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Ann Thorac Surg 1997;64:1309-1311
© 1997 The Society of Thoracic Surgeons

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Original Articles: Cardiovascular

Two-Stage Repair of Adult Coarctation of the Aorta With Congenital Valvular Lesions

Department of Cardiothoracic Surgery, Killingbeck Hospital, Leeds, United Kingdom

Accepted for publication May 10, 1997.

	Abstract

Top Footnotes Abstract Introduction Case Reports Comment Acknowledgments References

 
Background. Coarctation of the aorta associated with intracardiac pathologic conditions presenting in adult life poses some technical and management challenges. When deciding on the best surgical strategy, the surgeon must pay careful attention to the changes that will occur in the circulation.

Methods. In our small series of 3 patients, the intracardiac pathologic lesions were corrected first, and the coarctation was repaired as a second-stage procedure 2 to 3 months later.

Results. All patients had an uneventful recovery from both operations. The potential problems of renal impairment caused by inadequate perfusion during bypass and perioperative systemic hypertensive complications resulting from coarctation of the aorta were not observed. At the time of coarctation repair as a second-stage procedure, anticoagulation was easily controlled. All 3 patients had short intensive care unit and hospital stays.

Conclusions. Staged surgical repair of this complex pathologic combination in adult patients is a safe option and is easy to manage perioperatively.

	Introduction

Top Footnotes Abstract Introduction Case Reports Comment Acknowledgments References

 
See also page 1311.

Coarctation of the aorta in association with left-sided valvular lesions is a well-recognized entity, but because of the multiple pathologic processes, presentation normally occurs in early childhood. Presentation in adults is rare. Consequently there are few reports involving adults, and the appropriate management of adult patients has received little attention. We present the cases of 3 adult patients and discuss rationale for, benefits of, and risks of different surgical strategies for this condition.

	Case Reports

Top Footnotes Abstract Introduction Case Reports Comment Acknowledgments References

 
Patient 1
A 26-year-old male drug addict was seen with congestive cardiac failure secondary to bacterial endocarditis. He was also noted to have coarctation of the aorta. Echocardiography revealed a stenotic aortic valve with a gradient of 125 mm Hg, moderate regurgitation, and aortic valve vegetations. An aortogram revealed coarctation of the aorta with a gradient of 55 mm Hg. Blood cultures grew Streptococcus faecalis, and a regimen of intravenous antibiotics was commenced. Despite aggressive antibiotic treatment, the condition of the patient deteriorated. He underwent aortic valve replacement with a Carpentier-Edwards xenograft as first-stage management. At operation, the valve was found to be severely calcific and bicuspid with commissural fusion and vegetations on the noncoronary leaflet. Six weeks after aortic valve replacement, elective repair of the coarctation was performed through a left thoracotomy. The paraductal coarctation was repaired by patch aortoplasty. Four and a half years postoperatively, the patient is asymptomatic and requires no medication.

Patient 2
A 46-year-old man was seen with a 4-month history of progressive exertional dyspnea and hypertension. Echocardiography and aortography revealed a stenotic bicuspid aortic valve, mitral valve stenosis, and coarctation of the aorta. The patient underwent aortic valve replacement using a mechanical valve and mitral valve repair as first-stage management. The aortic valve was calcified and bicuspid. Congenital mitral stenosis and a supravalvular mitral membrane were present. After excision of the membrane and commissurotomy, the mitral valve sprang open. The patient had an uneventful recovery from this operation and 2 months later was readmitted for elective repair of the coarctation. Severe coarctation of the aorta with virtually acquired interruption was repaired with an interposition graft. Four years postoperatively, the patient is asymptomatic on a regimen of warfarin sodium and antihypertensive medication.

Patient 3
A 22-year-old man was seen with a 2-year history of progressive exertional dyspnea and headache. Echocardiography and cardiac catheterization revealed severe aortic insufficiency and coarctation of the aorta with a 100 mm Hg gradient across the coarctation. At operation, the patient was found to have a regurgitant bicuspid aortic valve, which was replaced with a mechanical valve. Three months later, the patient underwent elective repair of the coarctation by patch aortoplasty. Five years postoperatively, he is asymptomatic.

