Ascending-to-Descending Bypass for Simultaneous Surgery of Aortic Coarctation with Other Cardiac Pathologies

Abstract

Background The appropriate approach for aortic coarctation associated with other cardiac diseases necessitating surgery is still controversial. The aim of this study was to evaluate the results after simultaneous surgery performed via median sternotomy and consisting of extra-anatomical ascending-to-descending aortic bypass and various other cardiac procedures.

Methods Between January 1999 and February 2009, 13 consecutive patients with aortic coarctation coexistent with other cardiac diseases necessitating surgery underwent simultaneous surgery via median sternotomy. An extra-anatomical ascending-to-descending aortic bypass for coarctation repair was performed in all patients accompanied by various cardiac procedures (5 aortic root and valve replacement; 2 aortic valve replacement; 2 coronary artery bypass grafting; 2 mitral valve repair; 1 aortic valve replacement and coronary artery bypass grafting; 1 mitral and tricuspid valve repair). There were 3 women and 10 men with a mean age of 52 years (range 25–69). Two patients had recurrent or residual coarctation 37 and 46 years after previous surgical repair, respectively.

Results Early mortality was 0 and there was only 1 late death during the follow-up of up to 11 years. New York Heart Association (NYHA) functional class improved on average from 2.4 to 1.2. At the last follow-up, blood pressure measured at the upper and lower extremities showed no gradient in any patient, indicating a durable function of the extra-anatomical bypass. Only 3 patients were on reduced antihypertensive therapy; 8 patients were on the same medication and 1 patient required increased medication therapy compared with the medication prior to surgery.

Conclusions Ascending-to-descending bypass can be performed via median sternotomy simultaneously with various cardiac procedures without considerable extension of the procedure. The operative and long-term results are excellent, and this approach can be recommended as the procedure of choice in patients with aortic coarctation and additional cardiac diseases necessitating surgery.

Keywords

aorta/aortic - cardiac - surgery/incisions

• References

• 1 Kouchoukos NT, Blackstone EH, Doty DB, Hanley FL, Karp RB. Coarctation of the aorta and interrupted aortic arch. In: Kirklin J, Barratt-Boyes B, eds. Cardiac Surgery. 3rd ed. Philadelphia: Churchill Livingston;; 2003: 1315-1375
• 2 Warnes CA, Williams RG, Bashore TM , et al. ACC/AHA 2008 guidelines for the management of adults with congenital heart disease: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2008; 118: 2395-2451
• 3 Urbanski PP, Savedra Blume JC, Froehner S. Surgical repair of the aortic coarctation combined with complete replacement of the ascending aorta and aortic arch. Thorac Cardiovasc Surg 2006; 54: 276-278
• 4 Roques F, Michel P, Goldstone AR, Nashef SA. The logistic EuroSCORE. Eur Heart J 2003; 24: 882-883
• 5 Urbanski PP, Lenos A, Lindemann Y, Weigang E, Zacher M, Diegeler A. Carotid artery cannulation in aortic surgery. J Thorac Cardiovasc Surg 2006; 132: 1398-1403
• 6 Grinda JM, Mace L, Dervanian P, Folliguet TA, Neveux JY. Bypass graft for complex forms of isthmic aortic coarctation in adults. Ann Thorac Surg 1995; 60: 1299-1302
• 7 Brewer 3rd LA, Fosburg RG, Mulder GA, Verska JJ. Spinal cord complications following surgery for coarctation of the aorta. J Thorac Cardiovasc Surg 1972; 64: 368-381
• 8 Aebert H, Laas J, Bednarski P, Koch U, Prokop M, Borst HG. High incidence of aneurysm formation following patch plasty repair of coarctation. Eur J Cardiothorac Surg 1993; 7: 200-205
• 9 Hamdan MA, Maheshwari S, Fahey JT, Hellenbrand WE. Endovascular stents for coarctation of the aorta: initial results and intermediate-term follow-up. J Am Coll Cardiol 2001; 38: 1518-1523
• 10 Golden AB, Hellenbrand WE. Coarctation of the aorta: stenting in children and adults. Catheter Cardiovasc Interv 2007; 69: 289-299
• 11 Forbes TJ, Garekar S, Amin Z , et al. Procedural results and acute complications in stenting native and recurrent coarctation of the aorta in patients over 4 years of age: a multi-institutional study. Catheter Cardiovasc Interv 2007; 70: 276-285
• 12 Karl TR. Surgery is the best treatment for primary coarctation in the majority of cases. J Cardiovasc Med 2007; 8: 50-56
• 13 McKellar SH, Schaff HV, Dearani JA , et al. Intermediate-term results of ascending-descending posterior pericardial bypass of complex aortic coarctation. J Thorac Cardiovasc Surg 2007; 133: 1504-1509
• 14 Lang N, Sodian R, Malec E , et al. Off-pump extraanatomic bypass from the ascending to the descending aorta for re-operation of interrupted aortic arch in an adolescent. J Card Surg 2009; 24: 541-543
• 15 Vijayanagar R, Natarajan P, Eckstein PF, Bognolo DA, Toole JC. Aortic valvular insufficiency and postductal coarctation in the adult. Combined surgical management through median sternotomy: a new surgical approach. J Thorac Cardiovasc Surg 1980; 79: 266-268
• 16 Powell W, Adams P, Cooley D. Repair of coarctation of the aorta with intracardiac repair. Tex Heart Inst J 1983; 10: 409-413
• 17 Connoly HM, Schaff HV, Izhar U, Dearani JA, Warnes CA, Orszulak TA. Posterior pericardial ascending to descending aortic bypass. Circulation 2001; 104 (Suppl. 01) I133-I137
• 18 Morris R, Samuels L, Brockman S. Total simultaneous repair of coarctation and intracardiac pathology in adult patients. Ann Thorac Surg 1998; 65: 1698-1702
• 19 Birincioglu CL, Mavioglu L, Yavas S, Demirtas E, Altintas G, Iscan HZ. Single-stage repair of acute type a aortic dissection associated with aortic coarctation, perimembranous ventricular septal defect, and bicuspid aortic valve. Ann Thorac Surg 2008; 86: 284-287
• 20 Alexi-Meskishvili VV, Berger F. Eleven-year follow-up after descending thoracic aorta replacement in a small child. Ann Thorac Surg 2001; 71: 1006-1008
• 21 Heinemann MK, Ziemer G. Invited commentary. Ann Thorac Surg 2001; 71: 1008
• 22 Marx GR. “Repaired” aortic coarctation in adults: not a “simple” congenital heart defect. J Am Coll Cardiol 2000; 35: 1003-1006
• 23 Hager A, Kanz S, Kaemmerer H, Schreiber C, Hess J. Coarctation long-term assessment (COALA): significance of arterial hypertension in a cohort of 404 patients up to 27 years after surgical repair of isolated coarctation of the aorta, even in the absence of restenosis and prosthetic material. J Thorac Cardiovasc Surg 2007; 134: 738-745