Ann Thorac Surg 2009;87:930-933. doi:10.1016/j.athoracsur.2008.07.057
© 2009 The Society of Thoracic Surgeons
Case Reports
Aortic Root Replacement in a Patient With Previous Multiple Surgeries for Coarctation of Aorta
Kannan Ramachandran Nair, MCh,
Harilal Vasu, MCh,
Aju Jacob, MD,
Bashi V. Velayudhan, MCh*
Department of Cardiovascular and Thoracic Surgery, MIOT Hospital, Chennai, Tamilnadu, India
Accepted for publication July 16, 2008.
* Address correspondence to Dr Velayudhan, Department of Cardiovascular and Thoracic Surgery, MIOT Hospital, 4/112, Mount Poonamallee Rd, Manapakkam, Chennai, Tamilnadu, 600 089, India (Email: bashivelayudhan{at}gmail.com).
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Abstract
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Coarctation of the aorta is commonly associated with congenital and acquired cardiac pathology that may require surgical intervention. Adult patients with recurrent coarctation of the aorta, with or without associated intracardiac disease pose a surgical challenge. We report a 32-year-old man who presented with ascending aortic aneurysm with severe aortic regurgitation who underwent three previous surgeries for recurrent coarctation.
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Introduction
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Coarctation of the aorta is one of the most common cardiovascular congenital anomalies requiring corrective surgery in the pediatric age group. In surgically managed patients there is a larger incidence in the morbidity and mortality on long-term follow-up. Patients are at risk of late aneurysm formation, aortic dissection, and bacterial endocarditis. There is no consensus on the optimal approach for management of patients with recurrent coarctation. Several extra-anatomic bypass grafting techniques have been described, including methods in which distal anastomosis is performed on descending thoracic aorta or infrarenal abdominal aorta. Clearly this group requires careful follow-up to identify those patients in whom complications have developed.
A 32-year-old man who presented with a history of breathlessness was in New York Heart Association functional class II. In 1984 at the age of 11, he underwent resection of coarctation segment and repair with interposition graft. In 1987, he presented with claudication pain in the lower limb and an angiogram done at that time showed a long segment re-coarctation after the origin of left subclavian artery for which he underwent Dacron jump grafting (Hemashield; Boston Scientific, Natick, MA) between the aortic arch and the descending aorta. In 1991, he presented with hemoptysis; an angiogram showed aneurysm at the proximal anastomotic site, which was eroding into the left lung for which he underwent an extra-anatomical graft from the ascending aorta to the abdominal aorta with a prosthetic graft. At this operation, the prosthetic graft was positioned away from the midline toward the right side, and this was done by one of the authors (BVV). The aneurysmal thoracic aorta was excised through a left thoracotomy on femoro-femoral bypass.
On clinical examination, his BP was 140/30 mm Hg, CVS-S1S2+ (cardiovascular system-first heart sound, second heart sound), grade 3/6 systolic murmur heard over the aortic area radiating to carotids. General physical examination and rest of the systemic examinations were normal. Echocardiogram revealed an aneurysmal, dilated ascending aorta (more than 8 cm), aortic regurgitation of grade 4, dilated left ventricular concentric left ventricular hypertrophy, and an ejection fraction of 50%. An angiogram showed patent aortic interposition graft from the ascending aorta to the abdominal aorta and fusiform ascending aorta aneurysm with aortic regurgitation (Figs 1 and 2).
The femoral artery and the femoral vein were exposed and cannulated. Then a midline sternotomy was used after cardiopulmonary bypass was established. The adhesions were released. The ascending aorta was cannulated at the normal area close to the origin of the innominate artery and double perfusion was started. Since the patient had an extra-anatomical bypass, and as the thoracic aorta was excised after the origin of left subclavian artery at the time of third operation, the only way that the arch vessels could be perfused was through the ascending aortic cannula when the aorta was cross clamped. For this purpose, the cardiopulmonary bypass circuit was configured to accommodate a "Y" connector to the arterial outflow, one limb of the "Y" connector for arch vessels, and another limb for femoral vessels. The ascending aorta and the graft were then cross clamped. The aneurysm was opened. Cold cardioplegia arrest was achieved. The aortic valve and the aneurysmal aorta were then excised. The right and left coronary buttons were dissected and separated. The aortic root was replaced with a size #21 Carbomedics composite graft (Carbomedics Inc, Austin, TX). The coronary buttons were then reimplanted on to the graft using 4-0 Prolene sutures (Ethicon, Somerville, NJ). The distal end of the graft was anastomosed to the ascending aorta close to the origin of the innominate artery. The existing graft was then attached to the ascending aortic graft using 4-0 Prolene sutures (Ethicon). The patient was rewarmed and the aortic clamp was released (Fig 3).
