Transsternal repair of coarctation and associated cardiac defects

Extra-anatomical bypass in complex and recurrent aortic coarctation and hypoplastic arch

OBJECTIVES

Our goal was to report the selection schemes, technical variations and long-term outcome of extra-anatomical bypass to correct complex, recurrent aortic coarctation and hypoplastic aortic arch.

METHODS

Between 1989 and 2012, 53 patients (mean age 13.2 ± 4.3, median 11.6, range 9-23 years) with complex aortic coarctation (n = 33; long-segment hypoplastic aortic arch in 15), recurrent coarctation (n = 20; anastomosic pseudoaneurysm in 10), underwent correction using extra-anatomical bypass, either with (n = 18: femoral bypass = 13, left heart bypass = 5) or without (n = 35) extracorporeal circulation via a left lateral thoracotomy (n= 48) and combined median sternotomy and median laparotomy (n = 5). The decision to use extracorporeal circulation was based on the anatomical location of the coarctation, the length of the hypoplasia and a history of previous repair. Preoperatively, mean systolic blood pressure was 130 ± 30 mmHg at rest and 180 ± 40 mmHg during exercise, with a mean pressure gradient of 80 ± 11.6 (range 40-120) mmHg.

RESULTS

Various extra-anatomical bypass strategies included left subclavian artery to descending aorta (n = 38), ascending aorta to left subclavian artery (n = 3), ascending aorta to descending aorta (n = 4), aortic arch to descending aorta (n = 3) and ascending aorta to abdominal aorta (n = 5). Graft size (median 18, range 10-26, mm) was chosen according to the diameter of the vessel proximal and distal to the planned graft. No operative deaths, paraplegia or abdominal malperfusion occurred. The mean reduction in systolic blood pressure was 60 ± 25 mmHg without pressure gradients. During a mean follow-up of 18.3 ± 3.7 years, there were no reoperations, graft complications or pseudoaneurysm formation on anastomotic sites. Seven (11.6%) patients are on antihypertensive medications. No patient presented with claudication nor did anyone experience orthostatic problems from the steal phenomenon.

CONCLUSIONS

Extra-anatomical bypass is safe, an effective technique, and achieves satisfactory long-term results.

Single-stage surgical correction of combination lesions through thoracotomy

Coarctation of the descending aorta is associated with significant cardiac lesions in up to 50% of the patients. Under such circumstances, surgical management requires consideration of the nature of the associated lesion which usually requires a median sternotomy for surgical correction. Coarctation of the aorta (COA) is, therefore, rarely associated with lesions that are amenable to surgical correction through a thoracotomy incision. In this case report, we report a case of COA with significant associated cardiac disease that was repaired through a left thoracotomy incision. A 13-year-old boy was found to have COA and also partial anomalous pulmonary venous drainage of the left upper pulmonary vein to the innominate vein. Both the lesions were surgically corrected simultaneously through a thoracotomy.

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.

One-stage repair of cardiac and arch anomalies without circulatory arrest

Between 1999 and 2002, 23 patients underwent single-stage complete repair of cardiac anomalies and aortic arch obstruction, without circulatory arrest. Median age was 1.2 years. Intracardiac defects included ventricular septal defect in 9, double-outlet right ventricle in 6, d-transposition of the great arteries and ventricular septal defect in 2, subaortic obstruction in 3, and atrial septal defect in 3. Fourteen patients had coarctation of the aorta, 6 had coarctation with hypoplastic aortic arch, and 3 had interrupted aortic arch. Simple techniques were employed such as cannulation of the ascending aorta near the innominate artery and maintaining cerebral and myocardial perfusion. After correction of arch obstruction, intracardiac repair was undertaken. The mean cardiopulmonary bypass time was 169 min, aortic crossclamp time was 51 min, and arch repair took 16 min. There was no operative mortality or neurological deficit. In follow-up of 1-43 months, no patient had residual coarctation. This simplified technique avoids additional procedures, reduces ischemic time, and prevents problems related to circulatory arrest.

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.

Aortic arch reconstruction with pulmonary autograft patch aortoplasty

OBJECTIVE

The optimal technique for aortic arch reconstruction through median sternotomy is still under debate. We have introduced the technique of pulmonary autograft patch aortoplasty as a reliable alternative.

METHODS

The outcomes of 51 infants who underwent neonatal repair of interrupted aortic arch (n = 28) or coarctation associated with ventricular septal defect (n = 23) since 1992 were analyzed. The patients were reviewed in three groups according to the aortic arch reconstruction technique: group I underwent direct anastomosis (n = 23), group II underwent homograft or pericardial patch aortoplasty (n = 8), and group III underwent pulmonary autograft patch aortoplasty (n = 20). The pulmonary autograft patch consisted in the anterior wall of the main pulmonary artery, between the supracommissural level and the divided ductus arteriosus. The created defect was replaced with fresh autologous pericardium.

