Ann Thorac Surg 2005;79:343-345
© 2005 The Society of Thoracic Surgeons
Case report
Severe Coronary Artery Disease With Coarctation of the Aorta: Role of Off-Pump Coronary Artery Bypass Grafting
Komarakshi R. Balakrishnan, MDa,*,
Sadagopan Thanikachalam, DMb,
Jayanthi Satyanarayana Murthy, DipNBb,
Richard Saldanha, MDa,
Mariappan Jayarajah, DMb
a Department of Cardiothoracic Surgery Ramachandra Medical College Hospital, Porur, Madras, India
b Department of Cardiology, Ramachandra Medical College Hospital, Porur, Madras, India
Accepted for publication August 6, 2003.
* Address reprint requests to Dr Balakrishnan, Department of Cardiothoracic Surgery, Ramachandra Medical College Hospital, Porur, Madras 600116, India
krbalakrishnan{at}vsnl.com
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Abstract
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Severe coronary artery disease with coarctation of the aorta is an unusual and challenging clinical problem. We encountered three adults with severe coronary artery disease and tight coarctation of the aorta. Since angina was the dominant symptom in all, off-pump coronary artery bypass grafting (OPCABG) was done as a first stage. All survived the operation. After a gap of 3 weeks, coarctation repair has been done in 1 patient. We believe that OPCABG offers some unique advantages in this difficult situation.
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Introduction
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Severe coronary artery disease with coarctation of the aorta is an uncommon and difficult problem. In patients presenting with angina as the dominant symptom, off-pump coronary artery bypass grafting (OPCABG) is an attractive option that offers some unique advantages.
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Case Reports
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Patient 1
A 60-year-old man with a long-standing history of coarctation presented with severe angina and rest pain. An angiogram revealed severe triple-vessel disease with good left ventricular function. A magnetic resonance imaging scan confirmed a very tight coarctation between the left carotid and left subclavian arteries that amounted to near interruption (Fig 1). OPCABG was done with venous grafts to the left anterior descending, obtuse marginal, and right coronary arteries. After an uncomplicated recovery, he was discharged from the hospital in 4 days. At 2-year follow-up, he continues to be well and asymptomatic.
Patient 2
A 58-year-old man with disabling angina was found to have severe triple-vessel disease with severe left ventricular dysfunction and an ejection fraction of 30%. He underwent OPCABG with venous grafts to the left anterior descending, obtuse marginal, and posterior descending arteries. After 3 weeks, the coarctation was repaired through a posterolateral thoracotomy with a Dacron (DuPont, Wilmington, DE) graft. He was recatheterized a week later. All the coronary grafts were patent and the gradient across the coarctation was abolished. At 2-year follow-up, he continues to be well with improved ventricular function.
Patient 3
A 63-year-old hypertensive woman had severe rest angina, a long-segment coarctation owing to aortitis, and a tight left main stenosis with a severe osteal lesion of the right coronary artery. She underwent successful OPCABG with venous grafts to the left anterior descending, obtuse marginal, and posterior descending arteries and remains well at 1-year follow-up.
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Comment
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Patients with coronary artery disease and associated coarctation pose unique therapeutic challenges. One of the options we considered in this series of patients was to repair the coarctation first and then do the CABG in the usual manner. However, in the setting of unstable angina with critical coronary blocks, intraoperative ischemia was a real danger. Hence, this approach was not favored.
None of the three patients had a coronary anatomy that was suitable for angioplasty. Conventional CABG under cardiopulmonary bypass through a median sternotomy was rejected, as the associated coarctation may make cardiopulmonary bypass difficult, especially in a patient with presubclavian coarctation. Even though cardiopulmonary bypass has been used in an adult with untreated coarctation [1], important questions need to be addressed regarding the site of placement of the arterial return cannula and the advisability of additional femoral arterial cannulation in patients who are more than 60 years old.
We considered a simultaneous extra-anatomic bypass for the coarctation along with CABG, as has been described [2], but believed it was less ideal from the point of view of the coarctation than a more conventional approach. We considered OPCABG with coarctation repair from the left side of the chest as has been reported [3]. However, that report was of an isolated marginal graft and our patients needed three grafts, including the right coronary artery. Access to all the coronary vessels was considered difficult from a left thoracotomy.
A hybrid procedure with stenting of the coarctation followed by CABG has been described [4], but we did not do this because we have no experience with the stenting of adult coarctations, and 2 patients had atypical forms of aortic obstruction. The first patient had a near interruption of the presubclavian transverse arch and the third patient had a long-segment aortic obstruction, possibly due to aortitis. Stents have not been documented to be safe in these settings.
Because the primary problem in all 3 patients was angina and they had been living long-term with their coarctation, we decided to tackle the coronary artery disease first with OPCAB. Given the circumstances, the procedure was remarkably well tolerated, with surprisingly little morbidity. The left internal mammary artery was not used in the first patient as it was arising from the subclavian artery beyond the block. Moreover, we felt that in untreated coarctation, it is not advisable to sacrifice the internal mammary artery, which is an important source of collateral flow to the distal aorta. Also during the subsequent coarctation repair, clamping of the left subclavian artery would be hazardous with a left internal mammary artery graft in place. Associated coarctation of the aorta should be added to the other well-known anatomic conditions, such as a calcified aorta, where OPCAB offers unique advantages.
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References
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- Plunkett MD, Bond LM, Geiss DM. Staged repair of acute type I aortic dissection and coarctation in pregnancy. Ann Thorac Surg. 2000;69(6):1945–1947[Abstract/Free Full Text]
- Thomka I, Szedo F, Arvay A. Repair of coarctation of the aorta in adults with simultaneous aortic valve replacement and coronary artery bypass grafting. Thorac Cardiovasc Surg. 1997;45(2):93–96[Medline]
- Rozanski J, Juraszynski Z, Kusmierczyk M, Sitko T. Repair of coarctation of the aorta with simultaneous coronary artery bypass grafting without cardio pulmonary bypass. Eur J Cardiothorac Surg. 1999;15(4):536–538[Abstract/Free Full Text]
- Yiu P, Sigwart U, Pepper J. Hybrid management of coronary artery disease and coarctation of aorta. Ann Thorac Surg. 2000;70(6):2153–2154[Abstract/Free Full Text]
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Abstract
Introduction
