Ann Thorac Surg 2005;79:1049-1050
© 2005 The Society of Thoracic Surgeons
Case report
Bilateral Minithoractomy Repair of Aortic Coarctation With Ventricular Septal Defect and Persistent Ductus Arteriosus
Jie Ma, MDa,
Yongzhi Deng, MDa,*,
Xinhua Li, MDa
a Department of Cardiothoracic Surgery, The Second Teaching Hospital of Shanxi Medical University, Taiyuan, Shanxi, and Department of Cardiovascular Surgery, Xiehe Hospital of Tongji Medical College, Huazhong University of Science and Technology (HUST), Wuhan, Hubei, China
Accepted for publication September 8, 2003.
* Address reprint requests to Dr Deng, Department of Cardiothoracic Surgery, The Second Teaching Hospital of Shanxi Medical University, 382 Wuyilu, Taiyuan, Shanxi 030001, China
dengyongzhi{at}hotmail.com
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Abstract
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A 6-year-old female child with aortic coarctation, a ventricular septal defect, and a persistent ductus arteriosus underwent surgical repair by bilateral minithoracotomies. At 6-month follow-up, the patient had recovered well, with increased exercise tolerance. Transthoracic echocardiography revealed an intact ventricular septum and no significant gradient across the aortic repair.
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Introduction
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With the introduction of minimally invasive cardiac surgical procedures and the development of surgical technical skills, surgeons have adopted the use of minimal incisions for the repair of persistent ductus arteriosus (PDA), ventricular septal defect (VSD), and atrial septal defect (ASD) for the benefits of reducedmorbidity, faster recovery, improved cosmesis, and less economic burden on patients [1, 2]. We report a patient who underwent bilateral minithoracotomy repair of aortic coarctation, VSD, and PDA. The surgical techniques and treatment options for minimally invasive surgical procedures are presented and discussed.
A 6-year-old female child was admitted for an investigation of intermittent, bilateral lower extremity weakness and a cardiac murmur that had been present for 2 years. On physical examination, the patient's heart rate was 105 beats per minute, the apex beat was markedly displaced to the left, a 4/6 pan systolic precordial murmur radiated to the back, and P2 was accentuated. There was a gradient of 20 mmHg between the upper and lower extremities. A chest roentgenogram demonstrated pulmonary congestion, aortic prominence, and left ventricular hypertrophy. Transthoracic echocardiography showed a perimembranous VSD 6 mm in diameter, an aortic stenosis 7 mm in diameter beyond the subclavian artery, and a PDA 4 mm in diameter. Angiography revealed both left atrial and left ventricular enlargement, a 2-cm length of stenotic aorta located beyond the left subclavian artery measuring 7.35 mm in diameter, and a funnel PDA.
Under general anesthesia, and 34° to 35°C hypothermia, a 7-cm left minithoracotomy through the fourth intercostal space was made, the PDA was ligated, and a left subclavian flap aortoplasty was undertaken. The aorta was incised from below the coarctation across the narrow segment through the isthmus and along the lateral border of the subclavian artery, which was ligated and transected. The flap was secured with a continuous 5-0 polypropylene suture. The aortic cross-clamp time was 26 minutes. After the repair of the stenosis, the gradient between the upper and lower extremities was 5 mmHg.
The patient was moved to a 60-degree left lateral decubitus position, and through a 6-cm right subaxillary minithoracotomy through the fourth intercostal space, the pericardium was opened anterior and parallel to the phrenic nerve and suspended for easy aortic cannulation. With routine extracorporeal circulation and cardioplegic arrest, the VSD was closed directly with two 3-0 Dacron mattress sutures over Teflon pledgets, through a right atriotomy.
At 6-month follow-up, the patient had recovered well, with increased exercise tolerance, and transthoracic echocardiography revealed no VSD leakage or stenosis of the aortic repair.
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Comment
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Aortic coarctation occurs in approximately 30 of every 1 million live births [3] and accounts for 5% to 10% of congenital heart diseases, with VSDs accounting for 55% of associated intracardiac malformations [4]. Improvements in imaging techniques allow its early diagnosis and treatment, so the rare entity of child or adult coarctation may become even less common. Aortic coarctation is traditionally repaired through a 20-cm to 30-cm left posterolateral thoracotomy, and the VSD is closed through a median sternotomy in 1 or 2 stages. Both incisions cause greater morbidity than the minithoracotomies used in our case. Minithoracotomies also provide better cosmesis, faster recovery with less pain, and less blood transfusion [1, 2, 5], though the technique is more demanding, and right ventricular outflow tract obstruction must be carefully excluded.
Six-hundred one consecutive subaxillary vertical minithoracotomies were performed safely for the repair of ASD, VSD, ASD/VSD, ligation of PDA, and the repair or replacement of mitral valves between May 1997 and May 2002 in our medical center [5]. The present case represents a successful combination of both right and left minithoracotomies in one patient.
The optimal management strategy for patients with aortic coarctation and associated VSDs remains controversial. A variety of therapeutic strategies have been proposed, including coarctation repair alone with later VSD closure, coarctation repair with pulmonary artery banding followed by delayed VSD closure and debanding, and the single-stage repair of both defects. Multiple techniques have also been used for arch reconstruction in these patients, including subclavian flap aortoplasty, patch aortoplasty, and resection with end-to-end anastomosis. In our case involving a 6-year-old child, subclavian flap aortoplasty rather than resection with end-to-end anastomosis was used because the subclavian artery was not long enough for an end-to-end anastomosis. Because a 6-mm perimembranous VSD is not likely to close spontaneously, this was also closed as part of the single-stage repair of both defects.
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Acknowledgments
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We thank Hugh S. Paterson, FRACS, for editing the language of this manuscript.
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References
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- Ma J, Li JC, Wang ZL, et al. Using minimally invasive right thoracotomy in open heart surgery under cardiopulmonary bypass. Shanxi Med J. 1999;28:194–195
- Ma J, Li JC, Li XH, Feng XD, Zhao YH, Liang QY. Applying right vertical axillary minithoractomy in open heart surgery. Chin J Thorac Cardiovasc Surg. 2001;17:171–172
- Grech V. Diagnostic and surgical trends and epidemiology of coarctation in a population based study. Int J Cardiol. 1999;68:197–202[Medline]
- Quaegebeur JM, Jonas RA, Weinberg AD, et al. Outcomes in seriously ill neonates with coarctation of the aorta. J Thorac Cardiovasc Surg. 1994;108:841–854[Abstract/Free Full Text]
- Ma J, Li JC, Li XH, et al. The effect of using right subaxillary vertical minithoractomy in 601 consecutive open heart surgery. Symposium of the Fifth National Cardiovascular and Thoracic Conference of China, Kunming, China, 2002, p. 366
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Abstract
Introduction
