Ann Thorac Surg 2004;77:1463
© 2004 The Society of Thoracic Surgeons
Images in cardiothoracic surgery
Ascending aortic aneurysm, coarctation of the aortic isthmus and hypoplastic aortic arch: simultaneous treatment through sternotomy
Thierry P. Carrel, MDa*,
Pascal A. Berdat, MDa
a Clinic for Cardiovascular Surgery, University Hospital, Berne, Switzerland
* Address reprint requests to Dr Carrel, Department of Cardiovascular Surgery, Clinic for Cardiovascular Surgery, University Hospital Berne, Freiburgstrasse, CH-3010 Berne, Switzerland
e-mail: thierry.carrel{at}insel.ch
We report an 18-year-old woman who was diagnosed with a bicuspid but normal functioning aortic valve and ascending aortic aneurysm (5.2 cm) by transthoracic echocardiography. The preoperative magnetic resonance angiogram surprisingly showed aneurysm of the ascending aorta and severe aortic coarctation and hypoplastic aortic arch with well-developed collateral vessels from the intercostal arteries and internal thoracic artery, which had not been diagnosed by the cardiologist before (Fig 1).
Arterial pressure in the upper body part was normal, but femoral pulses were weak.
To avoid circulatory arrest and technical difficulties as a result of the length of arch hypoplasia and the extremely well-developed collateral vessels, operative treatment consisted of supracoronary graft replacement of the ascending aorta and ascending-to-descending extra-anatomic aortic bypass, using a 16-mm ring-reinforced polytetrafluoroethylene graft [1]. The distal anastomosis was performed behind the heart using an exposition technique similar to that required for beating heart surgery, and the graft was brought to the ascending aorta laterally from the right atrium [2]. Thereafter, the ascending aorta was replaced on cardiopulmonary bypass, and the extra-anatomic bypass was implanted in the ascending graft. Figure 2
shows the intraoperative finding after replacement of the ascending aorta and ascending-to-descending aortic bypass. Supracoronary graft replacement was performed because the aortic root had normal sizes and the aortic valve demonstrated normal function. Postoperative recovery was uneventful, and the patient was discharged home on postoperative day 6. Figure 3
depicts a control magnetic resonance angiogram after complete repair.
References
- Kanter K.R., Erez E., Williams W.H., Tam V.K. Extra-anatomic aortic bypass via sternotomy for complex aortic arch stenosis in children. J Thorac Cardiovasc Surg 2000;120:885-890.[Abstract/Free Full Text]
- Connolly H.M., Schaff H.V., Izhar U., Dereani J.A., Warnes C.A., Orszulak T.A. Posterior pericardial ascending-to-descending aortic bypass: an alternative surgical approach for complex coarctation of the aorta. Circulation 2001;I-104:133-137.