	Comment

Top Footnotes Abstract Introduction Case Reports Comment Acknowledgments References

 
The presentation of coarctation of the aorta in adulthood is rare. Associated congenital aortic and mitral valve lesions are extremely rare, and very little published data are available. The obvious problem for the surgeon is which management option to select: one-stage correction of both lesions simultaneously through a median sternotomy with valve replacement and an extraanatomic bypass graft from the ascending to the descending aorta [1–3] or a two-stage approach. In the latter, the advantage of correcting the valvular lesion before the coarctation has been described [4]. Experimental studies [5–7] have demonstrated the reduced forward flow through the coronary arteries during the diastolic phase in the setting of aortic incompetence, and Rufilanchas and associates [4] found that myocardial blood flow is further substantially reduced by the acute decrease in systemic vascular resistance if the coarctation is repaired first. This logically leads to acute myocardial hypoperfusion. Similarly, myocardial ischemia can be expected in the hypertrophied ventricle of aortic stenosis during diastole with a sudden drop in systemic vascular resistance [1, 4]. These acute changes can lead to myocardial irritability and left ventricular failure.

We thought that one-stage repair of the aortic valve and coarctation could mimic this same situation in the early period after bypass and that therefore the perioperative management of these patients would be easier with a two-stage approach. Also, although there are reports of successful repair without any perioperative complications [8, 9], a recent experience [1] highlighted the potential for major difficulties with the one-stage approach: both patients experienced myocardial hypoperfusion and ventricular arrhythmias when coming off bypass.

In our small series, we chose to use two stages. In patient 1, the intracardiac problem of endocarditis and cardiac failure was predominant and therefore needed to be dealt with first. Patient 2 had double-valve pathologic involvement, and we thought it wise to deal with that initially. In patient 3 with gross aortic regurgitation, we decided that coarctation repair with clamping of the descending thoracic aorta in the setting of valvular incompetence would be unwise and thus thought it appropriate and important to correct the intracardiac pathologic condition first.

All 3 patients came off bypass easily, and all had short stays in the intensive care unit and the hospital. The theoretic disadvantages of the approach are potential difficulties coming off bypass with higher afterload than normal and renal hypoperfusion perioperatively. The problem of increased afterload did not materialize probably because of the extensive collateral formation that occurs in adults. Careful control of mean arterial pressure (allowing it to be set at a higher level than normal both during bypass and after operation) neutralized the potential renal problem. Control of blood pressure in these patients was not difficult.

During the second stage (thoracotomy and coarctation repair), potential problems are cessation of anticoagulation and risk of prosthetic valve endocarditis. A standard approach involving cessation of warfarin and use of intravenous heparin sodium perioperatively was adopted. Standard perioperative prophylactic antibiotics were administered. Two patients had replacement with a mechanical valve, and 1 patient (patient 1) received a tissue valve for social reasons. Our current choice of valve for younger patients like those whose case reports were presented here is a pulmonary autograft rather than a mechanical prosthesis, which was used in the earlier time frame.

It appears that the advantages of a one-stage approach, ie, number of surgical procedures and length of hospital stay, do not outweigh the disadvantage of a significantly increased risk because of myocardial hypoperfusion consequent to an acute reduction in afterload. Balloon dilation in isolated adult coarctation of the aorta has been described [10–14], and if the long-term results prove to be successful, it may have a role in patients with a mild or moderate coarctation.

In conclusion, we chose a staged procedure with intracardiac repair first and then repair of the coarctation after 6 weeks. Our reasons were threefold. First, it was important to deal with the intracardiac pathologic processes first. Coarctation repair with a conduit at the same time would have caused a sudden decrease in systemic vascular resistance. Second, lower-body perfusion was not a particular problem during cardiopulmonary bypass because of the good collateral circulation in these adult patients with coarctation. Third, staged repair allows recovery of the myocardium and redistribution of coronary blood flow during the interval between the two operations. Therefore, a two-stage approach with a valve-first strategy, although not completely ideal, is a safe option in terms of morbidity and mortality.

	Acknowledgments

Top Footnotes Abstract Introduction Case Reports Comment Acknowledgments References

 
We thank Dr R. Clark, Dr C. Morley, and Dr A. Macintosh for referring these patients.

	Footnotes

Top Footnotes Abstract Introduction Case Reports Comment Acknowledgments References

 
Address reprint requests to Mr Watterson, Department of Cardiothoracic Surgery, Killingbeck Hospital, York Rd, Leeds LS14 6UQ, UK.

	References

Top Footnotes Abstract Introduction Case Reports Comment Acknowledgments References

 

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Kevin G. Watterson Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Mulay, A. V. Articles by Watterson, K. G. Search for Related Content PubMed PubMed Citation Articles by Mulay, A. V. Articles by Watterson, K. G.