Ann Thorac Surg 2001;71:713-715
© 2001 The Society of Thoracic Surgeons
Case report
Interventional and surgical management of aortic stenosis and coarctation
Alan G. Magee, MRCPa,b,
Christopher I. Blauth, FRCSa,b,
Shakeel A. Qureshi, FRCPa,b
a Department of Pediatric Cardiology, Guy’s Hospital, London, England, UK
b Department of Cardiothoracic Surgery, St Thomas Hospital, London, England, UK
Accepted for publication April 6, 2000.
Address reprint requests to Dr Magee, Department of Pediatric Cardiology, Royal Brompton and Harefield NHS Trust, Sydney St, London SW3 6NP, England
e-mail: a.magee{at}rbh.nthames.nhs.uk
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Abstract
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Two patients, aged 42 and 44 years old, presented with the combination of aortic valve stenosis and coarctation. To avoid potential problems associated with one stage repair, both patients underwent successful endovascular stent implantation for coarctation followed within 2 weeks by aortic valve replacement using pulmonary autografts (Ross operation). Spiral thoracic computed tomographic scans were performed within 1 week of stent implantation to ensure the absence of aneurysm formation related to the stent before cardiopulmonary bypass.
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Introduction
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Although a bicuspid aortic valve is a common finding in association with coarctation of the aorta [1], the combination of significant aortic valve stenosis and coarctation of the aorta is less common outside the setting of hypoplastic left heart syndrome. In children aortic valve stenosis has been reported in 7% of a large group undergoing balloon angioplasty of native coarctation of the aorta [2]. In an adult population aortic valve replacement was only required in 4% of those with coarctation [3]. Previously reported surgical options are either a two-staged approach or a one-stage repair combining aortic valve replacement with the insertion of a graft from the ascending to the descending aorta [4]. We report 2 patients, who underwent stent implantation for coarctation of the aorta followed by aortic valve replacement using pulmonary autografts [5]. Spiral computed tomographic scanning was performed before cardiopulmonary bypass to ensure absence of aneurysm formation.
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Case reports
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Patient 1
Clinical evidence of aortic valve disease was discovered incidentally in a normotensive 42-year-old man. An echocardiogram revealed left ventricular hypertrophy, a Doppler estimated gradient of 70 mm Hg across the aortic valve, and probable aortic coarctation. Cardiac catheterization confirmed calcific aortic stenosis, discrete coarctation of the aorta, and normal coronary arteries.
Patient 2
A 44-year-old man was found to have a heart murmur in infancy but was not investigated and remained asymptomatic. During an employment medical examination he was found to have borderline hypertension (blood pressure, 155/85 mm Hg) and a loud murmur. Echocardiography showed the combination of aortic stenosis (Doppler estimated gradient, 60 mm Hg) and coarctation of the aorta (Doppler estimated gradient, 50 mm Hg). Cardiac catheterization showed normal coronary arteries and confirmed a discrete coarctation of the aorta.
In both patients stent implantation was performed under general anesthesia with percutaneous entry through the femoral arteries. Angiography revealed a discrete coarctation of the aorta in both patients with minimum diameters of 7 mm and 10 mm and systolic pressure gradients of 25 mm Hg and 30 mm Hg, respectively.
After full anticoagulation with 100 U/kg of heparin and administration of antibiotics an 11 Fr Mullins long trans-septal sheath (William Cook Europe ApS, Bjaeverskov, Denmark) was advanced over an Amplatz SuperStiff guidewire (Meditech, Watertown, MA) previously placed across the coarctation site. A 4014 Palmaz iliac stent (Johnson and Johnson, Warren, NJ) was mounted onto an 18 mm Cristal angioplasty balloon (E Merck Inc, Montmorency, France) and advanced through the sheath to the desired position. After check angiography, both the angiographic catheter and the sheath were withdrawn to uncover the stent, and the balloon was inflated. Care was taken not to expand the stent fully to the diameter of the adjacent aorta. After stent deployment, there were no residual gradients and the narrowest diameters increased to 13 mm and 16 mm, respectively (Fig 1A, B).
