Ann Thorac Surg 2007;83:1174-1175
© 2007 The Society of Thoracic Surgeons
Case Reports
Single-Stage Surgical Repair of Type II Acute Aortic Dissection Associated With Coarctation of the Aorta
Tetsuya Horai, MDa,*,
Tomoki Shimokawa, MDa,
Susumu Takeuchi, MDa,
Yutaka Okita, MDb,
Shuichiro Takanashi, MDa
a Department of Cardiovascular Surgery at Sakakibara Heart Institute, Tokyo
b Department of Cardiovascular Surgery, University of Kobe, Kobe, Japan
Accepted for publication September 11, 2006.
* Address correspondence to Dr Horai, Department of Cardiovascular Surgery, Sakakibara Heart Institute, 3-16-1 Asahi-cho, Fuchu, Tokyo 183-0003, Japan (Email: thourai-tky{at}umin.ac.jp).
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Abstract
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A 36-year-old man, who was referred for severe chest pains, was found to have acute type II aortic dissection associated with a dilated ascending aorta, aortic coarctation, and congenitally bicuspid valve. A single-stage surgical repair consisting of valve-sparing aortic root implantation and graft replacement of the ascending aorta, arch, and the coarctation segment was successful.
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Introduction
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The association of congenitally bicuspid valve with coarctation of the aorta (CoA) is not rare; however, a simultaneous repair of both conditions, especially complicated with acute aortic dissection (AAD), has been seldom reported. There are several previous reports of two-stage repair or single-stage repair using an extraanatomic bypass from the ascending aorta to the descending aorta [1–5], and one of a single-stage repair from the ascending aorta to the distal arch excluding the coarctation [6]. We report a simultaneous operation involving valve-sparing root implantation and graft replacement of the ascending aorta, arch, and the coarctation segment.
A 36-year-old man was referred to our hospital for severe chest pains. His blood pressure was 128/83 mm Hg in the upper limbs and 88/67 mm Hg in the lower limbs. Computed tomography showed an aneurysmal ascending aorta, 7.5 cm in diameter, with intimal flap and postductal coarctation. Magnetic resonance imaging showed the identical images with developed collateral vessels to the lower body (Fig 1). Echocardiogram revealed the aortic valve was bicuspid with trivial regurgitation.
With a diagnosis of type II aortic dissection and associated CoA, emergent surgery was performed through a median sternotomy. Cardiopulmonary bypass (CPB) was established by perfusion through the true lumen of the ascending aorta and venous cannula drainage. The mean blood pressure of the dorsalis pedis was not satisfactory, however, and another cannula was inserted to the femoral artery to perfuse the lower body adequately. The ascending aorta was cross-clamped, opened, and blood cardioplegia was infused in the coronary ostia. There was an intimal tear in the anterior aortic wall just above the Valsalva sinus. The aortic annulus was dilated and the valve was bicuspid, but the valves were anatomically normal.
Valve-sparing aortic root implantation was performed using a handmade Valsalva graft with 90-degree rotated Dacron (DuPont, Wilmington, DE) fabric corrugations necked down to 26 mm proximally and distally between tube grafts. Each of two coronary buttons was directory anastomosed to the respective neosinus of the graft.
The patient’s body temperature was reduced to 20°, and the aortic arch was opened to the CoA under selective cerebral perfusion with circulatory arrest of the lower body. The aorta was transected distal to the coarctation, and a 22-mm graft was anastomosed to the normal descending aorta. Neck vessels were intact and anastomosed to the graft as a cuff. Rewarming was initiated, and two Dacron grafts were anastomosed.
Weaning from cardiopulmonary bypass was easy. Cardiopulmonary bypass, myocardial ischemia, and circulatory arrest times were 333, 259, and 51 minutes, respectively.
The patient’s postoperative course was straightforward, and he was discharged on postoperative day 18. Computed tomography revealed satisfactory repair, and no aortic valve insufficiency was detected on echocardiograms at 1 week or at 8 months after surgery.
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Comment
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Although CoA sometimes is accompanied with a congenitally bicuspid aortic valve, surgical experience for AAD, which occurred in this combination, has been rarely reported. Several surgical options have been reported. As a staged strategy, Sampath and colleagues [1] advocated the initial repair of the coarctation to relieve proximal hypertension, thereby decreasing the chance of progressive dissection or rupture. This also permits safe perfusion during repair of the dissection in the second stage of an operation.