The patient had an uneventful recovery and is doing well 2 years after the procedure. Histopathologic examination of the aorta revealed medial degeneration.
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Comment
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Coarctation of the aorta is one of the most common cardiovascular congenital anomalies requiring a corrective operation in the pediatric age group. The first clinical surgical repair of coarctation of the aorta was reported by Crawford and Nylin [1]. In surgically managed patients, a long-term increased risk of cardiac mortality and morbidity may persist. In 5% to 30% of patients with previous repair of coarctation of the aorta have re-coarctation and require reintervention [2]. Patients are at the risk of late aneurysm formations, aortic dissections, and bacterial endocarditis.
Aneurysm formation in the aortic isthmus after repair of coarctation may be preconditioned by congenital or acquired changes of the aortic valve, as well as attendant hemodynamics. Aneurysm can also be attributed to excess of excision of coarctation, damage to the intima, and increase aortic wall stress, which is transformed through a rigid patch onto a more elastic compromised aortic wall opposite to the patch [3–5].
Patients with bicuspid aortic valve, advanced age, reoperation of coarctation of the aorta, and high preoperative systolic peak pressure are most likely to develop proximal aneurysm. With high prevalence of severe aortic regurgitation, dissection, and rupture, this condition can be life threatening and carries high mortality. Formation of aortic aneurysm after corrective surgery for coarctation of the aorta was previously reported in 9% of patients, irrespective of the techniques of surgical correction. Aneurysm formation after coarctation of aorta repair is not exclusively related to patch graft repair, and aneurysms of the ascending aorta are completely unrelated to surgical technique [6].
In addition to the well-known problems of hypertension and re-coarctation, aortic arch pathology is commonly encountered in patients with previous coarctation repair. Aortic abnormalities may predispose to dilatations and dissection, which necessitates careful lifelong surveillance in all patients with coarctation of the aorta [7]. In a series of 149 patients with coarctation repair, a report by Simoom and colleagues [6] showed dilatation of the ascending aorta in 28% of patients, but they concluded that no relation between dilatation and hypertension [7]. Other series suggested a definite correlation between an ascending aortic aneurysm and hypertension. Possibility of intrinsic abnormality of the media, probably cystic median necrosis was also suggested [8]. Hence, continued clinical and radiological surveillance of coarctation repair is warranted
In conclusion, clearly this group requires careful follow-up to identify those patients in whom complications can develop. We believe that the fourth time reoperation for coarctation of the aorta needing a Bentall's procedure is not reported.
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References
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- Crawford C, Nylin G. Congenital coarctation of aorta and its surgical treatment J Thorac Surg 1945;14:347-361.
- Foster E. Reoperation for aortic coarctation Ann Thorac Surg 1984;38:81-89.[Abstract/Free Full Text]
- Bergdahl L, Ljungquist A. Long-term results after repair of coarctation of the aorta by patch grafting J Thor Cardiovasc Surg 1980;80:177-181.[Abstract]
- Ala-Kulju K, Heikkinen L. Aneurysms after patch graft aortoplasty for coarctation of the aorta: long-term results of surgical management Ann Thorac Surg 1989;47:853-856.[Abstract/Free Full Text]
- DeSanto A, Bills RG, King H, et al. Pathogenesis of aneurysm formation opposite prosthetic patches used for coarctation repair J Thorac Cardiovasc Surg 1987;94:720-723.[Abstract]
- Roos-Hesselink JW, Schölzel BE, Heijdra RJ, et al. Aortic valve and aortic arch pathology after coarctation repair Heart 2003;89:1074-1077.[Abstract/Free Full Text]
- von Kodolitsch Y, Aydin MA, Koschyk DH. Predictors of aneurysmal formation after surgical correction of aortic coarctation J Am Coll Cardiol 2002;39:617-624.[Abstract/Free Full Text]
- White CW, Zoller RP. Left aortic dissection following repair of coarctation. The contribution of abnormal hemodynamics to median degeneration. Chest 1973;634:573-577.
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Abstract
Introduction