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Fig 1. Aortogram (A) in a right anterior oblique projection showing a discrete coarctation of the aorta just distal to the origin of the left subclavian artery in patient 1. After stent implantation (B), there is a substantial increase in minimum vessel diameter with abolition of the pressure gradient.
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Heparin (to maintain activated clotting time of 200 seconds) and antibiotics were continued for 48 hours after the procedure. An antiplatelet dose of aspirin was commenced on the day after the procedure for 6 months. Spiral computed topographic scanning was performed within 1 week of stent implantation with no evidence of aneurysm formation in either patient.
Aortic valve replacement using pulmonary autografts was performed at 7 and 15 days, respectively, after stent implantation. The pulmonary roots were reconstructed using 24 mm pulmonary homografts. In the second patient the right coronary button disintegrated and a short segment of the left long saphenous vein was harvested and interposed between the stump of the right coronary artery and the ascending aorta. Both patients were weaned from cardiopulmonary bypass uneventfully. At follow-up, 9 months after valve replacement, both patients are well and normotensive. Repeat spiral computed topographic scanning has also been performed with no evidence of aortic aneurysm formation.
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Comment
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The combination of significant aortic stenosis and coarctation of the aorta presents a surgical challenge. When valve replacement is performed first as part of a staged approach there is a potential for difficulty in reestablishing the patient’s circulation with persistent left heart obstruction. A single stage approach involving transpericardial bypass of the coarctation has evolved because it may be difficult to reach the coarcted segment from the midline. With this approach, difficulty in weaning from cardiopulmonary bypass has been reported [4]. Therefore, nonsurgical treatment of the coarctation could offer a significant advantage.
The mechanism of successful balloon dilation of coarctation involves tearing of the aortic intima and media. Thus, there is a risk of transmural tears and aneurysm formation with balloon dilation. In contrast, during stent implantation it is not necessary to overdilate the coarctation to produce a good result. Stent implantation has been successfully performed in both native and recurrent coarctation of the aorta [6]. However, it does not abolish the risk of aneurysm formation entirely, and careful evaluation by computed topographic scanning is necessary before cardiopulmonary bypass.
Combined interventional and surgical management of aortic stenosis and native coarctation of the aorta was performed successfully in 2 patients. Neither patient has developed any evidence of aortic aneurysm formation and both remain normotensive. Although continued follow-up is necessary, we believe this combined approach offers significant advantages over previous strategies for managing this condition.
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References
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Becker A.E., Becker M.J., Edwards J.E. Anomalies associated with coarctation of the aorta. Particular reference to infancy. Circulation 1970;41:1067-1075.[Abstract/Free Full Text]
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McCrindle B.W., Jones T.K., Morrow W.R., et al. Acute results of balloon angioplasty of native coarctation versus recurrent aortic obstruction are equivalent. J Am Coll Cardiol 1996;28:1810-1817.[Abstract]
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Turina J., Hippenmeyer-Zingg I., Schonbeck M., Turina M. Severe aortic valve diseases and aortic isthmus stenosis in adults. Incidence, clinical aspects and long-term results of surgical treatment. Z Kardiol 1997;86:676-683.[Medline]
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Pethig K., Wahlers T., Tager S., Borst H.G. Perioperative complications in combined aortic valve replacement and extraanatomic ascending-descending bypass. Ann Thorac Surg 1996;61:1724-1726.[Abstract/Free Full Text]
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Gonzalez-Lavin L., Geens M., Ross D.N. Pulmonary valve autograft for aortic valve replacement. J Thorac Cardiovasc Surg 1970;60:322-330.[Medline]
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Bulbul Z.R., Bruckheimer E., Love J.C., Fahey J.T., Hellenbrand W.E. Implantation of balloon-expandable stents for coarctation of the aorta: implantation data and short-term results. Cathet Cardiovasc Diagn 1996;39:36-42.[Medline]
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