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Ann Thorac Surg 2000;70:1488-1489
© 2000 The Society of Thoracic Surgeons
Discussion
DR CARL L. BACKER (Chicago, IL): I would like to congratulate Dr Bouchart and colleagues on an outstanding review of coarctation repair in adult patients. I also thank you for the advance copy of the manuscript. This series of 35 adults having coarctation repair with no mortality, no paraplegia, and no late deaths is truly excellent. I have several comments and questions.
My first comment is that this report confirms the importance of early repair of coarctation. In your series, one third of the patients remained hypertensive and of those who were normotensive at rest, a full one third were still hypertensive with exercise. It is the elimination of this hypertension that underlies the importance of early repair of coarctation and not delaying until the adult years.
My second comment is that this series helps establish a true gold standard for comparison of surgical outcomes in adult patients versus transcatheter techniques. Several recent series have documented "good" results with balloon dilatation of coarctation in older adolescents and adults. Some of these series have improved their results by the use of a balloon-expandable stent placed at the time of coarctation dilatation. Your surgical standard of no mortality, no paraplegia, and no late deaths is a difficult one for the transcatheter enthusiasts to duplicate or surpass.
My final comment is that it would appear clear that you have demonstrated an alteration in the natural history of unoperated coarctation, even in adult patients. In Campbell’s series, 50% of unoperated coarctation patients were dead by the age of 32. You operated on patients at a mean age of 28 years and with 14 years of follow-up have no late deaths.
I have several questions. You had no paraplegia in your series. What types of spinal cord and distal arterial pressure monitoring techniques did you use?
A question with regard to the surgical techniques. In my practice I have preferred to use an interposition graft for older patients because of the abnormal aortic tissue found in the coarctation area. I am concerned personally about the tension on the anastomosis given the abnormal aortic wall, and I believe you touched on some of these issues in your manuscript. My question is, why have you preferred the end-to-end anastomosis versus the use of an interposition graft?
My final question relates to postoperative paradoxical hypertension. It appears that there were no episodes of mesenteric arteritis in your series. Do you believe that mesenteric arteritis is a thing of the past with the use of modern antihypertensive agents?
Again, I strongly congratulate you on an outstanding series of coarctation repairs with the spectacular outcome of no mortality, no paraplegia, and no late deaths. This is truly a gold standard for comparison with any other techniques.
Thank you for the privilege of discussing this fine paper.
DR ALEJANDRO ARIS (Barcelona, Spain): I wish to congratulate Dr Bouchart on his excellent presentation. The results of his group confirm the efficacy of coarctation repair in adult patients and parallel the findings of my colleagues and I on the subject.
In a recent article that appeared in the May issue of The Annals of Thoracic Surgery, we reported the results in 8 patients who were older than 50 years at the time of operation. The oldest patient was 73 years old. All of them were normotensive at a mean follow-up of 4.5 years. Only 3 patients were taking antihypertensive medication. However, in our experience, this is a difficult operation. Besides the fact that 3 patients had concomitant coronary artery disease, needing bypass grafts in 1, we found a heavily calcified aortic arch and left subclavian artery in several occasions and aneurysmal dilatation of the intercostal arteries in 2 patients. We elected to perform a bypass graft of the coarctation in all of the cases and the results have been excellent.
I am surprised that Dr Bouchart and colleagues were able to perform an end-to-end anastomosis in 85% of the cases. My question is, was the procedure more difficult in older patients? Were the Dacron grafts employed mainly in the older population?
I congratulate you again for your good results and I thank the Society for allowing me to discuss this paper.
DR EDWARD R. ZECH (Potomac, MD): Two questions, please. In a recent patient that we cared for there was a great deal of discussion about requirement for screening for intracranial aneurysms before we did the operation. I wondered if you had noticed any association.
I also would like to know more about your decision to use some kind of left atrial-to-distal bypass or fem-fem bypass to support distal circulation. Did you monitor lower body pressures?
DR BOUCHART: I want to thank Dr Backer for his comments. For the first question on paraplegia and lower body perfusion, we did not use any kind of shunt or distal perfusion because we think with a coarctation you have collateral vessel development and you do not need to have any kind of distal perfusion to have spinal cord protection.
Why did we choose to make an end-to-end anastomosis? I think we tried to avoid the placement of any graft in this old population for coarctation repair but a still young population when compared to the general population. So we did what effort was possible to make a direct end-to-end anastomosis.
The third question was about abdominal pain and postoperative arteritis. Of course there were some patients who had abdominal pain, but with treatment of hypertension you can get rid of that very quickly, and so I think it is, like Dr Backer said, something of the past with the treatment of hypertension.
The last question was about intracranial aneurysms. This is a large series beginning in 1977, and we have for some patients data on intracranial anatomy but not for all patients. So I cannot tell you how many patients could have some sort of aneurysm, but what I can tell you is that there was no problem with that in any patient during the follow-up period.
This article has been cited by other articles:
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