Different approaches have also been reported [2, 3]. Replacement of the ascending aorta was first performed, and repair of the coarctation was done as the second procedure because repair of AAD was necessary for survival. There are a few reports of single-stage surgical repair of this combination [4–6]. Svensson [4] and Buket and colleagues [5] reported cases of insertion of both composite valve grafts for the ascending aorta and extraanatomic bypass grafts from the ascending aorta to the descending aorta or the abdominal aorta. Paparella and colleagues [6] described a case of total arch graft replacement resecting the segment of the coarctation through median sternotomy and left thoracotomy.
We were able to perform a one-stage repair of AAD and CoA through a median sternotomy. In infants, CoA is usually accessed and the descending aorta can be mobilized through the median sternotomy. In adults, the descending aorta can be managed down to the carina level thorough the same approach, as in patients with distal arch aneurysm. This approach has some advantages compared with left thoracotomy because numerous collateral vessels, which may be important for the blood supply, sometimes preclude access to the CoA.
Valve-sparing aortic replacement for root aneurysm with a morphologically intact valve has become a common procedure with acceptable results, but this operation for a dilated aorta with bicuspid valve remains challenging. Some reports have demonstrated acceptable early and mid-term results of valve-sparing root replacement in patients with a bicuspid valve [7, 8]. In our patient, the aortic valve was bicuspid, but each valve was intact. We performed a single-stage, valve-sparing aortic root implantation with a Valsalva graft for this combination of AAD and CoA, and postoperative echocardiograms at 1 week and at 8 months showed no aortic valve insufficiency.
In an adult patient with CoA, providing adequate blood flow to the whole body during cardiopulmonary bypass is another problem. Some authors recommend perfusing above and below the coarctation through two arterial cannulas [2, 4, 6]; others have stated that maintaining adequate blood flow through a single perfusion is possible in the presence of well-developed collateral vessels [3, 5]. In our patient, the blood flow for the lower body was not satisfactory through a single perfusion from the ascending aorta. We believe that simultaneous perfusion to both the upper and lower body is necessary for safe extracorporeal circulation when single-stage surgical repair is conducted for such a combination.
In summary, we successfully performed single-stage anatomic repair of valve-sparing aortic root implantation and replacement of the ascending aorta, arch, and the isthmus for acute type II aortic dissection with CoA. For safe extracorporeal circulation, simultaneous perfusion to both the upper and lower body is required when single-stage surgical repair is performed.
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References
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- Sampath R, O’Connor WN, Noonan JA, Todd EP. Management of ascending aortic aneurysm complicating coarctation of the aorta Ann Thorac Surg 1982;34:125-131.[Abstract]
- Rampoldi V, Trimarchi S, Tolva V, Righini P. Acute type A aortic dissection and coarctation of aortic isthmus J Cardiovasc Surg 2002;43:701-703.[Medline]
- Hovaguimian H, Aru GM, Floten HS. Acute type 1 aortic dissection with coarctation of the aorta: discussion of management and the report of a successful brain perfusion across an aortic coarctation J Thorac Cardiovasc Surg 1990;100:152-153.[Medline]
- Svensson LG. Management of acute aortic dissection associated with coarctation by a single operation Ann Thorac Surg 1994;58:241-243.[Abstract]
- Buket S, Yagdi T, Cikirikcioglu M, Alayunt EA. Single-stage transpericardial repair of acute aortic dissection associated with recoarctation J Thorac Cardiovasc Surg 2001;121:987-989.[Free Full Text]
- Paparella D, Schena S, Schinosa LLT, Vitale N. One step surgical repair of type 2 acute aortic dissection and aortic coarctation Eur J Cardiothorac Surg 1999;16:584-586.[Abstract/Free Full Text]
- Aicher D, Langer F, Kissinger A, Lauberg H, Fries R, Schafers HJ. Valve-sparing aortic root replacement in bicuspid aortic valves: a reasonable option? J Thoracic Cardiovasc Surg 2004;128:662-668.[Abstract/Free Full Text]
- Kallenbach K, Karck M, Pak D, et al. Decade of aortic valve sparing reimplantation: are we pushing limits too far? Circulation 2005;112:I253-I259.
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Abstract
Introduction