RESULTS

All patients except 1 were discharged without significant residual gradient at the level of the aortic arch. At a median delay of 7 months (range 2-51 months), 11 patients (22%) had recurrence of arch obstruction and underwent balloon angioplasty (n = 8) or surgical correction (n = 3). One patient who had undergone direct anastomosis required reoperation for bronchial compression. At a median follow-up of 29 months, the actuarial freedoms from recurrent arch obstruction were 81% for direct anastomosis, 28% for homograft or pericardial patch aortoplasty, and 100% for pulmonary autograft aortoplasty (P =.03 for group III vs group I and P <.0001 for group III vs group II).

CONCLUSIONS

The aortic arch repair associated with pulmonary autograft patch augmentation resulted in superior midterm outcomes and therefore constitutes a reliable alternative to the direct anastomosis technique. It allowed complete relief of anatomic afterload and diminished the anastomotic tension, thus reducing the risk of restenosis and tracheobronchial compression. We observed a significantly higher rate of recurrence after patch aortoplasty with other materials.

Outcome following single-stage repair of coarctation with ventricular septal defect

OBJECTIVE

A recent multi-institutional study suggested improved survival (97%) after staged repair of coarctation with ventricular septal defect (VSD) compared with single-stage repair. The current study was undertaken to determine outcome and need for reintervention following single-stage repair of coarctation and VSD at our institution.

METHODS

Retrospective review of patients undergoing single-stage repair of coarctation with VSD between October 1, 1994 and August 15, 1999.

RESULTS

Single-stage repair of coarctation with VSD was performed in 25 infants (12 males, 13 females) at a median age of 12 days (range 1-87 days) and median weight of 3.3 kg (range 1.3-4.4 kg). The VSD was conoventricular in ten patients, malalignment type with posterior deviation of the infundibular septum in ten, muscular in four and conal septal hypoplasia in one. Arch hypoplasia was present in all patients and bicuspid aortic valve in 13. At least moderate subaortic narrowing was present in six patients (secondary to prolapse of tricuspid valve tissue across the VSD in four). Repairs were performed via a median sternotomy with a mean circulatory arrest time of 38+/-12 min. Overall patient survival was 96% with one operative death and no late deaths at a median follow-up of 16 months (range 1-50 months). Reinterventions included balloon dilatation of recurrent coarctation (five), closure of residual VSD (one) and Ross-Konno procedure (two). Actuarial freedom from reintervention for the hospital survivors was 81% (95% confidence limit (CL) 61%, 92%) at 6 months, 71% (95% CL 47%, 87%) at 1 year and 59% (95% CL 31%, 82%) at 2 years following surgery.

CONCLUSION

Single-stage repair of coarctation with VSD can be performed with low operative mortality and good midterm survival equivalent to reported results for staged repair.

Extended end-to-end repair and enlargement of the entire arch in complex coarctation

BACKGROUND

Treatment of hypoplasia of the entire arch in coarctation is a surgical challenge. The current approaches have technical difficulties, high recurrence rates, and increased morbidity and mortality.

METHODS

Over a 14-month period, a combined extended end-to-end repair with patch enlargement of the concavity of the entire arch was performed in 6 neonates and 1 infant. Through a midsternotomy and using cardiopulmonary bypass and hypothermia, extended end-to-end repair was performed initially leaving the proximal anastomosis open. The enlarging polytetrafluoroethylene patch was then sutured starting at the incised descending aorta distal to the extended end-to-end repair and continued retrogradely through the transverse arch to the ascending aorta proximal to the aortic cannulation site. One neonate had a patent ductus arteriosus and another had ventricular septal defect closure. One neonate had arterial switch and 3 had Norwood-type procedures performed with the enlarging patch extended to the pulmonary artery anastomosis. The remaining infant had arch enlargement performed after an arterial switch procedure and extended end-to-end repair.

RESULTS

All patients did well and showed no residual gradient up to 1 year follow-up. Two patients successfully had bidirectional Glenn shunt at 9 months of age, and one had closure of residual arterial septal defect at 8 months of age.

CONCLUSION

The combined extended end-to-end repair and arch enlargement procedure should minimize recurrence rates because of a tension-free enlargement of the entire aortic arch and elimination of the coarctation ridge and ductile tissues. Combined with the arterial switch and Norwood-type procedures, the approach results in a large neoaorta.

Single-stage repair of aortic arch obstruction and associated intracardiac defects with pulmonary homograft patch aortoplasty

OBJECTIVE

Intracardiac malformations associated with coarctation and aortic arch hypoplasia have traditionally been repaired in 2 stages, with a high mortality rate. We review our experience with single-stage biventricular repair of intracardiac defects associated with aortic arch hypoplasia by means of pulmonary homograft patch aortoplasty.

