined with other cardiovascular procedures, enabling simultaneous repair of recoarctation and associated lesions. Despite complex surgical techniques and multiple reoperations, morbidity and mortality were low in our series.

Hybrid management of coronary artery disease and coarctation of aorta

The treatment of coarctation of aorta with an additional cardiac lesion in adults remains a difficult surgical challenge. We present here an alternative, two-stage, hybrid approach that combined stent repair of aortic coarctation followed by coronary artery bypass operation in an adult with critical coronary lesions and a poor ventricle. This method may be a potentially useful strategy in reducing the comorbidity of operation to both lesions.

Extra-anatomic aortic bypass via sternotomy for complex aortic arch stenosis in children

OBJECTIVE

Recurrent aortic narrowing after repair of aortic coarctation or interrupted aortic arch, as well as diffuse, long-segment aortic hypoplasia, can be difficult to manage. Extra-anatomic ascending aorta-descending aorta bypass grafting through a sternotomy is an alternative approach for this problem.

METHODS

Since 1985, 19 patients aged 2 months to 18 years (mean 10.7 years) underwent extra-anatomic bypass with 10- to 30-mm Dacron grafts. The initial diagnosis was coarctation with hypoplastic arch in 15, interrupted aortic arch in 3, and diffuse long-segment aortic hypoplasia in 1. Seventeen of the children had a total of 22 previous operations: transthoracic interposition or bypass graft (n = 7), end-to-end anastomosis (n = 7), subclavian arterioplasty (n = 6), and synthetic patch (n = 2). The mean time from initial repair was 8.0 years (range 0.6-18 years). Three children had previous sternotomies. Cardiopulmonary bypass was avoided in all but 6 patients (5 with simultaneous intracardiac repairs).

RESULTS

No hospital or late deaths occurred. On follow-up from 4 months to 14.7 years (mean 7.9 years), no reoperations for recurrent stenosis were performed. Two patients have arm-to-leg pressure gradients: 20 mm Hg at rest in 1 patient and a 60-mm Hg systolic exercise gradient with no resting gradient in the other. One patient required exclusion of an aortic aneurysm at the old coarctation repair site 13 years after extra-anatomic bypass. Three children had subsequent successful cardiac operations.

CONCLUSIONS

Extra-anatomic bypass is an effective and relatively easy approach for selected cases of complex or reoperative aortic arch obstruction. It should be considered as an alternative operative technique for complex aortic arch reconstruction.