METHODS

Between October 1988 and October 1997, 39 of 40 consecutive patients underwent single-stage biventricular repair for aortic arch obstruction and associated intracardiac defects. The median age at operation was 17 days and the mean weight was 3.71 +/- 1.09 kg. Nineteen patients had either dextrotransposition of the great arteries or the Taussig-Bing anomaly. Sixteen patients had multiple left-sided obstructive lesions (2 cases of critical aortic stenosis, 3 of subaortic stenosis and ventricular septal defect, and 11 of hypoplastic left heart complex). One patient had an associated complete atrioventricular septal defect. Four patients had only an associated ventricular septal defect. Through a median sternotomy, the hypoplastic aortic arch was enlarged with a pulmonary homograft patch in 36 patients. In 4 patients an extended end-to-end anastomosis was performed.

RESULTS

There were 2 early deaths (5%) and 2 late deaths (5%). One late death was not cardiac related. The mean follow-up time was 36 months (range 1 month-9 years). The recoarctation rate after pulmonary homograft patch aortoplasty was 8. 3%, but after exclusion of those patients with associated left-sided obstructive lesions this decreased to 0%. No aneurysm formation in the aorta has occurred. The actuarial survival at 8 years is 89% +/- 10%.

CONCLUSIONS

Single-stage biventricular repair of aortic arch obstruction and associated intracardiac defects can achieve excellent survival. We recommend pulmonary homograft patch aortoplasty because it achieves complete relief of anatomic afterload with a tension-free anastomosis and low incidence of recoarctation.

Total simultaneous repair of coarctation and intracardiac pathology in adult patients

BACKGROUND

Thoracic aortic coarctation accompanied by a second surgically reparable lesion is a rare combination in the adult patient. The simultaneous operative management of both lesions is desirable because of the higher morbidity and mortality that would occur with staged procedures.

METHODS

We describe the simultaneous operative management in three adult patients with coarctation and a second cardiac lesion. All 3 patients had intrapericardial ascending aorta-descending aorta bypass and concomitant repair of a cardiac lesion. The attendant repairs in the 3 patients, respectively, were aortic valve replacement, orthotopic heart transplantation, and coronary artery bypass grafting.

RESULTS

Double arterial cannulation, retrograde cardioplegia, large-bore aorto-aortic bypass grafts, and early use of alpha-agonists to stabilize systemic pressure were all key to ensuring safe conduct of the operation. Each patient had an essentially uneventful postoperative course.

CONCLUSIONS

Thoracic coarctation and concomitant cardiac pathology can be safely and readily managed with a single-stage approach involving cardiac repair and extraanatomic ascending aorta-descending aorta bypass grafting. A review of the English-language literature of patients managed similarly is included.

Management of arch hypoplasia after successful coarctation repair

BACKGROUND

Pronounced arch obstruction can be seen after a well-repaired coarctation, and this probably results from the failure of a somewhat hypoplastic arch to grow or from clamp injury at the time of the initial repair, or from both causes. Because of mediastinal adhesions and minimal collateral circulation, use of extraanatomic bypass grafts appears to be the preferred approach.

METHODS

Six children or young adults presented with arch obstruction over a 3-year period. Their mean age was 13.5 +/- 4 years, and the mean interval from the time of the initial repair was 10 +/- 4 years. The mean age of the patients at the time of the initial repair was 3.2 +/- 5 years. Symptoms included exertional headache and chest pain. The mean systolic gradients, as shown by echocardiography and cardiac catheterization, were 34 +/- 7 mm Hg and 33 +/- 6 mm Hg, respectively. Repair was accomplished through a midsternotomy using a polytetrafluoroethylene patch placed in the concavity of the arch, which extended from the ascending to the descending aorta. Dissection was kept close to the aorta and arch to minimize injury to the phrenic and recurrent laryngeal nerves. Cardiopulmonary bypass and moderate hypothermia (25 degrees to 27 degrees C bladder temperature) without circulatory arrest were used.

RESULTS

All patients were discharged home 4 to 20 days postoperatively (mean, 7 +/- 6 days). All patients were found to be normotensive at a mean follow-up of 1.3 +/- 1 years. Postoperative echocardiograms, which were obtained in all patients, revealed no residual gradients. Exercise blood pressure was evaluated in 2 patients and found to be normal.

CONCLUSIONS

Transsternal arch enlargement using cardiopulmonary bypass and moderate hypothermia without circulatory arrest is an attractive and safe approach for the treatment of arch obstruction after coarctation repair. Unlike the use of extraanatomic bypass grafts, it allows complete relief of the obstruction, unhampered aortic growth, the minimal use of foreign material, and a repair that is protected deep within the mediastinal space.

Technique for extraanatomic bypass in complex aortic coarctation

A variety of approaches and surgical techniques have been described for the management of recurrent coarctation. When there is an additional intracardiac defect that requires surgical correction it is preferable to correct both lesions simultaneously and through the same incision. This article reports two new techniques of connecting ascending to descending aorta using an intrathoracic conduit and performed through a median sternotomy.